The most effective approach to osteoporosis combines weight-bearing exercise, adequate calcium and vitamin D, lifestyle changes, and, for many people, medication. No single intervention works as well alone as these strategies do together. What matters most depends on where you are: someone with a bone density T-score of -2.5 or lower (the threshold for an osteoporosis diagnosis) needs a different plan than someone with mild bone loss caught early.
Exercise That Actually Builds Bone
Not all exercise helps your bones equally. Swimming, cycling, and even regular walking provide little stimulus to prevent bone loss, despite being excellent for cardiovascular health. Your bones respond to mechanical loading, meaning they need impact or heavy resistance to grow stronger.
Resistance training is the single most effective exercise for maintaining or increasing bone density. Exercises like squats, deadlifts, weighted lunges, and back extensions target the large muscle groups that attach to your hip and spine, the two areas most vulnerable to osteoporotic fractures. The greatest benefits come from progressively increasing the weight over time, working at high intensity (around 80% to 85% of the maximum you can lift once), and training at least twice a week.
High-impact weight-bearing activities provide a second layer of benefit. Jogging, jumping, dancing, and hopping all load your skeleton above what gravity alone provides. Combining resistance training with these impact exercises gives your bones both muscular loading and mechanical loading, a pairing that research consistently supports over either type alone. Balance exercises like tai chi and single-leg standing don’t build much bone on their own, but they reduce the falls that cause fractures in the first place.
Calcium, Vitamin D, and Protein
Adults over 50 need 1,000 to 1,200 milligrams of calcium daily. Food sources are preferable to supplements when possible: dairy products, fortified plant milks, canned sardines or salmon with bones, leafy greens like kale and bok choy, and fortified cereals can all contribute. If you supplement, splitting your dose (taking 500 to 600 mg at a time rather than the full amount at once) improves absorption. The recommended vitamin D intake for most adults is 600 international units per day, though many clinicians suggest higher amounts for people with diagnosed deficiency.
Protein matters more than many people realize. Bone is roughly half protein by volume, and your body needs a steady supply to maintain it. For adults over 65, a daily intake of 1.0 gram of protein per kilogram of body weight is the baseline recommendation. Some evidence suggests that 1.2 to 1.5 grams per kilogram may help slow the combined loss of bone and muscle that accelerates with aging. For a 150-pound person, that translates to roughly 82 to 102 grams of protein per day.
How Medications Work
Osteoporosis medications fall into two broad categories: those that slow bone breakdown and those that stimulate new bone growth.
Bisphosphonates are the most commonly prescribed class. They work by slowing the natural process of bone resorption, the cycle in which old bone is broken down. This allows your body to gradually rebuild density. They reduce the risk of spine fractures, and most also lower hip fracture risk. Some are taken as a weekly or monthly pill, while one form is given as an annual infusion.
Denosumab works through a different mechanism but achieves a similar result: slowing bone breakdown. It’s given as an injection every six months and is often used when bisphosphonates aren’t tolerated or aren’t effective enough.
Bone-building medications take the opposite approach. Instead of just preventing loss, they stimulate your body to form new bone. Teriparatide and abaloparatide are self-administered daily injections, limited to a two-year treatment window. Romosozumab, given as a pair of monthly injections, is the newest option and does something unique: it simultaneously stimulates bone formation and reduces bone breakdown. In clinical trials, romosozumab at the standard dose increased spine bone density by 11.3% and hip density by 4.1%, significantly outperforming both bisphosphonates and older bone-building drugs.
Medication Risks in Perspective
Two rare side effects of long-term bisphosphonate use get a lot of attention: atypical femur fractures and osteonecrosis of the jaw (where a section of jawbone loses its blood supply). Both are real but uncommon. A national review in Sweden found 172 atypical femur fractures over three years in a population that experienced 43,000 hip fractures during the same period. Osteonecrosis of the jaw severe enough to need surgery occurs in roughly 2.5 per 10,000 patient-years of oral bisphosphonate treatment.
The risk of atypical fractures increases with longer use, which is why treatment is often limited to three to five years for people at moderate risk, then reassessed. For those who remain at high fracture risk, continuing treatment for ten years or more may still be the better trade-off. The fractures these drugs prevent far outnumber the rare complications they cause.
What Alcohol and Smoking Do to Bone
Heavy alcohol consumption damages bone through multiple pathways. It directly suppresses the cells responsible for building new bone (osteoblasts) while leaving the cells that break bone down largely unaffected. In animal studies, this imbalance reduced new bone wall thickness by 52% compared to controls. Alcohol also disrupts calcium metabolism by lowering activated vitamin D levels, which means less calcium gets absorbed from food. On top of that, it alters hormone levels: in men, it lowers testosterone; in women, it shifts hormone balance in ways that can accelerate bone loss.
Smoking accelerates bone loss through similar hormonal disruptions and reduced blood supply to bone tissue. Quitting smoking and moderating alcohol intake are two of the most impactful lifestyle changes you can make for bone health, particularly because their effects compound over years.
Medications That Can Cause Bone Loss
Glucocorticoids (commonly prescribed for asthma, autoimmune conditions, and inflammatory diseases) are the best-known culprits, but they’re far from the only ones. Proton pump inhibitors used for acid reflux, certain antidepressants, anti-seizure medications, some diabetes drugs, hormone-blocking cancer treatments, and long-term blood thinners all have documented effects on bone density. If you take any of these regularly, bone density monitoring becomes more important, and your provider may recommend protective measures earlier than they otherwise would.
Understanding Your Bone Density Score
A bone density scan produces a T-score that compares your bones to those of a healthy 30-year-old. A score of -1 or higher is considered healthy. Between -1 and -2.5 indicates osteopenia, a milder form of bone loss that signals it’s time to act. A score of -2.5 or lower meets the diagnostic threshold for osteoporosis. Each 1-point drop in T-score increases fracture risk by 1.5 to 2 times, so the difference between -1 and -3 is substantial.
Where you fall on this scale shapes the conversation about treatment. Someone with mild osteopenia may do well with exercise, nutrition, and lifestyle changes alone. Someone with a T-score below -2.5, or anyone who has already had a fragility fracture, typically benefits from adding medication. The goal isn’t just a better number on a scan. It’s fewer broken bones over the next decade.