Exercise for Bone Mineral Density in People with Inflammatory Bowel Disease: A Systematic Review

Inflammatory bowel disease (IBD) is associated with reduced areal bone mineral density (aBMD) and an increased risk of osteoporosis and fragility fractures. Although exercise improves bone health in the general population, its effects on aBMD in adults with IBD are unclear. This systematic review aimed to evaluate the effects of structured exercise interventions on aBMD in adults with IBD and to assess the certainty of the evidence.

We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook. Searches were performed in CENTRAL, MEDLINE, Scopus, and Web of Science from inception to November 2025. We included randomized controlled trials comparing structured exercise interventions with usual care, no structured exercise or no intervention in participants aged 16 years and older with IBD. The primary outcome was aBMD; physical activity was a secondary outcome. Risk of bias was assessed using the Cochrane Risk of Bias tool (RoB 2.0), and certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE). The review protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO) CRD42024617200.

Two randomized controlled trials (n = 164), both conducted exclusively in adults with Crohn's disease, met the inclusion criteria. Combined impact and resistance training for 6 months was associated with greater lumbar spine aBMD compared with usual care, while hip outcomes were not consistently improved. A 12-month low-impact exercise program compared with no intervention suggested greater trochanter aBMD gain among fully compliant participants, but intention-to-treat between-group differences were not statistically significant across skeletal sites. Due to heterogeneity in interventions and reporting, meta-analysis was not performed. Overall certainty of the evidence was very low because of methodological limitations and imprecision.

We are very uncertain about the effect of exercise interventions on aBMD in adults with IBD. Current randomized evidence is limited to adults with Crohn's disease and is insufficient to determine the optimal exercise modality, frequency, intensity, progression, or loading characteristics for improving bone health. Well-designed trials across IBD phenotypes are needed to clarify the role of exercise in bone health management in IBD.