>[!summary] >- **High Calcium Diet**: If you are already consuming adequate calcium through your diet (1000-1200 mg daily), calcium supplements are not necessary. However, if you are not getting enough calcium through food, taking a supplemental calcium dose of 600 to 1000 mg/day. >- **Vitamin D Supplementation**: Take a daily intake of 2000-4000 international units per day with a blood vitamin D level goal of 40-50 ng/mL. >- **Exercise**: Engage in exercise for at least 30 minutes, most days. Various forms of exercise, including resistance training, jogging, jumping, and walking, have proven effective in preventing bone density loss. The key to progress in improving your density is the consistency of activity. > - [Exercises for Osteoporosis](https://healthybonesaustralia.org.au/news/exercises-for-osteoporosis/). >- **Emerging Therapy**: There are small studies that indicate vitamin K2, magnesium, and collagen peptide supplements may have benefit in improving bone density, though these are not part of the official recommendations. >- **Prescription Medications**: Medications for the treatment of osteopenia and osteoporosis are generally safe and effective but do have rare severe risks of atypical fractures and osteonecrosis of the jaw. # Recommendations for Healthy Bones ## Calcium The recommended amount of calcium per day is: - 1,000 mg per day for men aged 19 to 70 years and women aged 19 to 50 years. - 1,200 mg per day for women over 51 and men over 71. It's best to get calcium from food rather than pills. Food based calcium absorb better into your body and have fewer side effects, like kidney stones or possible heart issues. Only use supplements if you can't get enough from diet, and keep total calcium (food + supplements) under 1,500 mg daily to avoid problems. Foods high in calcium include dairy (milk, yogurt, cheese), leafy greens (kale, broccoli), fortified foods (orange juice, cereals), and nuts (almonds). However, some foods like those rich in phytates (whole grains, beans) or oxalates (spinach, rhubarb) can reduce how much calcium your body absorbs, so balance your diet. ## Vitamin D Vitamin D helps your body absorb calcium and supports bone growth. Aim for a maintenance dose of 2,000 to 4,000 IU per day of vitamin D3 (cholecalciferol) . Your goal: Keep blood levels of vitamin D near 40 to 50 ng/mL. ## Comprehensive Exercise Approach Engage in weightbearing exercise for at least 30 minutes on most days of the week and incorporate muscle-strengthening and posture exercises two to three days a week. Exercises that increase muscular strength and improve balance may confer the most benefit for fracture reduction by decreasing risk of falls. - [Exercises for Osteoporosis](https://healthybonesaustralia.org.au/news/exercises-for-osteoporosis/). ### Walking for Bone Health - Intensity matters: brisk/fast walking (>5–6 km/h) generates greater femoral neck strains and hip contact forces than slow walking, with higher osteogenic potential; very slow walking is generally considered bone-preserving rather than bone-building. - Small trials suggest that performing walking shortly after a meal and in the morning may augment anabolic indices, with longer (≈40–45 min) impulses outperforming shorter bouts. ### Resistance Training - Progressive resistance training ≥2–3 days/week targeting major muscle groups for hip/spine loading. - Balance and functional training ≥2 days/week to reduce falls. - Posture and trunk extensor strengthening to mitigate kyphosis and vertebral load. ### Hopping and Jumping - Provide a stronger boost to bones, especially at the hip (femoral neck). A review of studies showed jumping increases hip BMD by about 1.5%. It's more effective in younger people but helps older adults too. - Safety first: If you're frail, have poor balance, or have osteoporosis, avoid or start slow to avoid injury. - 30-50 jumps per session, 4 times a week. Video demos: - [Countermovement Jump](https://www.youtube.com/watch?v=Gn5gLYzCjBA) - [Star Jump](https://www.youtube.com/watch?v=SXJm1f6b_yg) - [Stride Jump](https://www.youtube.com/watch?v=Kf-c15CEz-Q) - [Lateral Hop](https://www.youtube.com/watch?v=sSb9b8TYQrc) - [Forward Hop](https://www.youtube.com/watch?v=pWqbH2yki2A) ## Emerging Therapies These are newer or supportive treatments. They're not first-line but may help when combined with basics like calcium and exercise. ### Vitamin K2 This vitamin helps direct calcium to bones and may reduce bone breakdown. Studies in postmenopausal women show it improves BMD in the spine and forearm, and may cut fracture risk by over half (after adjusting for study differences). It lowers a marker of bone turnover (undercarboxylated osteocalcin) and works well with vitamin D. Side effects are rare. ### Magnesium Magnesium supports bone formation and is linked to higher BMD at the hip and femoral neck in older adults. Supplements (250 to 1,800 mg/day) may help, but studies are small. It's safe, though high doses can cause stomach upset. ### Collagen Peptides Collagen is a protein in bones. A study in postmenopausal women with mild bone loss found that 5 g