Osteoporosis is a bone-density T-score of -2.5 or below, and the fracture is the harm: a hip, spine or wrist that gives way from a fall at standing height or less. Most of what lowers that risk you can do yourself.
Heavy resistance and impact training build bone, balance training prevents the falls that break hips, and enough protein, calcium and vitamin D come mostly from the plate. When density is low or a bone has already broken, medication cuts fractures well, added on top of the basics for people whose risk is high enough to need it.
Practice Ranking
Every practice we track for Osteoporosis, ranked by how well the evidence supports it for this condition. Strength describes the evidence, not our endorsement.
7 practices · 2 to start with
| # | Practice | Evidence | Type | Cost | Effort | Results In | Add to plan |
|---|---|---|---|---|---|---|---|
| 1 | Balance & Fall Prevention Most fractures come from a fall, so balance and strength training prevents the break as directly as bone density does. | Strong | Self-Directed | Free | Easy to Moderate | Weeks to Months | |
| 2 | Resistance Training Heavy resistance and impact loading is the lever that actually builds bone; gentle, low-load movement does not. | Moderate | Self-Directed | Free to $$ | Moderate to Hard | Weeks to Months | |
| 3 | Protein & Muscle Eating more protein slightly helps spine density and, contrary to old worries, does not weaken bone. | Moderate | Self-Directed | $ to $$ | Easy to Moderate | Weeks to Months | |
| 4 | Quitting Smoking Smoking weakens bone; quitting slows the loss, a reduce-lever alongside alcohol. | Moderate | Pro | Free to $$ | Hard | Days to Longer | |
| 5 | Vitamin D Calcium and vitamin D help most in people who are genuinely deficient or in care; they add little for the already-replete, and very large single doses backfire. | Moderate | Supplement | $ | Easy | Weeks to Months | |
| 6 | Reduce Alcohol Heavier drinking raises fracture risk, so cutting back is a protective lever for bone. | Moderate | Self-Directed | Free | Moderate to Hard | Weeks to Months | |
| 7 | Vitamin K2 Vitamin K2 slowed bone loss in one trial of healthy postmenopausal women, on early evidence. | Preliminary | Supplement | $ | Easy | Months to Longer | |
Default order puts the best-supported practices first, with self-directed care ahead of clinical options. Click any row to open the practice.
What It Is
Osteoporosis is bone that has thinned and weakened to the point that it breaks easily. It is diagnosed on a bone-density scan called a DXA scan, which reports a T-score: how far your density sits from that of a healthy young adult, counted in standard deviations. A T-score of -2.5 or below is osteoporosis. A T-score between -1.0 and -2.5 is osteopenia, thinning that has not yet reached osteoporosis. The score is only an estimate of risk.
The harm is the fragility fracture: a hip, spine or wrist that gives way from a fall at standing height or less. The T-score estimates that risk. A tool called FRAX turns your age, sex, weight and a few risk factors into a ten-year estimate of fracture risk, and that estimate, more than the raw T-score, guides whether medication is worth starting. Most fragility fractures happen to people in the osteopenia range, because far more people sit there than in the osteoporosis range, so a borderline scan is not a reason to relax.
Some people carry more risk than others. It runs higher:
- in women after menopause, when bone loss speeds up
- in older men, who fracture too and are treated for it less often
- with long-term oral steroids, which thin bone fast
- with early menopause, low body weight, heavy smoking or drinking, celiac disease or an overactive thyroid
A first fragility fracture is the strongest signal of all, because the risk of the next one is highest in the year or two after it.
What Works
The steps below are ordered by effort and cost: the free, lasting ones first, then medication for people whose risk is high enough to need it. Each finding carries its own evidence grade.
The Research & Studies
Everything here is based on the research we have collected and checked, sorted into groups and ordered with the strongest evidence first. Click any claim to open the studies behind it.
Balance And Falls
Balance and strength exercise cut the rate of falls by about a quarter
Across many trials of older people, exercise that trains balance and strength cut the rate of falls by about a quarter, and since most hip and wrist breaks happen in a fall, this lowers fracture risk from the other side.
A Cochrane review of 108 randomized trials in 23,407 community-dwelling older adults found that exercise reduced the rate of falls by 23% (rate ratio 0.77, 95% CI 0.71 to 0.83; 59 studies), high-certainty evidence. Programs built on balance and functional exercise drove the effect (rate ratio 0.76), while multiple-component programs and Tai Chi also helped. Exercise may also reduce fall-related fractures (risk ratio 0.73), though that estimate is low-certainty. Measured in: 23,407 community-dwelling adults aged 60+ across 108 randomized trials in 25 countries; on average 76 years old and 77% women. The strong finding is for falls themselves; the effect on fractures specifically is only low-certainty because far fewer trials tracked fractures, and most trials had unclear or high risk of bias on at least one item.
