Weight Loss Without Bone Loss: Mediterranean Diet and Exercise in Older Women
July 15, 2025
By Ellen Feldman, MD
Synopsis: This systematic review found that, among older women undergoing intentional weight loss, bone density is better preserved with a calorie-restricted Mediterranean diet combined with physical activity, compared to a standard Mediterranean diet alone.
Source: Vázquez-Lorente H, García-Gavilán JF, Syam S, et al. Mediterranean diet, physical activity, and bone health in older adults: A secondary analysis of a randomized clinical trial. JAMA Netw Open. 2025;8(4):e253710.238.
This systematic review and secondary analysis explore the effect of a calorie-reduced Mediterranean diet combined with specified physical activity (PA) on bone health during weight loss in older adults. As age-related bone loss and osteoporotic fractures increase in prevalence, particularly during periods of intentional weight loss, the study addresses a key concern for many clinicians: how to support healthy weight reduction without compromising skeletal integrity.1
The analysis is based on data from the PREDIMED-Plus randomized controlled trial, which enrolled 924 Spanish adults aged 55 to 75 years with overweight or obesity and metabolic syndrome. Participants were randomized into one of the two arms:2
- An intervention group that received an energy-restricted Mediterranean diet with specified goals for PA promoting, via behavioral interventions, at least 150 minutes weekly of moderate-to-vigorous aerobic activity along with individualized programs incorporating resistance, flexibility and balance exercises.
- A control group that followed a standard (non-calorie-restricted) Mediterranean diet without structured PA guidance.
The primary outcome for this secondary analysis was change in bone mineral density (BMD), which was assessed at baseline and at one year and three years at the lumbar spine, femoral neck, and total hip. BMD was measured using dual-energy X-ray absorptiometry (DXA). Additional outcomes included changes in total bone mineral content (BMC) and prevalence of low BMD (osteoporosis or osteopenia) over the three-year period. For this study, low BMD status was defined as T-scores of ≤ -1.
Key findings include that women in the intervention group experienced a statistically significant benefit in lumbar spine BMD over three years compared to controls (between-group difference: 1.8 g/cm2; 95% confidence interval, 0.6-2.9; P = 0.005). Similar, but smaller not statistically significant gains were seen in total femur and femoral trochanter BMD. However, no significant differences were seen in men or in overall BMC or low BMD prevalence.
Notably, although both groups showed mean net weight loss, participants in the intervention group achieved greater weight loss (mean -2.2 kg at three years) compared with those in the control group. The benefits in bone health among women persisted after adjusting for potential confounders and excluding participants taking calcium or vitamin D supplements. This is significant, since greater weight loss often is accompanied by higher BMD loss, especially in this population. Importantly, the intervention was well-tolerated, and fracture rates did not differ significantly between the groups during the follow-up period.
Commentary
Weight loss in older adults often presents a clinical conundrum: While reducing adiposity improves cardiometabolic health, it can accelerate bone loss, increasing fracture risk.1 Primary care clinicians frequently face this dilemma when guiding aging patients through lifestyle changes for obesity, hypertension, or diabetes. Vázquez-Lorente et al offer evidence-based reassurance — and a practical, clinically applicable framework — for preserving bone health during weight reduction.
Drawing from the large, well-conducted PREDIMED-Plus randomized trial, the authors analyzed how combining an energy-restricted Mediterranean diet with structured physical activity affects BMD in older adults intentionally losing weight. The Mediterranean diet already is known for its cardiovascular and metabolic benefits.3 Here, it was paired with increased PA and behavioral counseling over three years — an intensive, real-world approach well-suited for primary care.
The results are compelling. Among older women, those in the intervention group experienced less lumbar spine BMD loss, even though both groups lost weight. This suggests that the quality of the weight loss intervention, and not just the weight change itself, affects bone health. This finding is particularly meaningful because weight loss in older adults typically accelerates bone loss, especially at trabecular-rich sites, such as the spine.1,4 The attenuation of bone loss in the intervention group suggests a protective effect of combining caloric restriction with nutrient-dense dietary patterns and increased PA.
While BMD changes at the femoral head and total hip were not significantly different between the two groups, the results suggest site-specific skeletal responses. The lumbar spine, composed predominately of trabecular bone, is more metabolically active and responsive to nutritional and hormonal changes.5 These site-specific findings reinforce the importance of targeting bone-saving strategies to areas most vulnerable to osteoporotic fractures, particularly in postmenopausal women.