daily, plus calcium (500 mg) and vitamin D (400 IU), improved bone structure and density at the spine and tibia over a year, better than calcium and D alone. # Prescription Medications for Bone Density ## Osteopenia Medications ### Zoledronate for Osteopenia Zoledronate (also called zoledronic acid) is a medication given by IV infusion typically used to treat osteoporosis. New research shows benefits in osteopenia with minimal side effects with less frequent dosing of once every 18 months (vs 1 year)[^1]. - In women over 65 with osteopenia (T-score -1.0 to -2.5, a bone density measure), 5 mg every 18 months reduced fractures by about one-third over 6 years. - Benefits lasted 1.5 to 3.5 years after the last dose, but faded later. - In early postmenopausal women (50 to 60 years, T-scores 0 to -2.5), two doses (at start and year 5) cut vertebral fractures by 44% and other fractures over 10 years. - Good safety profile, with no rise in serious side effects in the trial. ## Osteoporosis Medications ### Alendronate for Osteoporosis Alendronate is an oral bisphosphonate medication used to prevent and treat osteoporosis. - Typical dose: 70 mg once weekly, taken on an empty stomach with water, remaining upright for at least 30 minutes to avoid esophageal irritation. - Reduces risk of vertebral fractures by about 50%, hip fractures by 40 to 50%, and other nonvertebral fractures. In women with prior fractures or very low BMD, the number needed to treat (NNT) over 3 years is approximately 20 to prevent one vertebral fracture, 50 for one nonvertebral fracture, and 67 to 100 for one hip fracture. ### Zoledronate for Osteoporosis Zoledronate is an intravenous bisphosphonate medication used to treat osteoporosis. - It is given as a once-yearly IV infusion of 5 mg. - Reduces vertebral fracture risk by about 70%, hip fractures by 40%, and nonvertebral fractures by 25%. In women with osteoporosis, NNT over 3 years is approximately 14 to 20 to prevent one vertebral fracture and at least 91 for one hip fracture. ### Prolia for Osteoporosis Prolia (denosumab) is a monoclonal antibody medication used to treat osteoporosis in postmenopausal women at high risk for fractures. It is given as a subcutaneous injection of 60 mg every 6 months. Works by inhibiting osteoclast activity, reducing bone breakdown, and increasing bone density. - Reduces vertebral fractures by about 68%, hip fractures by 40%, and nonvertebral fractures by 20%. In postmenopausal women with osteoporosis (from FREEDOM trial), over 3 years, NNT is approximately 21 to prevent one vertebral fracture (ARR 4.9%), 67 for one nonvertebral fracture (ARR 1.5%), and 200 for one hip fracture (ARR 0.5%). For clinical vertebral fractures, NNT is 62 (ARR 1.6%), and for multiple vertebral fractures, NNT is 103. ## Risks of prescription therapy ### Osteonecrosis of the Jaw This is a rare condition where jaw bone tissue dies, often linked to dental procedures. - For bisphosphonates: Estimated incidence is 1 in 10,000 to 1 in 100,000 patient-years in osteoporosis treatment. Absolute risk is low, about 0.05% after 5 years and 0.18% after 10 years. - For denosumab: No cases in the 3-year FREEDOM trial. In the 7-year extension, incidence was 5.2 per 10,000 patient-years (13 cases total). - Risk factors: Dental extractions, poor oral hygiene, smoking, diabetes, or cancer treatments. Prevention includes good dental care and possibly pausing therapy before major dental work. ### Atypical Femur Fractures These are unusual breaks in the thigh bone, often starting as stress fractures with groin or thigh pain. - For bisphosphonates: Absolute risk is low (3.2 to 50 cases per 100,000 person-years), but increases with duration of use. Risk is higher in Asian women than White women. - For denosumab: No cases in the 3-year FREEDOM trial (vs. 3 in placebo). In the extension, only 2 cases, with rate under 1 per 10,000 patient-years. - Risk factors: Long-term use (over 3 to 5 years), glucocorticoid therapy, or certain ethnicities. --- ## Medication for Osteoporosis Benefits and Risks Table | Therapy | Fracture Type | NNT (over 3 years) | ONJ NNH (approx., over 3 years) | AFF NNH (approx., over 3 years) | | ------------------ | ---------------------------------- | -------------------- | ------------------------------- | ---------------------------------------- | | Alendronate | Vertebral<br/>Nonvertebral<br/>Hip | 20<br/>50<br/>67-100 | 2,000 | 5,000 (White women); 1,250 (Asian women) | | Zoledronate | Vertebral<br/>Nonvertebral<br/>Hip | 14-20<br/>50<br/>91 | 2,000 | 5,000 (White women); 1,250 (Asian women) | | Prolia (Denosumab) | Vertebral<br/>Nonvertebral<br/>Hip | 21<br/>67<br/>200 | 641 | >3,333 | * NNT: The number of patients needed to treat with the medication to prevent a fracture (lower numbers mean greater benefit in preventing fractures). * NNH: The number of patients needed to treat to cause harm from side effects (higher numbers mean rarer side effects). * ONJ: Osteonecrosis of the Jaw (rare jaw bone issue). * AFF: Atypical Femur Fractures (unusual thigh bone breaks). [^1]: https://www.nejm.org/doi/full/10.1056/NEJMoa1808082