The study · 1
Sherrington et al., exercise for preventing falls in older people living in the community · Cochrane Database Syst Rev 2019;1:CD012424
Bone Density
Calcium plus vitamin D did not clearly cut hip fractures in unselected older women
In a very large trial of older women who were not selected for low bone or vitamin levels, a standard calcium-and-vitamin-D pill did not clearly cut hip fractures overall and slightly raised kidney-stone risk, though it did help the women who took it reliably.
In the Women's Health Initiative, 36,282 postmenopausal women were randomized to 1000 mg calcium plus 400 IU vitamin D daily or placebo. Hip bone density was 1.06% higher with supplements, but hip fracture was not significantly reduced overall (hazard ratio 0.88, 95% CI 0.72 to 1.08). Among women who actually took their pills, hip fracture fell significantly (hazard ratio 0.71), and the supplements raised the risk of kidney stones (hazard ratio 1.17). Measured in: 36,282 generally healthy postmenopausal women aged 50 to 79, not selected for low calcium, low vitamin D or osteoporosis. Adherence was incomplete, the vitamin D dose (400 IU) is low by current standards, and the significant hip-fracture benefit appeared only in the per-protocol subgroup, not the intention-to-treat population; kidney-stone risk rose.
Who this may not transfer to:Conducted entirely in postmenopausal women. The null overall result reflects an unselected, largely replete population and cannot be read as the effect in men or in people who are genuinely deficient.
The study · 1
Jackson et al., calcium plus vitamin D supplementation and the risk of fractures (Women's Health Initiative) · N Engl J Med 2006;354(7):669-683
Vitamin D alone did not reduce fractures in adults who were not deficient
Giving vitamin D to healthy older adults who were not short of it did not reduce broken bones of any kind over about five years.
In the VITAL bone ancillary trial, 25,871 generally healthy adults were randomized to 2000 IU/day vitamin D3 or placebo and were not selected for vitamin D deficiency, low bone mass or osteoporosis. Over a median 5.3 years, vitamin D did not significantly change total fractures (hazard ratio 0.98), nonvertebral fractures (0.97) or hip fractures (1.01), with no benefit in any baseline subgroup including those with lower vitamin D levels. Measured in: 25,871 US adults, men 50+ and women 55+, generally healthy and not selected for deficiency or low bone mass; about 51% women. The trial deliberately did not enroll people who were vitamin D deficient or osteoporotic, so it speaks to routine supplementation in people who are already replete, not to correcting a true deficiency, where vitamin D still matters.
The study · 1
LeBoff et al., supplemental vitamin D and incident fractures in midlife and older adults (VITAL) · N Engl J Med 2022;387(4):299-309
Alendronate cut new spine fractures roughly in half in women with a prior fracture
In women who had already broken a bone in the spine, three years of the bisphosphonate alendronate cut new spine fractures roughly in half and about halved hip fractures.
In the Fracture Intervention Trial, 2,027 postmenopausal women with an existing vertebral fracture were randomized to alendronate or placebo for 36 months. New morphometric vertebral fractures occurred in 8.0% on alendronate versus 15.0% on placebo (relative risk 0.53), clinically apparent vertebral fractures in 2.3% versus 5.0% (relative hazard 0.45), and hip fractures were about halved (relative hazard 0.49, 95% CI 0.23 to 0.99). Measured in: 2,027 postmenopausal women aged 55 to 81 with low femoral-neck bone density and at least one existing vertebral fracture. This trial was in women with an existing vertebral fracture, the group at highest risk, so the absolute benefit is largest there; the effect is smaller in people with low density but no prior fracture.
Who this may not transfer to:Tested in postmenopausal women with prior vertebral fracture; bisphosphonates also reduce fractures in men with osteoporosis in separate trials, but the figures here are women's.
The study · 1
Black et al., randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures (Fracture Intervention Trial) · Lancet 1996;348(9041):1535-1541
Denosumab cut new spine fractures by more than two-thirds and hip fractures by 40%
A twice-yearly injection of denosumab cut new spine fractures by more than two-thirds and hip fractures by 40% over three years in women with osteoporosis.
In the FREEDOM trial, 7,868 postmenopausal women with osteoporosis were randomized to denosumab 60 mg or placebo subcutaneously every 6 months for 36 months. Denosumab cut new vertebral fractures to 2.3% versus 7.2% (relative decrease 68%), hip fractures to 0.7% versus 1.2% (40% decrease) and nonvertebral fractures to 6.5% versus 8.0% (20% decrease), with no excess of cancer, infection or osteonecrosis of the jaw over three years. Measured in: 7,868 women aged 60 to 90 with a bone-density T-score between -2.5 and -4.0 at the spine or hip. The clean three-year safety picture does not cover what happens on stopping: bone turnover and fracture risk rebound quickly after denosumab is discontinued, so it is a treatment that has to be continued or handed over to another drug.
