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Mediating Effect of Muscle on the Relationship of Physical Activity and Bone


Medicine & Science in Sports & Exercise: January 2019 - Volume 51 - Issue 1 - p 202–210
doi: 10.1249/MSS.0000000000001759

Purpose This study analyzed prospective associations between distinct trajectories of objectively measured physical activity (PA) and late adolescent bone parameters and explored the mediating effects of lean soft tissue, a surrogate of muscle mass to associations.

Methods Physical activity was measured by accelerometry starting at age 5 yr and continuing at 8, 11, 13, 15, and 17 yr in approximately 524 participants from the Iowa Bone Development Study. Sex-specific group-based trajectory modeling was used to construct developmental trajectories of moderate- and vigorous-intensity PA (MVPA) from childhood to late adolescence. At age 17 yr, proximal femur bone mineral density (aBMD) was assessed by dual X-ray energy absorptiometry, and its distribution was calculated by aBMD ratios. Specific geometric measures of the proximal femur were assessed using hip structural analysis.

Results A significant portion of the total effect of MVPA from age 5 to 17 yr on bone parameters at age 17 yr was explained by an increase in leg lean soft tissue in both sexes. For males and females, indirect effects were observed on the total and all regional proximal femur aBMD, and on the ratio between the inferomedial and superolateral neck aBMD. The effect on the ratio between the trochanter and the total proximal femur was specific to females, whereas the effect on the hip axis length was specific to males. Direct effects of MVPA on aBMD were identified only in males.

Conclusions Using robust mediation analysis, this is the first study addressing the indirect effect (through muscle) of PA across childhood and adolescence on proximal femur bone parameters. To improve bone health at the proximal femur, the results suggest PA interventions during growth that increase muscle mass, particularly in females.

1Department of Sport and Health, Faculdade de Motricidade Humana, Universidade de Lisboa, Lisbon, PORTUGAL;

2Department of Epidemiology, The University of Iowa, Iowa City, IA;

3Department of Health and Human Physiology, The University of Iowa, Iowa City, IA; and

4Department of Preventive and Community Dentistry, College of Dentistry, The University of Iowa, Iowa City, IA

Address for correspondence: Vera Zymbal, Ph.D., Department of Sport and Health, Faculdade de Motricidade Humana, Universidade de Lisboa, Estrada da Costa, 1499-002, Cruz Quebrada Lisbon, Portugal; E-mail:

Submitted for publication November 2017.

Accepted for publication August 2018.

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© 2019 American College of Sports Medicine