What is peak bone mass?
Nearly 20% of women over 50 live with osteoporosis.
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The worldwide prevalence of osteoporosis in women over 50 is 21.2%
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The US age-adjusted prevalence of osteoporosis in women over 50 is 19.6%
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Fragility-fracture risk — the lifetime risk of having a fracture — is 1 in 3 worldwide and 1 in 2 in the US.
Hip fractures per 10,000 women, per year
For every 10,000 women tracked over a year, this is roughly how many had a hip fracture, by race/ethnicity.
White women had the highest reported rate; Black women the lowest, at roughly a quarter of the rate of White women.
Assess your risk factors for lower peak bone mass
Women who have factors that prevent them from reaching their peak bone mass should be evaluated with a DXA scan when their periods become noticeably irregular. This is particularly true for thin women and those who have a family history of osteoporosis.
Genetics accounts for roughly 60% to 75% of variance of peak bone mass
Family History: Ask about your family history if possible. Did your mother or grandmother have osteoporosis? Did they have early or frequent fractures? A parent history of hip fracture carries a twofold increased fracture risk for children.
Ethnicity: Caucasian and Asian women tend to have lower peak bone mass. African American and Afro-Caribbean women tend to have higher peak bone mass.
Hormonal health & estrogren
If you have an overactive thyroid gland or high levels of cortisol (a stress hormone) it can interfere with bone formation.
Nutritional intake
Being underweight (BMI <21)
Some medications can affect peak bone mass
Lack of physical activity growing up
Smoking and alcohol
Alcohol: Excessive consumption interferes with the balance of calcium and the hormones that regulate it. High alcohol intake (>2 units/day),
What is osteoporosis?
While we think of bone as solid, it is actually living tissue that is constantly being torn down, rebuilt and renewed. Over time, bones can become less dense and develop small spaces inside them, making them more fragile.
Osteoporosis increases the risk of fractures (broken bones), most often in the hip, spine, and wrist. These breaks can happen from a simple fall or sometimes from everyday movements like bending or lifting when bone is less dense, more fragile.
Understanding the real stakes of bone loss is the first step toward taking action.
How do you know if you have osteoporosis?
- Having a low “t-score” from a bone density scan, referred to as a DXA scan, pronounced “dexa”, stands for (dual-energy X-ray absorptiometry)
- Having a fragility fracture which means you break a bone from falling from standing height or lower after age 50 in your spine, hip, wrist, shoulder, rib, pelvis (regardless of a T-score from a DXA). That is, you can have a t-score that doesn’t qualify as osteoporosis but if you have this kind of fracture, you have an osteoporosis diagnosis.
What is a DXA (dual-energy X-ray absorptiometry) scan?
A DXA scan is an x-ray. It scans the hip and lower spine to get measurements to assess bone strength and bone loss.
- The procedure requires no preparation.
- There is nothing that touches your body. You lay on a scanning bed, and an arm passes over you.
- It takes 10 to 30 minutes, including positioning for each measurement.
- Here is a video (skip to 1:50) to see the scan itself.
What does a DXA measure?
A DXA scan measures the bone density at 3 locations:
- your lower back (lumbar spine, L1-L4 vertebrae)
- a place on your hip (a part of the hip joint called the femoral neck)
- your wrist.
Of these three sites, the spine often shows bone loss first because the spine contains more spongy bone tissue (trabecular), which is more reactive to changes in hormone levels. The lowest measurement or “t-score” of the three sites is used for diagnosis.
Understanding DXA Scoring (The T-score)
Your T-score compares your bone density to that of a healthy 30-year-old woman (peak bone mass). This is the standard diagnostic criterion.
| T-score | Diagnosis | Interpretation | Treatment |
| +1 to -1.0 | Normal | Healthy 30-year-old (peak) bone density = 0 | None, prevention in perimenopause |
| -1.0 to -2.5 | Osteopenia (Low Bone Mass) | Bones are weaker but
not osteoporotic |
lifestyle intervention |
| – 2.5 or below | Osteoporosis | Increased fracture risk | medication + lifestyle intervention |
| – 2.5 or below
+ a previous fragility fracture |
Severe Osteoporosis | Significantly increased fracture risk | high priority for
treatment |
Preventing bone loss isn’t the same as treating osteoporosis.
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Bone mineral density (BMD) = Bone mineral density or bone mass, usually measured by a DXA scan.
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Bone strength = BMD (quantity) and microarchitecture.
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Bone loss = changes to BMD (quantity) and microarchitecture.
Both moderate to high intensity resistance training and impact exercise stimulate bone formation by straining your muscles.