Who this may not transfer to:The pivotal fracture trial was in postmenopausal women; denosumab is also used to increase bone density in men, but the fracture figures here are women's.
The study · 1
Cummings et al., denosumab for prevention of fractures in postmenopausal women with osteoporosis (FREEDOM) · N Engl J Med 2009;361(8):756-765
Teriparatide cut new spine fractures by about 65% and built spine density
A daily injection of the bone-building drug teriparatide cut new spine fractures by about 65% and other fragility fractures by about half in women who had already fractured, and built spine density substantially.
In the Fracture Prevention Trial, 1,637 postmenopausal women with prior vertebral fractures received daily self-injected parathyroid hormone (1-34), teriparatide, at 20 or 40 micrograms or placebo for a median 21 months. New vertebral fractures occurred in 5% (20 microgram) versus 14% on placebo (relative risk 0.35), and new nonvertebral fragility fractures in 3% versus 6% (relative risk 0.47). Spine bone density rose 9 to 13 percentage points more than placebo. Side effects were minor. Measured in: 1,637 postmenopausal women with at least one prior vertebral fracture. Teriparatide builds bone but is given for a limited course (typically up to two years) and its gains fade unless followed by an antiresorptive drug; the trial was stopped early, so long-term fracture data from it are limited.
Who this may not transfer to:The pivotal fracture trial enrolled women only; teriparatide is also approved to raise bone density in men, but the fracture figures here are women's.
The study · 1
Neer et al., effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis · N Engl J Med 2001;344(19):1434-1441
Romosozumab cut new spine fractures by about three-quarters in one year
The bone-building drug romosozumab cut new spine fractures by about three-quarters in its first year against placebo, and by about half against a bisphosphonate in higher-risk women, though it carried a small excess of serious heart events.
In the FRAME trial, 7,180 postmenopausal women with osteoporosis received monthly romosozumab or placebo for 12 months, then denosumab in both groups. New vertebral fractures occurred in 0.5% on romosozumab versus 1.8% on placebo at 12 months, a 73% lower risk. In the separate ARCH trial of higher-risk women, romosozumab followed by alendronate cut new vertebral fractures by 48% versus alendronate throughout, but serious cardiovascular adverse events were more frequent during the romosozumab year (2.5% versus 1.9%). Measured in: 7,180 postmenopausal women with osteoporosis in FRAME; 4,093 higher-risk women with a fragility fracture in ARCH. The cardiovascular signal seen in ARCH means romosozumab is generally avoided in people with recent heart attack or stroke; it is a 12-month course that must be followed by an antiresorptive drug to keep the gains.
Who this may not transfer to:Both pivotal trials were in postmenopausal women; romosozumab has since been studied in men, but the fracture and cardiovascular figures here are women's.
The studies · 2
Cosman et al., romosozumab treatment in postmenopausal women with osteoporosis (FRAME) · N Engl J Med 2016;375(16):1532-1543
Saag et al., romosozumab or alendronate for fracture prevention in women with osteoporosis (ARCH) · N Engl J Med 2017;377(15):1417-1427
Menopausal hormone therapy cut total fractures by about a quarter and hip fractures by a third
Menopausal hormone therapy cut total fractures by about a quarter and hip fractures by about a third in a large trial, the clearest fracture proof in a general population of women.
In the Women's Health Initiative, 16,608 postmenopausal women were randomized to conjugated equine estrogen plus medroxyprogesterone or placebo. Total osteoporotic fractures occurred in 8.6% versus 11.1% (hazard ratio 0.76), hip fractures were reduced by about a third, and total-hip bone density rose 3.7% over three years versus 0.14% on placebo. The fracture benefit held across all risk subgroups. Measured in: 16,608 postmenopausal women aged 50 to 79 with an intact uterus. The same trial found excess breast cancer, stroke, blood clots and, in this arm, coronary events, so the overall balance means hormone therapy is chosen mainly for women taking it for menopausal symptoms, with the bone protection as an added benefit rather than the reason.
The study · 1
Cauley et al., effects of estrogen plus progestin on risk of fracture and bone mineral density: the Women's Health Initiative randomized trial · JAMA 2003;290(13):1729-1738
A yearly zoledronic acid infusion after a hip fracture cut new fractures by 35% and deaths by 28%
In people who had just broken a hip, a once-a-year drip of zoledronic acid cut the chance of another fracture by about a third over the next two years, and fewer of them died. It is given as an annual infusion, which suits someone who struggles with the weekly bisphosphonate tablets.
