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How to Keep Your Bones Strong

Article at-a-glance:

  • Fracture a hip with osteoporosis and you have a 20-40% chance of dying in a year.
  • Modifiable risk factors are in your control.
  • Learn how to protect your bones with this six-step action plan.

By Dr. John Neustadt

Given how common osteporosis fractures are, and the suffering and death they create, it’s important to learn a bit about your bones what you can do to keep them strong. If you’re a woman, there’s a 50% chance that you’ll break a bone because of osteoporosis. If you’re a man, you have a 20% lifetime risk for an osteoporosis fracture.

If you break a hip, there’s a 40% chance of dying in six months. The risk of dying isn’t just increased in the months following the fracture. The risk of death is increased for the next five to ten years.mTherefore, keeping your bones strong to protect yourself if crucial. Fractures resulting from osteoporosis are surprisingly common.

If you’re one of the lucky ones who survives a fracture, breaking a bone inevitably reduces physical function. We always hope the disability will be temporary, but there’s a 50% chance you won’t regain the same level of independence you had before the fracture, and 20% of people who survive require long-term care.

The Bone Density Myth

Bone mineral density is a measurement of the amount of minerals in the bone. A person’s bone density is determined by a bone density test, which is a special type of radiology technique called a dual-energy x-ray absorptiometry (DXA) scan. Results are reported as a T-score, which is a number that indicates how different a person’s bone density is compared to healthy women in their 20s.

While measurements of bone mineral density are the way osteoporosis and pre-osteoporosis (osteopenia) are diagnosed and monitored, the question remains: How well does this test predict fractures? While bone density tests are important, most healthcare providers are either unaware or simply don’t tell their patients that a bone density test predicts only 44% of women who will break a bone and 21% of men.

Based on this data–and other studies–the World Health Organization (WHO) and the North American Menopause Society (NAMS) correctly concluded that fracture risk depends on factors largely other than bone mineral density. To protect your bones, you need to  look beyond bone density to other indicators of fracture risk and what you can do about them.

Fracture Risks You Control

The World Health Organization (WHO) and other medical groups, such as the American College of Obstetricians and Gynecologists (ACOG) established risk factors for osteoporosis fractures that have remained relatively consistent over the years. Many risk factors are out of our control and are called “non modifiable” risks. For example, being female increases your risk, as does simply getting older. If you’ve had an osteoporotic fracture in the past, you’re at increased risk for a future fracture. If one of your parents had an osteoporotic fracture, if you entered menopause before the age of 45 or if you are underweight also increase your risk.

Other risk factors, however, are called “modifiable” risks because you can do something about them. For example, cigarette smoking, excessive alcohol consumption, low amounts of calcium, vitamin D and vitamin K, and never exercising increase risk for osteoporosis and fracture.

6-Steps to Reduce Your Risks

The 6-step plan described here is based on research showing that taking these actions protect your bones and reduce your fracture risk.

Step 1: Hazard-proof your home

The number one risk for fracture is falling. Simple changes that reduce your risk of tripping over something in your home, or slipping and falling are important to make. You can wear slippers or shoes that have non-slip soles; tuck electric cords away; secure loose rugs to the floor; place non-slip mats in the shower (or install a seat in the shower); and keep the home well-lit, including a lamp you can reach before you get out of bed.

Step 2: Stop smoking

Smoking cigarettes is strongly associated with osteoporotic fractures. Smoking alters the blood supply to bone and also exposes the body to cadmium and other heavy metals that are toxic to bone.

A 2015 study looked at the effects of smoking as well as smoking cessation on fracture risk. Researchers followed 1033 women for 10 years, beginning at the age of 75 years old. They found that both former smokers and current smokers had a 31% increased risk for osteoporotic fractures overall, but women who quit smoking had a significantly lower risk of vertebral fractures than women who continued to smoke.

Step 3: Eat for bone health

Food provides the building blocks for excellent health.  A whole-foods diet is naturally rich in the vitamins, minerals, protein and phytonutrients has been shown to grow stronger bones and reduce fractures. The most studied dietary pattern is the Mediterranean Diet. Over the past fifty years this way of eating has been shown to reduce the risk of cardiovascular disease, diabetes, osteoporosis, cancer, death from cancer and death from other causes.

A 2017 review article found that following a Mediterranean Diet was associated with an increased bone density and a 21% decreased risk of hip fracture. Their analysis further showed that the more someone adheres to the diet the greater the benefit.

The Mediterranean Diet is essentially the opposite of the Standard American Diet. It’s low in processed foods, fried foods and red meat. Instead, it emphasizes fruits, vegetables, grains, legumes, nuts  and healthy oils such as olive oil. Following a Mediterranean Diet means eating lean proteins such as chicken and fish a few times a week, and eating red meat only a couple times a month. Transitioning to a Mediterranean Diet will give your body a good foundation to maintain strong, healthy bones.

Step 4: Exercise

To evaluate the effect of exercise on fracture risk, researchers followed 9704 women, aged 65 and older, for an average of 7.6 years. They found that women who participated in more leisure time, more sport activity, more household chores, and fewer hours of sitting per day had a significantly reduced risk for hip fractures. When compared to no activity, vigorous or moderate physical activity reduced the risk of hip fracture by 42% and spinal fracture by 33%.

Most experts recommend a combination of balance and strength training to reduce the risk of falls and fragility fractures. An expert panel of clinicians published exercise recommendations in 2014 for people with osteoporosis, concluding that aerobic exercise should not be done without also including balance and strength training. Not all exercise is appropriate for everyone. Prior to starting an exercise routine, you should check with your healthcare provider to discuss appropriate and safe levels of exercise you.

