Introduction
Advice around bone health has never been more widely available, yet it can often feel confusing. Some sources suggest that bone loss can be reversed through exercise alone, such as wearing weighted vests or increasing physical load. Others promote specific diets, supplements, or training methods as alternatives to medication.
For individuals with generally good health who are aiming to maintain bone density, lifestyle approaches can be highly beneficial. However, for those identified as having a high risk of fracture and who have been advised to take medication, choosing to delay or avoid treatment in favour of lifestyle changes alone may carry important clinical risks.
This article outlines what current evidence supports and explains why understanding your bone density through DEXA scanning is a crucial first step in making informed decisions
What Exercise Can and Cannot Achieve
There is strong evidence supporting exercise as part of a bone health strategy, but it is important to understand its role.
Three main types of exercise have been shown to reduce fracture risk:
- Balance training, which helps prevent falls and has the strongest evidence for reducing fractures
- Resistance training, which improves muscle strength and stimulates bone through muscular force
- Impact training, which applies force through the skeleton and can lead to small improvements in bone density at weight-bearing areas
While these forms of exercise are beneficial, the improvements in bone mineral density are generally modest. Even with a well-designed, high-intensity programme, individuals with osteoporosis may only see increases of around 1–3% in specific areas.
It is important to recognise that exercise reduces fracture risk mainly by improving strength, coordination, and balance, rather than significantly rebuilding bone. This benefit is still highly valuable but works differently from medication.
When Medication Is Recommended
Medications used to treat osteoporosis, including bisphosphonates (such as alendronate and zoledronic acid), as well as treatments like denosumab and romosozumab, have strong clinical evidence for reducing fracture risk in people with established osteoporosis or a high risk of fractures.
These treatments work by either slowing down bone breakdown or encouraging new bone formation. This can lead to meaningful improvements in bone density and, importantly, a reduction in fracture rates.
The decision to begin medication is based on overall fracture risk rather than bone density alone. Factors typically considered include:
- A T-score below -2.5
- A previous fragility fracture
- A high estimated fracture risk over the next 10 years (for example, using tools such as FRAX)
- Additional clinical risk factors that increase fracture likelihood
For individuals in this higher-risk group, relying on lifestyle measures alone instead of taking recommended medication may significantly reduce the opportunity to lower fracture risk.
The Challenge with Online Advice
Many lifestyle strategies promoted online, such as strength training or using weighted vests, can be helpful. However, problems arise when individuals with a high fracture risk use these approaches as a reason to avoid medication that has been specifically recommended by their doctor.
Research studies often focus on younger, healthier individuals without established osteoporosis. These findings cannot always be applied to someone with more advanced bone loss or multiple risk factors. Applying results from one group to another in this way can be misleading and clinically inappropriate.
A More Effective Approach: Combining Exercise and Medication
For individuals at higher risk, the most effective strategy is not choosing between exercise and medication, but using both together.
- Medication helps reduce bone loss and lowers the risk of serious fractures, particularly in the spine and hips
- Exercise improves muscle strength, balance, coordination, and overall physical function, while also reducing the likelihood of falls
When combined, these approaches provide greater overall benefit than either strategy alone.
The Role of Supplements
Calcium and vitamin D are essential for maintaining healthy bones. If levels are low, bone quality can be affected regardless of exercise or medication.
However, taking supplements in the absence of a deficiency has not been shown to significantly reduce fracture risk on its own. Ensuring adequate calcium intake (typically 1,000–1,300 mg per day for adults over 50) and maintaining sufficient vitamin D levels through sunlight exposure or supplementation is important, but these measures alone are not enough to address bone loss.
There is also emerging interest in supplements such as creatine. Current evidence suggests any potential benefit for bone health is relatively small and likely dependent on participation in a structured, high-intensity exercise programme. As such, it should be considered an additional option rather than a primary strategy.
How a DEXA Scan Supports Decision-Making
A DEXA scan provides an accurate and objective measure of bone mineral density, forming the foundation for all treatment decisions.
Without this information, it is difficult to determine:
- Whether your current exercise programme is effective
- Whether medication may be necessary
- Whether your nutrition and supplementation are appropriate
- Your actual level of fracture risk
Repeating DEXA scans at appropriate intervals allows both you and your clinician to monitor whether your bone density is improving, stable, or declining over time.
If you have not had a scan within the past two years, or if there have been changes to your treatment or exercise routine, a reassessment may be recommended.
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