In the HORIZON Recurrent Fracture Trial, 2,127 patients (mean age 74.5) who had recently had surgical repair of a low-trauma hip fracture were randomized to a yearly 5 mg intravenous infusion of zoledronic acid or placebo and followed a median of 1.9 years. New clinical fractures fell to 8.6% with zoledronic acid versus 13.9% with placebo, a 35% relative reduction (P=0.001), with fewer clinical vertebral (1.7% vs 3.8%, P=0.02) and nonvertebral (7.6% vs 10.7%, P=0.03) fractures. Death from any cause fell to 9.6% versus 13.3%, a 28% relative reduction (P=0.01). Measured in: 2,127 women and men (mean age 74.5) who had undergone surgical repair of a low-trauma hip fracture within the previous 90 days, from 23 countries. The trial enrolled people right after a hip fracture, the highest-risk moment, so the size of the benefit is likely smaller in someone with low density who has not yet broken a bone. The first infusion can bring a short flu-like reaction in the following days, and the class carries the rare jaw and atypical-thigh-fracture cautions covered elsewhere on the page.
Who this may not transfer to:One of the few large fracture-drug trials to enrol both women and men, so its finding carries to older men after a hip fracture, not women only. The lower death rate is specific to the post-hip-fracture setting and should not be read as a general longevity effect of the drug.
The study · 1
Lyles et al., zoledronic acid and clinical fractures and mortality after hip fracture · N Engl J Med 2007;357(18):1799-1809
Raloxifene cut new spine fractures by about 30% to 50% over three years
Raloxifene, a drug that acts like estrogen on bone but not on the breast, cut the chance of a new spine fracture by roughly a third to a half over three years in women with osteoporosis. It did not lower fractures elsewhere such as the hip, so it fits a woman whose risk sits mainly in the spine, and it lowers breast-cancer risk as part of its profile.
In the Multiple Outcomes of Raloxifene Evaluation (MORE) trial, 7,705 postmenopausal women with osteoporosis were randomized to raloxifene 60 mg/day, 120 mg/day, or placebo for three years. New vertebral fractures occurred in 10.1% on placebo versus 6.6% on 60 mg (relative risk 0.7, 95% CI 0.5 to 0.8) and 5.4% on 120 mg (relative risk 0.5, 95% CI 0.4 to 0.7). Nonvertebral fractures were not significantly reduced (relative risk 0.9, 95% CI 0.8 to 1.1). Measured in: 7,705 postmenopausal women (mean age 66) with osteoporosis, across 25 countries. The clear benefit is for spine fractures only; it did not reduce hip or other nonvertebral fractures, so it is not the choice when hip protection is the main goal. Raloxifene raises the risk of venous blood clots and can worsen hot flashes, which is weighed when choosing it.
Who this may not transfer to:Tested only in postmenopausal women; raloxifene is a selective estrogen receptor modulator and is not used for bone in men. The spine-only benefit means it does not stand in for a drug that also protects the hip.
The study · 1
Ettinger et al., reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial (MORE) · JAMA 1999;282(7):637-645
Heavy resistance and impact training built about 2.9% spine density while gentle exercise lost it
Older women with thin bones who lifted heavy weights and did impact exercise twice a week for eight months gained about 3% spine density, while a gentle home-exercise group lost density, and the heavy training caused almost no injuries.
In the LIFTMOR trial, 101 postmenopausal women with low bone mass were randomized to 8 months of twice-weekly, supervised high-intensity resistance and impact training (5 sets of 5 reps above 85% of one-rep max) or a home-based low-intensity program. The training group gained lumbar-spine BMD by 2.9% versus a 1.2% loss in controls, and gained femoral-neck BMD (0.3% vs -1.9%), height and every functional-performance measure. Compliance was high and only one minor adverse event (a lower-back spasm) was reported. Measured in: 101 postmenopausal women (mean age 65) with osteopenia or osteoporosis (T-score below -1.0), screened to exclude conditions and drugs affecting bone. A single 8-month trial with 101 women, all under close supervision by trained staff; the safety and gains cannot be assumed for unsupervised heavy lifting, and it measured bone density and function rather than actual fractures.
Who this may not transfer to:Tested only in postmenopausal women with low bone mass. The osteogenic response to heavy loading is expected in men too on general physiology, but this trial did not enrol men, so the size of the effect in men is not established here.
The study · 1
Watson et al., high-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial · J Bone Miner Res 2018;33(2):211-220
More dietary protein slightly raised spine density and did not harm bone
Eating more protein was tied to a small gain in spine bone density and no harm to bone, which counters the old worry that protein leaches calcium out of bone.