- Squats (hips, thighs, lower back)
- Deadlifts (spine, hips)
- Overhead press (arms, shoulders, upper spine)
- Lunges (hips, femur)
- Back extensions (for spine)
Impact exercise ground reaction forces trigger bone building
Examples
- Jumping
- Jumping jacks
- Hopping
- Running
- Jump rope
- Heel drops
Recommendations
- Frequency: 3+ days per week
- Volume: 50+ impacts per session minimum, divided into sets of 10-15 reps with rest in between
- Start slow if you haven’t been active (6-12 weeks) then gradually increase
- Integrate these into your day “exercise snacks”
Combine resistance + impact for the greatest impact
Medications that stimulate new bone formation
Generic name (Brand) — Route of administration
- Teriparatide (Forteo®) — Daily injection for up to 2 years
- Abaloparatide (Tymlos®) — Daily injection for up to 2 years
- Romosozumab (Evenity®) — Monthly injections for 1 year
Calcium, Vitamin D, and Protein can help reduce loss and support bone maintenance.
- More than the RDA is not better.
- Assess your current calcium with this calcium calculator.
- If you are lactose intolerant, consider supplementation
Calcium reduces loss and maintains bone (doesn’t build new bone). Vitamin D is needed to be effective.
- Ages 19-50 (women): 1,000 mg
- Ages 51+ (women): 1,200 mg
- Postmenopausal women with osteoporosis: 1,000-1,200 mg
Best Sources – food first
- Dairy: milk, yogurt, cheese (highest amounts)
- Leafy greens: collards, turnip greens, kale, bok choy
- Fortified foods: orange juice, cereals, soy milk, almond milk
- Canned fish with bones: sardines, salmon
- Tofu
- Almonds
Supplements
- Use if cannot get enough from diet
- Calcium carbonate (take with food)
- Calcium citrate (can take anytime)
- Many multivitamins contain some calcium – check labels
Evidence
- Calcium + vitamin D together modestly improves BMD (especially pelvis)
- Combined supplementation reduces total fractures by 15%, hip fractures by 30%
- Most effective when combined with vitamin D
Vitamin D reduces loss by ensuring calcium absorption
- Adults 19-70: 600 IU (15 mcg)
- Adults 71+: 800 IU (20 mcg)
- People with osteoporosis: 800-2,000 IU
Optimal Blood Level (25-OH vitamin D):
The Endocrine Society guideline in 2011 gave a target level of 30 IU/ml for testing but their 2024 guideline moves away from test and target levels to recommended dosage.
“Healthy adults under 75 are unlikely to benefit from vitamin D above the current recommendation (600–800 IU/day) — no target, no testing needed.”
Sources
- Sunlight (15-30 minutes several times weekly, but varies by latitude, season, skin tone)
- Food
- Fatty fish (salmon, mackerel, sardines)
- Fish liver oils
- Fortified milk, cereals, orange juice
- Egg yolks
- Supplements
- Vitamin D2 (ergocalciferol) or D3 (cholecalciferol) – both effective
- Can take with or without food
- Don’t need to take at same time as calcium
Protein reduces loss and supports bone maintenance
- General adults: 0.8 g/kg body weight
- Postmenopausal women with osteoporosis: 1.0-1.2 g/kg
- Elderly with osteoporosis: Up to 1.2 g/kg
Why it matters:
- Affects bone mineral density, bone microstructure, and bone strength
- Insufficient protein accelerates bone loss
- Adequate protein helps reduce bone loss and fracture risk (especially hip)
- Critical for muscle strength (which supports bones and prevents falls)
Important points about protein, calcium and vitamin D from research
- Higher dietary protein associated with LOWER fracture risk when calcium intake is adequate
- Very low calcium intakes may negate or even invert protein’s benefit, so for a woman increasing protein (e.g., for sarcopenia or weight management), ensuring adequate calcium and vitamin D is an important part of fracture‑risk reduction strategy.
Best sources:
- Dairy products (also provide calcium)
- Lean meats, poultry, fish
- Eggs
- Legumes, beans
- Nuts, seeds
- Soy products
Lifestyle adjustments like weight-bearing aerobic exercise and balance training prevent bone loss and fractures.
- Weight-bearing aerobic exercise (walking, dancing, tennis, jogging/running) prevents loss.
- Balance training – prevents fractures by preventing falls (this is not a bone-specific measure)
- Not smoking – prevents accelerated loss
- Limiting alcohol – prevents accelerated loss
- Note: Walking alone has modest benefits; needs to be brisk and combined with other exercises
- NOT effective: Swimming, cycling (non-weight-bearing)
Antiresorptive medications slow the breakdown of bone.
Learn more about different types of antiresorptive medications
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- Alendronate (Fosamax®)
- Residronate (Actonel®)
- Denosumab (Prolia®)
- Estrogen and selective estrogen receptor modulators (raloxifene, Evista®)
The risks associated with side effects from bisphosphonates are much smaller than perceived. They are scary but not common.
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- These side effects generally occur with long-term use greater than 5 yrs
- Over 135 fractures are prevented for every 1 atypical femur fracture.
Many women do not get the recommended evaluations and care for their bone health.
If you’ve had a hip or spine fracture, you should be treated regardless of your T-score on a DXA scan, as the risk of suffering another fracture is very high.
Pharmacologic treatments for osteoporosis reduce the risk of fractures by 50 to 80%.
