Startling projections reveal that by 2050, the global incidence of hip fractures in men will soar by 310%, and by 240% in women. Even more concerning, by 2040, the number of people at high risk for fractures will double. Currently one in three women and one in five men, are at risk of fracture.^1,2

The most common fractures associated with osteoporosis affect the hip, spine, or wrist. These fractures lead to significant health issues, including increased morbidity, mortality, diminished quality of life, higher rates of institutionalisation, and substantial economic burden.³

The World Health Organization (WHO) defines osteoporosis as having a bone mineral density (BMD) that is 2.5 standard deviations or more below the average for young, healthy women (a T-score of <−2.5).³

Apart from ageing (>65-years), other risk factors for the development of osteoporosis include oestrogen deficiency, extended periods of immobilisation, inflammation, bone and hormone metabolism disorders, and stress associated with transcriptional changes in osteogenic genes. These factors can disrupt the delicate balance between bone formation, driven by osteoblasts, and bone resorption, controlled by osteoclasts.⁴

Maintaining strong bone health throughout the lifespan is key to preventing osteoporosis, however, even after a diagnosis, a bone-friendly lifestyle can reduce the risk of fracture. Research shows that moderate exercise, nutrition, smoking cessation and limiting alcohol consumption can boost bone health.^1,4

Exercise interventions

As people age, physical activity decreases and they tend to adopt more sedentary lifestyles, leading to so-called skeletal unloading, decreasing bone formation and bone mass.^4,5

Exercising regularly plays a crucial role in maintaining and improving bone health by stimulating bone formation and strength through mechanical loading, according to Zhang et al.⁴

Weight-bearing and resistance exercises, such as whole-body vibration training, have been shown to maintain or even improve bone mass and BMD in post-menopausal women, enhancing overall QoL.⁴

Aerobic exercise, too, supports bone health by promoting osteocyte survival and muscle-bone interactions, which are regulated by mechanical load. Additionally, endurance exercise can help slow age-related mitochondrial decline.⁴

Beyond bone health, exercises like Tai Chi and yoga improve balance and postural stability, reducing the risk of falls and fractures. Studies show that Tai Chi can lower fall-related injury risks by up to 50% in older adults.⁴

In their study, Pinheiro et al observed a dose-response relationship in exercise programmes that typically last 60 minutes, two to three times per week, and bone health.³

Lifestyle interventions

Apart from regular exercise, other key lifestyle factors that impact bone health include nutrition, smoking, and alcohol consumption. Calcium and vitamin D are essential for bone metabolism. Calcium-rich foods such as dairy products, green vegetables, and mineral water are important, while vitamin D is found in fatty fish and eggs.¹

Sun exposure is vital for the body’s production of vitamin D, and the International Osteoporosis Foundation recommends at least 15 minutes of daily outdoor time.¹

Research suggests that tobacco smoking disrupts bone turnover, leading to reduced bone mass and BMD, which increases the risk of osteoporosis. Similarly, alcohol consumption - more than one glass per day for women and two for men - can reduce bone mass and strength due to an imbalance in bone remodelling, and should be avoided.^1,5

When is pharmacological intervention needed?

The American Association of Clinical Endocrinologists/American College of Endocrinology guidelines recommend that pharmacological treatment should be initiated for patients with:⁶

• Osteopenia or low bone mass and a history of fragility fracture at the hip or spine
• A T-score of −2.5 or less in the lumbar spine, femoral neck, total hip, or 33% radius despite the absence of a fracture
• A T-score between −1.0 and −2.5 if the FRAX 10-year probability for a major osteoporotic fracture is greater than 20% or for a hip fracture is >3%.

How effective is pharmacotherapy?