A National Osteoporosis Foundation systematic review (16 RCTs, 20 cohort studies) found moderate evidence that higher versus lower protein intake had a small protective effect on lumbar-spine BMD (net change +0.52%, 95% CI 0.06 to 0.97), with no effect on total-hip, femoral-neck or total-body BMD and no adverse effect on bone. Evidence for protein plus calcium and vitamin D on fractures was limited or insufficient. Measured in: Adults across 16 randomized trials and 20 prospective cohorts of dietary protein and bone outcomes. The BMD gain is small and limited to the spine, the studies were heterogeneous with possible confounding, and there was insufficient evidence to show that higher protein reduces fractures.
The study · 1
Shams-White et al., dietary protein and bone health: a systematic review and meta-analysis from the National Osteoporosis Foundation · Am J Clin Nutr 2017;105(6):1528-1543
Calcium plus vitamin D cut total fractures by about 15% and hip fractures by about 30%
Taking calcium and vitamin D together lowered the chance of breaking any bone by about 15% and of breaking a hip by about 30% in older adults.
A meta-analysis of 8 randomized trials (30,970 participants) found that calcium plus vitamin D supplementation cut total fractures by 15% (summary relative risk 0.85, 95% CI 0.73 to 0.98) and hip fractures by 30% (0.70, 95% CI 0.56 to 0.87). The benefit was most consistent in older, community-dwelling and institutionalized adults. Measured in: 30,970 mostly older adults across 8 randomized trials of calcium plus vitamin D versus placebo. The pooled estimate leans heavily on a subgroup analysis of the large Women's Health Initiative trial, and the benefit is clearest in people who are short of calcium or vitamin D, not those already replete.
The study · 1
Weaver et al., calcium plus vitamin D supplementation and risk of fractures: an updated meta-analysis from the National Osteoporosis Foundation · Osteoporos Int 2016;27(1):367-376
Smoking is behind roughly one hip fracture in eight
Smokers lose bone faster after menopause and end up with a clearly higher chance of breaking a hip; roughly one hip fracture in eight is put down to smoking.
A meta-analysis of bone-density data in 2,156 smokers and 9,705 non-smokers, plus 19 cohort and case-control studies recording 3,889 hip fractures, found that postmenopausal bone loss was greater in smokers, with density falling about 2% more per decade of age and a 6% deficit by age 80. The estimated cumulative hip-fracture risk to age 85 was 19% in smokers versus 12% in non-smokers, and about one hip fracture in eight was attributed to smoking. Measured in: Postmenopausal women across pooled bone-density and hip-fracture studies; limited data in men suggested a similar proportional effect. The association was not explained by smokers being thinner, younger at menopause or less active, but as observational data it cannot fully exclude other lifestyle differences that travel with smoking.
Who this may not transfer to:The pooled estimates are from women; the authors noted limited data in men suggesting a similar proportional effect, but the hip-fracture figures here are women's.
The study · 1
Law and Hackshaw, a meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture: recognition of a major effect · BMJ 1997;315(7112):841-846
Drinking more than two a day was tied to about 40% more hip fractures
Very light drinking was tied to slightly fewer hip fractures, but drinking more than two a day was tied to about 40% more, so the risk rises once intake is regular and heavier.
A systematic review pooling alcohol and bone outcomes found a U-shaped pattern for hip fracture: compared with abstainers, people drinking more than 0.5 to 1.0 drinks a day had a lower hip-fracture risk (relative risk 0.80, 95% CI 0.71 to 0.91), while those drinking more than 2 drinks a day had a higher risk (relative risk 1.39, 95% CI 1.08 to 1.79). Femoral-neck bone density rose roughly linearly with alcohol intake. Measured in: Adults across the pooled observational studies of alcohol, hip fracture and bone density. The data are observational, so unmeasured differences between drinkers and abstainers may explain part of the pattern, and many studies combined moderate and heavy drinkers so the exact beneficial range could not be pinned down.
The study · 1
Berg et al., association between alcohol consumption and both osteoporotic fracture and bone density · Am J Med 2008;121(5):406-418
One very large annual dose of vitamin D raised falls by 15% and fractures by 26%
Giving older women one very large dose of vitamin D once a year led to about 15% more falls and 26% more fractures, not fewer, with the extra falls clustered in the months right after the dose. Steady, modest vitamin D to correct a shortfall is the aim; big infrequent mega-doses can work against you.
In a double-blind trial, 2,256 community-dwelling women aged 70 or older at high fracture risk were randomized to a single 500,000 IU oral dose of vitamin D once a year or placebo for three to five years. The vitamin D group fell more often (rate 83.4 vs 72.7 falls per 100 person-years; relative risk 1.15, 95% CI 1.02 to 1.30) and had more fractures (171 vs 135; relative risk 1.26, 95% CI 1.00 to 1.59), with the excess falls concentrated in the first three months after each dose. Measured in: 2,256 community-dwelling women aged 70 and older at high risk of fracture. This tested one very large annual bolus; it does not argue against correcting a true deficiency with an ordinary daily or weekly amount, where vitamin D's fracture benefit lies. Why the mega-dose raised falls is not fully settled.