Step 5: Moderate Alcohol

If you drink alcohol, it’s important to understand the link between the amount and type of alcohol you’re drinking and your risk for osteoporosis fractures. Research shows that drinking too much alcohol increases your risk of fracture while drinking alcohol in moderation can reduce people’s risk.

Researchers analyzed 33 studies that looked at the link between drinking and fractures. They concluded that people who consume 2 or more drinks per day have a 39% increased risk of hip fracture.

Drinking less alcohol protected bones. Compared to people who didn’t drink alcohol at all, those who drank an average of half to one alcoholic beverage per day had a 20% reduced risk of hip fracture compared to non-drinkers.

And a second study confirms the results. When more than 100,000 postmenopausal women were evaluated for their drinking habits and fracture risk, researchers discovered that women who drank an average of 3.3 glasses of wine per week (approximately 0.5 glasses per day) had a 22% lower risk of hip fracture than women who did not drink alcohol at all. This study is interesting in that it concluded that the reduced fracture risk was seen in women who drank wine and not hard alcohol.

If you drink alcohol, limit your intake to 3-3.5 drinks per week.

Step 6: Take Bone Building Dietary Supplements

There are many nutrients in bone health dietary supplements; however, only a few nutrients have been shown in clinical trials to maintain strong bones and reduce fractures. These are calcium, vitamin D, vitamin K2 (as MK4) and strontium. While you may not decide to take them all, these are the ones supported by clinical trials.

Calcium and Vitamin D

Calcium and vitamin D have long been heralded as the most important nutrients for bone health, and the Food and Drug Administration (FDA) has approved calcium and vitamin D for the prevention of osteoporosis.

Calcium. An extensive systematic review was published in 2015 that looked at 52 studies comparing calcium intake to fracture risk. Researchers found that most studies reported no relationship between calcium intake from foods and fracture risk. Of the 26 randomized controlled trials of calcium supplementation, there was evidence that calcium supplementation reduced the risk of total fractures by 11%. When specific fracture locations were examined, calcium supplementation reduced the risk of spinal fractures by 14% but did not reduce the risk of wrist or hip fractures.

Vitamin D. Because calcium and vitamin D work synergistically to support bone health, most clinical trials evaluate the combination of these 2 nutrients. A randomized controlled trial of 2532 adults over the age of 65 found that supplementation with 1000 mg of calcium and 400 IU of vitamin D for 3 months reduced fracture risk by 16% when compared with placebo. A 2015 meta-analysis of 8 randomized controlled trials (involving 30,970 participants) concluded that calcium plus vitamin D supplementation produced a 15% reduction in total fracture risk and a 30% reduction in hip fracture risk. In line with these studies, a 2014 review of 53 studies concluded that supplementation with calcium and vitamin D produces a statistically significant reduction in the risk for hip fractures, spinal fractures, and overall fractures.

Overall, studies show that calcium and vitamin D supplementation reduces the risk of osteoporotic fractures by approximately 15-16%.

Vitamin K2 (as MK4)

Vitamin K is an essential nutrient with many important functions. For bone health, vitamin K is required for deposition of calcium in bones and for the formation of bone collagen. Vitamin K2 is available as a supplement in two forms: MK7 and MK4. It is important to distinguish between these 2 forms because only MK4 has been shown to reduce the risk of fractures in clinical trials of people with osteoporosis.

More than 28 human clinical trials have been conducted in over 7,000 participants using 45 mg/day or more of MK4. While most of those studies looked at changes in bone density or laboratory markers for osteoporosis risk, many studies also evaluated the most important outcome—fractures. An analysis of seven clinical trials on the effect of MK4 on fracture risk  reported that supplementing with 45 mg/day of MK4 reduced fractures by more than 70%. MK4 (45 mg/day) is the only amount of MK4 shown to maintain strong bones and reduce fractures.


Strontium is another mineral that can be deposited in bone and contribute to bone mineral density. A certain form of strontium, called strontium ranelate (SR), has been extensively researched and is approved as a treatment for osteoporosis in most of Europe.

In the strontium ranelate for the treatment of osteoporosis (STRATOS) trial, researchers  evaluated the ability of different amounts of SR to reduce fractures in 353 post-menopausal women with osteoporosis. The most interesting results were in volunteers who took either SR 500 mg /day or 2.0 grams/day. Studies like this are called dose-response studies and are interesting because they provide data that help us learn the best amount to take.

After two years of taking SR, the people taking less SR (500 mg/day) had fewer fractures than those taking 2.0 grams/day, 29% reduced fracture risk versus only a 23% reduction, respectively. Interestingly, while bone density increased in both groups, those taking 2.0 grams/day had their bone density increase the most, and yet they suffered more fractures. A second study gave SR 2.0 grams/day to 1,649 postmenopausal women for 3 years. Unlike the first study, these women experienced 41% fewer fractures.

A few cautionary notes about strontium. Strontium has an atomic mass greater than calcium. As such it attenuates the X-rays from a DEXA scan to a greater extent than calcium. Unless the radiologist corrects for this, the DEXA scan will not provide an accurate measure of BMD. Strontium may also interfere with calcium absorption. Thus, if you take strontium make sure to take it away from calcium. Finally, the form of strontium used in clinical trials (strontium ranelate) is not available in the United States. The form available in dietary supplements in the US is strontium citrate.

Final Thoughts

You may already be following many of the recommendations listed here. While not all risk factors for osteoporosis fractures are within your control, I hope this action plan inspires you to take practical steps to reduce those risks you can control. Whether you have osteoporosis, osteopenia or your bone mineral density is in a healthy range, you have the power to reduce your fracture risks.

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