An independent evidence review team performed a systematic review and network meta-analysis of osteoporosis treatments that analysed 34 randomised controlled trials and 36 observational studies. They found that in post-menopausal women with osteoporosis, bisphosphonates and denosumab have been shown to significantly reduce the risk of hip, vertebral, and other clinical fractures.⁷

Teriparatide reduces clinical and radiographic vertebral fractures, while selective estrogen receptor modulators are effective in reducing radiographic vertebral fractures but not clinical fractures.⁷

Sequential therapy, particularly using romosozumab followed by alendronate, has demonstrated greater efficacy in reducing fractures than alendronate alone for women at very high risk of fractures. However, romosozumab carries a cardiovascular (CV) risk, making it unsuitable for those with a history of myocardial infarction or stroke.⁷

There is limited evidence on the impact of longer-term treatments, especially beyond three to four years. Bisphosphonates may offer additional benefits when extended beyond six years, although the risks of adverse effects such as osteonecrosis of the jaw and atypical femoral fractures increase with prolonged use. The optimal duration of treatment for other therapies, such as teriparatide, and denosumab, remains unclear.⁷

New recommendations for men living with osteoporosis

An international multi-disciplinary working group of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis, and Musculoskeletal Diseases recently published their recommendations for treating men living with osteoporosis.⁸

Extensive research supports the use of oral bisphosphonates, such as alendronate and risedronate, to improve BMD in men living with osteoporosis. A meta-analysis demonstrated significant increases in BMD at various sites, including the lumbar spine and femoral neck.⁸

Zoledronate, administered intravenously, also significantly improved BMD and reduced vertebral fractures. Denosumab, administered as subcutaneous injections every six months, showed benefits in BMD accrual over two years in men living with osteoporosis.⁸

Teriparatide has demonstrated significant improvements in BMD. Romosozumab also showed improvements in BMD, though its potential CV risks must be considered.⁸

Testosterone replacement may benefit bone health in hypogonadal men, with increases in lumbar spine BMD observed in trials. However, robust evidence for fracture prevention is limited. While testosterone replacement might be considered for men with symptomatic deficiency, it should be combined with anti-osteoporosis medications for maximum fracture risk reduction.⁸

Conclusion

Preventing bone loss requires a holistic approach, with lifestyle changes playing a crucial role. Regular weight-bearing and resistance exercises enhance bone strength and reduce fracture risk. Aerobic activities like Tai Chi further support bone health by improving balance and reducing fall-related injuries. Nutrition also plays a key role, with calcium- and vitamin D-rich diets essential for bone metabolism. Avoiding smoking and limiting alcohol consumption can also help maintain bone density. For those diagnosed with osteoporosis, pharmacotherapy is recommended, with treatments like bisphosphonates shown to reduce fracture risk. Combining a bone-friendly lifestyle with pharmacotherapy is crucial for optimal bone health.

References

1. Albrecht BM, Stalling I, Foettinger L, Recke C, Bammann K. Adherence to Lifestyle Recommendations for Bone Health in Older Adults with and without Osteoporosis: Cross-Sectional Results of the OUTDOOR ACTIVE Study. Nutrients, 2022.
2. International Osteoporosis Foundation. Fragility fractures. Epidemiology.  [Internet]. Available at: https://www.osteoporosis.foundation/health-professionals/fragility-fractures/epidemiology#:~:text=In%20fact%2C%20it%20is%20estimated,in%20their%20remaining%20lifetimes%20%5B4%5D
3. Pinheiro MB, Oliveira J, Bauman A et al. Evidence on physical activity and osteoporosis prevention for people aged 65+ years: a systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. Int J Behav Nutr Phys Act, 2020.
4. Zhang L, Zheng YL, Wang R, et al. Exercise for osteoporosis: A literature review of pathology and mechanism. Front Immunol, 2022.
5. Yang CY, Cheng-Yen Lai J, Huang WL, et al. Effects of sex, tobacco smoking, and alcohol consumption osteoporosis development: Evidence from Taiwan biobank participants. Tob Induc Dis, 2021.
6. Tu KN, Lie JD, Wan CKV, et al. Osteoporosis: A Review of Treatment Options. PT, 2018.
7. Ayers C, Kansagara D, Lazur B, et al. Effectiveness and Safety of Treatments to Prevent Fractures in People with Low Bone Mass or Primary Osteoporosis: A Living Systematic Review and Network Meta-analysis for the American College of Physicians. Annals of Internal Medicine, 2023.
8. Fuggle NR, Beaudart C, Bruyère O, et al. Evidence-Based Guideline for the management of osteoporosis in men. Nat Rev Rheumatol, 2024.