Who this may not transfer to:Tested in older women given a single huge annual dose; the harm is about that mega-dose pattern and does not transfer to ordinary daily or weekly dosing in either sex.
The study · 1
Sanders et al., annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial · JAMA 2010;303(18):1815-1822
Vitamin K2 (MK-7) slowed spine and hip bone loss in healthy postmenopausal women
Over three years, a daily vitamin K2 supplement slowed the normal loss of spine and hip bone in healthy women past menopause and improved measures of bone strength.
In a 3-year randomized trial, 244 healthy postmenopausal women took 180 micrograms/day of vitamin K2 (menaquinone-7, MK-7) or placebo. MK-7 improved vitamin K status and significantly slowed the age-related decline in bone density at the lumbar spine and femoral neck (though not the total hip), improved calculated bone-strength indices, and reduced loss of vertebral height. Measured in: 244 healthy postmenopausal women (not selected for osteoporosis). Tested in healthy women with normal bones rather than in osteoporosis, over a single trial, and it measured density and calculated strength rather than actual fractures, so it sits as a supporting supplement, not a treatment.
Who this may not transfer to:Studied only in healthy postmenopausal women; the effect in men or in people with established osteoporosis has not been established here.
The study · 1
Knapen et al., three-year low-dose menaquinone-7 supplementation helps decrease bone loss in healthy postmenopausal women · Osteoporos Int 2013;24(9):2499-2507
Heart And Vascular
Calcium supplements without vitamin D were tied to about 30% more heart attacks
Calcium taken as a supplement without vitamin D was linked to roughly a 30% higher risk of heart attack across pooled trials, which is why large calcium pills are no longer recommended casually.
A meta-analysis of 15 randomized, placebo-controlled trials of calcium supplements (at least 500 mg/day, without co-administered vitamin D) found an increased risk of myocardial infarction: patient-level data (8,151 people) gave a hazard ratio of 1.31 (95% CI 1.02 to 1.67), and trial-level data (11,921 people) a relative risk of 1.27 (95% CI 1.01 to 1.59). Stroke and death showed smaller, non-significant increases. Measured in: About 12,000 mostly older adults across 15 randomized trials of calcium supplements without vitamin D. The absolute increase is modest and the finding is disputed; some cardiovascular events came from self-report and hospital records, later analyzes have disagreed, and the signal was for calcium taken without vitamin D, not for dietary calcium.
The study · 1
Bolland et al., effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis · BMJ 2010;341:c3691
Loading and balance lead because they are free and they build strength no drug restores. The loading has to be heavy and progressive to raise density; gentle walking helps balance and general health without loading bone hard enough to build it, so learn the lifts with a coach if the movements are new. Balance training earns its place by preventing the falls in which most hip and wrist fractures happen.
Protein, calcium and vitamin D should come from food before supplements. Take calcium from food where you can: milk, yogurt, canned fish with bones, tofu set with calcium, and leafy greens. Read the supplement findings together:
- calcium and vitamin D together help people who are short of them
- vitamin D adds nothing for people who already have enough
- one very large yearly dose works against you
- calcium taken as pills without vitamin D is tied to more heart attacks
The aim is to fill a measured gap, not to pile pills on top of a normal diet. Vitamin K2 sits as a supporting supplement, not a treatment. Stopping smoking and keeping alcohol light protect bone as well.
When density is low with a high FRAX estimate, or a bone has already broken, medication cuts fractures, and it is added on top of the loading, balance work and food. The order runs by cost and evidence:
- Bisphosphonates are the usual first choice, cheap and well proven. A once-a-year zoledronic acid infusion is the alternative for someone who struggles with weekly tablets, and it suits the weeks right after a hip fracture.
- Denosumab is used when risk is higher.
- The bone-building drugs, teriparatide and romosozumab, are for very high risk or several spine fractures, and each is followed by a bisphosphonate or denosumab to hold the gain. Romosozumab is avoided soon after a heart attack or stroke.
- Raloxifene fits a woman whose risk sits mainly in the spine, since it does not protect the hip, and it lowers breast-cancer risk. Menopausal hormone therapy is chosen mainly by women already taking it for menopausal symptoms, where the bone protection comes with it.
Denosumab is never simply stopped: spine-fracture risk rebounds to untreated levels and people can break several vertebrae at once, so any change is arranged with a prescriber and followed by another bone drug.