Interestingly, the protective effect was not observed in men, possibly because of baseline differences in hormonal status, muscle mass, or activity level. Notably, mean BMD was higher in men than women at baseline. The results suggest that women are more susceptible to age-related bone loss and more responsive to lifestyle interventions, emphasizing the clinical importance of personalizing lifestyle recommendations based on sex, age, and fracture risk profile.
The clinical takeaway is unmistakable: Not all weight loss strategies are equal when it comes to preserving skeletal health. Calorie restriction alone can lead to bone loss, especially in postmenopausal women.1,4 However, when combined with a nutrient-rich Mediterranean diet and regular PA, weight loss becomes not only safer, but more sustainable. The diet’s richness in calcium, vitamin K, antioxidants, and anti-inflammatory compounds likely supports bone remodeling, while PA — particularly resistance and weight-bearing forms — stimulates bone formation and reduces fall risk.3,6
It is notable that participants in both arms of the study followed a Mediterranean diet. However, only the intervention group received an energy-restricted version combined with structured PA. Therefore, the between-group differences in bone outcomes likely reflect the added effect of caloric restriction and increased PA, rather than the Mediterranean diet itself. While the findings suggest that the combination of energy reduction, the nutrient-rich Mediterranean diet, and exercise helped preserve BMD, the study design does not allow us to determine the independent contribution of each component. Future research would benefit from isolating these variables to clarify their individual and synergistic effects on bone health.
For primary care professionals, this study provides a concrete way to counsel older adults: Weight loss can still be a goal, but it must be paired with bone-supportive habits. This aligns well with real-world practice, where lifestyle recommendations often need to address multiple chronic conditions simultaneously, such as obesity, hypertension, and osteoporosis.
Moreover, the results underscore the value of integrated lifestyle approaches rather than isolated interventions. A calorie-restricted diet alone or exercise without nutritional guidance may not offer the same skeletal benefits. Coordinated messaging that emphasizes “how you lose weight” matters as much as “how much you lose” is key in working with patients.
This study also may serve as a reminder to healthcare professionals working with older adults to monitor bone health proactively, especially in women and especially when these patients are pursuing weight loss. DXA screening, fracture risk calculators, and assessment of calcium and vitamin D intake remain essential.7 For women older than 65 years of age and men older than 70 years of age, or those with risk factors, early identification of osteopenia may guide whether pharmacologic treatment should accompany lifestyle strategies.
In summary, this trial equips primary care professionals with a practical, evidence-based framework for guiding safe and effective weight loss in older adults. An energy-restricted Mediterranean-style eating pattern coupled with structured PA not only delivers favorable cardiometabolic benefits but preserves bone density in postmenopausal women. These results highlight the power of holistic, individualized lifestyle interventions in primary care — offering a single dual-purpose strategy that simultaneously targets metabolic syndrome and osteoporosis risk. For older women facing both cardiometabolic and skeletal health challenges, this combined approach presents an attractive, nonpharmacologic option that sustains bone health for at least three years with the potential of enhancing functional capacity and quality of life.
Ellen Feldman, MD, works for Altru Health System, Grand Forks, ND.
References
- Johnson KC, Anderson A, Beavers KM, et al. The long-term effect of intentional weight loss on changes in bone mineral density in persons with type 2 diabetes: Results from the Look AHEAD randomized trial. Arch Osteoporos. 2023;18(1):97.
- PREDIMED-Plus clinical trial. https://www.predimedplus.com/en/project/
- Nicklett EJ, Kadell AR. Fruit and vegetable intake among older adults: A scoping review. Maturitas. 2013;75(4):305-312.
- Jiang BC, Villareal DT. Weight loss-induced reduction of bone mineral density in older adults with obesity. J Nutr Gerontol Geriatr. 2019;38(1):100-114.
- Akhiiarova K, Khusainova R, Minniakhmetov I, et al. Peak bone mass formation: Modern view of the problem. Biomedicines. 2023;11(11):2982.
- Zhong Y-J, Meng Q, Su C-H. Mechanism-driven strategies for reducing fall risk in the elderly: A multidisciplinary review of exercise interventions. Healthcare. 2024;12(23):2394.
- Zaheer S, LeBoff MS. Osteoporosis: Prevention and treatment. In: Endotext [Internet]. Updated Dec. 27, 2022. https://www.ncbi.nlm.nih.gov/books/NBK279073/#osteoporosis-prevent.VITAMIN_D
This systematic review found that, among older women undergoing intentional weight loss, bone density is better preserved with a calorie-restricted Mediterranean diet combined with physical activity, compared to a standard Mediterranean diet alone.
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