What To Do This Month
Most of keeping bone strong is steady, everyday work you lead yourself. Find out where you stand, then put the loading, balance and food in place, and treat medication as the earned next step when your risk warrants it.
Ask for a bone-density (DXA) scan and a FRAX ten-year fracture-risk estimate so any decision about medication rests on where you actually stand. If you have already broken a bone from a minor fall, say so, because that changes the picture on its own.
Progressive resistance, the squat, deadlift and overhead press, plus some impact such as jumping, hopping or brisk stepping within what your joints tolerate. Learn the lifts with a coach if they are new. This is the part that builds bone; gentle walking alone does not.
Standing balance work, tai chi or a strength-and-balance class cuts the rate of falls by about a quarter. Since most fractures happen in a fall, this is the other half of the job, and it costs nothing.
Aim for 1.0 to 1.2 grams of protein per kilogram of body weight a day and calcium from food. Add vitamin D only to correct a measured shortfall, at an ordinary daily or weekly amount, not a once-a-year mega-dose. Keep alcohol under two a day and stop smoking.
If your risk is high or you have already fractured, a fracture-reducing drug is the earned next step on top of the basics, chosen with a prescriber for its cautions as much as its benefits. Denosumab in particular is never simply stopped; a follow-on drug is arranged first.
Go Deeper
Three of these have their own page, with the how-to in full.
- Balance and fall prevention: the training that lowers fall rates, and how fewer falls mean fewer fractures.
- Heavy resistance training: how to load bone hard enough to build it, and how to start safely.
- Protein: how much bone and muscle need, and where the old calcium-leaching fear went wrong.
The Chinese Medicine View
Chinese medicine has no bone-density scan and no word for osteoporosis. It reads the picture that tends to come with thinning bone in later life, the aching low back and knees, the loss of height and stoop, the fatigue, as patterns rooted mostly in the Kidney. The classical line is that the Kidney governs the bones and generates marrow, so the strength of the skeleton is tied to Kidney essence, which declines with age.
Held as a description of how a person presents and ages, that lines up with the Western picture. As a measurement of bone density it does not, and neither one validates the other.
The tradition does not always use warming Kidney tonics. A person running hot and dry, with night sweats and a red tongue, fits a Kidney Yin picture that calls for nourishing. Where digestion is weak the Spleen is supported first, because in this system the Spleen governs the muscles and the transformation of food into what builds bone. Herbs belong with a qualified practitioner who can match the formula to the pattern, since a tonic that suits one person can be wrong for the next.
The Chinese Medicine View
The patterns most often read behind thinning bone in later life, each with its signature and the direction it points treatment:
Low back and knee weakness and aching, a cold body and cold limbs, tiredness, frequent pale urination, a pale swollen tongue. The direction is to warm and tonify Kidney Yang and strengthen the bones. This is the pattern most often mapped onto age-related bone loss in a person who runs cold.
Aching weak low back and knees with heat signs: night sweats, warm palms and soles, a dry mouth, a red tongue with little coat. The direction is to nourish Kidney Yin and essence; warming is avoided here. It fits the drier, warmer presentation and often the years around and after menopause.
Poor appetite and digestion, loose stools, tiredness after eating, and easy loss of weight or muscle alongside the back and knee weakness. The direction is to strengthen the Spleen so food is transformed and to support the Kidney, since weak digestion is seen as leaving the bones short of what they need.
Cautions
Extra restraintEverything to be aware of is here, in one place. This practice suits most healthy people; a few situations call for real care.
Bisphosphonates prevent far more hip fractures than the rare thigh fractures they cause
Among 196,129 women aged 50+ taking bisphosphonates in the Kaiser Permanente Southern California system, 277 atypical femur fractures occurred, and the risk rose with longer duration of use and fell rapidly after stopping. In a risk-benefit model, over 3 years of use in White women, 149 hip fractures were prevented against 2 atypical fractures caused; the balance was less favorable in Asian women (91 prevented against 8 caused), who had higher atypical-fracture risk. Atypical femur fractures are rare in absolute terms and the net balance favors the drug for the first several years, but risk climbs with use beyond about 5 years, which is why prescribers reassess and sometimes pause treatment.Black et al., atypical femur fracture risk versus fragility fracture prevention with bisphosphonates
Stopping denosumab without a follow-on drug rebounds spine-fracture risk to untreated levels
A post hoc analysis of the FREEDOM trial and its extension examined 1,001 participants who stopped denosumab. The vertebral-fracture rate rose after discontinuation to the level of untreated participants, and among those who had any off-treatment vertebral fracture, the proportion with multiple (more than one) was higher after stopping denosumab (60.7%) than after stopping placebo (38.7%). Prior vertebral fracture raised the odds of multiple rebound fractures nearly fourfold. This is a post hoc analysis rather than a trial designed around discontinuation, but the signal is consistent enough that guidelines now advise transitioning to a bisphosphonate rather than simply stopping.Cummings et al., vertebral fractures after discontinuation of denosumab: a post hoc analysis of the randomized placebo-controlled FREEDOM trial and its extension
Start slow, be smart, read the research, and consult a professional if you have any concerns. This is here to inform your choice, not make it for you.
When to See Someone
A few situations need a professional, and one is an emergency: sudden severe back pain with new leg weakness or loss of bladder or bowel control. These are the signs to get seen about:
- Sudden severe back pain together with new leg weakness or numbness, or any loss of bladder or bowel control, which can mean a spinal fracture pressing on nerves and needs emergency assessment(seek urgent care)
- A bone that breaks from a minor fall or knock, or from standing height, which is a fragility fracture and needs both treatment of the break and a proper bone-health review(seek urgent care)
- A widespread rash, blistering, facial swelling or peeling skin after starting any bone medication, which can be a serious reaction; stop and seek care(seek urgent care)
- New, unexplained back pain in an older adult, a noticeable loss of height, or a new stoop, any of which can be a spine fracture that happened without a dramatic injury
- A new, dull, aching pain in the thigh or groin while on a bisphosphonate or denosumab for several years, which can rarely signal an atypical thigh-bone fracture and is worth flagging promptly
- A tooth or jaw problem, or planned major dental surgery, while on these drugs, since jaw complications are rare but the timing of dental work is worth coordinating
- Being due to stop denosumab, which should never simply lapse; the protection reverses and spine fractures can rebound, so a follow-on drug is arranged first
- Bone loss with a possible driver behind it, such as long-term steroids, early menopause, an overactive thyroid, celiac disease or very low body weight, all of which change the plan and are worth investigating
None of this is meant to alarm you. Osteoporosis is one of the more workable conditions of aging: the loading and balance work that lower fracture risk are mostly yours to do, the medications cut fractures well when they are needed, and the main things to catch early are a fracture that has already happened and a spine fracture pressing on nerves. You can ask for a DXA scan and a FRAX estimate to see where you stand, and take any decision about medication to the person who prescribes it.
Common Questions
I have a low T-score. How worried should I be?
The T-score estimates risk; it does not measure damage. A score of -2.5 or below is osteoporosis and one between -1.0 and -2.5 is osteopenia, but the number itself is only an estimate of risk. What matters is your ten-year fracture risk, which a FRAX estimate reads from your age, weight and history alongside the scan, and how much of the loading, balance and nutrition work you put in place. Ask for the FRAX number and use it to decide, with a clinician, whether medication is worth it yet.
What is the single most effective thing I can do?
Train the skeleton hard and train your balance. Heavy resistance and impact work build bone that gentle walking cannot, and balance training cuts falls by about a quarter, which prevents the fractures that falls cause. Both are free, and together they are the foundation everything else layers onto. Get enough protein and correct any vitamin D shortfall alongside them.
Do I need calcium and vitamin D pills?
Get calcium from food first and correct a measured vitamin D shortfall with an ordinary daily or weekly amount. The pair cut fractures in older adults who were short of them, but vitamin D alone in people who are not deficient did not reduce fractures, one very large annual dose of vitamin D raised falls and fractures, and calcium supplements without vitamin D were tied to more heart attacks. So the aim is to fill a measured gap, not to pile pills on top of a normal diet.
Are the bone drugs safe, and when are they worth it?
They are worth it when your fracture risk is high or a bone has already broken, and they cut fractures well, some by half or more. Bisphosphonates come first for most people because they are cheap and well proven; denosumab and the bone-building drugs are used when risk is higher, each with specific cautions. The rare thigh-bone and jaw complications are far outweighed by the hip fractures prevented over a few years. The one hard rule is that denosumab is never simply stopped, because spine fractures rebound; a follow-on drug is arranged first.
Is it safe to lift heavy weights if my bones are thin?
Yes, when it is progressive and supervised. In the LIFTMOR trial, postmenopausal women with low bone mass trained with heavy deadlifts, squats and presses and gained spine density with only one minor injury across the study. Avoiding all exercise for fear of breaking something costs you the one thing that builds bone. Learn the lifts with a coach, start where you are, and add load over time.
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All 21 sources on this page independently checked and cross-referenced.
Thomas Dehli, Founder & Editor, Sacred Lotus
Sacred Lotus has published Chinese medicine reference material since 2001. Integrative pages are held to the same standard as the herb and formula library: cite the source, grade the claim at its real strength, and say where the research has not looked. This page is educational and it is not medical advice. Last reviewed and updated August 9, 2026.
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