Osteoporosis: The Prevention That Starts in Your Thirties

Osteoporosis is almost always discussed after a fracture has already happened. That is the inconvenient property of the disease: it does not hurt and gives no sign of itself until a bone breaks in a fall from standing height. Yet the window in which prevention is most effective opens decades earlier — in your early twenties, while the body is still building peak bone mass.

How bone works#

Bone is not an inert mineral frame but living tissue in constant remodelling. Osteoclasts break down old sections while osteoblasts build new ones. A full remodelling cycle takes several months, and over ten years the skeleton renews itself almost entirely.

While building outpaces breakdown, bone mass grows. That period ends at roughly 25–30, when peak bone mass is reached. After that the balance first levels out and then tips towards resorption.

Hence the central point of prevention: the size of that peak determines the reserve available for the rest of your life. Estimates suggest a 10% higher peak bone mass delays the onset of osteoporosis by about 13 years. Which is exactly why nutrition and physical activity in adolescence and early adulthood are not a problem for later.

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Who is at risk#

Factor	How much it matters	Modifiable?
Age	Very strongly	No
Female sex and early menopause (before 45)	Strongly	Partly, via HRT where indicated
Prior fracture from minimal trauma	Very strongly	No, but it changes management
Parental hip fracture	Strongly	No
Long-term glucocorticoids	Very strongly	Yes, in discussion with a doctor
Smoking	Moderately	Yes
More than three drinks a day	Moderately to strongly	Yes
Low body weight (BMI under 19)	Strongly	Yes
Inactivity	Moderately	Yes
Calcium and vitamin D shortfall	Moderately	Yes
Rheumatoid arthritis, coeliac disease, hyperthyroidism	Strongly	Through treating the underlying condition

Eating disorders and the athlete triad deserve separate mention — low energy availability, menstrual disturbance and reduced bone density. In young women training in chronic energy deficit, bone loss occurs precisely during the years when bone should be accumulating, and what is missed cannot be fully recovered later.

Diagnosis#

The standard is dual-energy X-ray absorptiometry (DXA) of the lumbar spine and femoral neck. Results are expressed as a T-score — the deviation from mean peak young-adult density in standard deviations.

T-score	Interpretation	What follows
≥ −1.0	Normal	Prevention, repeat as indicated
−1.0 to −2.5	Osteopenia	FRAX risk assessment, lifestyle change
≤ −2.5	Osteoporosis	Discussion of drug therapy
≤ −2.5 plus a fracture	Severe osteoporosis	Treatment required

An important detail: treatment decisions never rest on a single number. FRAX combines age, sex, risk factors and, where available, bone density into a 10-year fracture probability. Someone with osteopenia and multiple risk factors may need therapy more than someone with formal osteoporosis and none.

What works#

Progressive resistance training. Bone responds to mechanical strain — Wolff's law, formulated in the nineteenth century. Meaningful stimulus comes specifically from loaded and impact work rather than from activity in general. A Cochrane review found a small but statistically significant effect of exercise on bone mineral density in postmenopausal women.

Impact loading. Jumping, running, brisk walking, dancing. Even 10–20 jumps a day produce a measurable effect on femoral neck density in young women. Where osteoporosis with vertebral fractures is already established, impact work and deep forward flexion are instead restricted, and the programme should be set by a specialist.

Balance training. The frequently underrated component. A fracture is nearly always the result of a fall rather than spontaneous bone failure. A 2019 Cochrane review found exercise reduces falls in older people by around a quarter. Tai chi, balance work and leg strength training deliver more here than any supplement.

Nutrition. Calcium at 1,000 mg a day for adults and 1,200 mg for women over 50, preferably from food. Adequate protein — contrary to the old "acid load" myth, higher protein intake is associated with better bone density. Vitamin D at 800–1,000 IU where sun exposure is insufficient.

Not smoking, and moderation with alcohol. Smoking directly suppresses osteoblasts and reduces calcium absorption.

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What to expect from drugs#

Where risk is high, lifestyle alone is not enough. The main drug classes are bisphosphonates, denosumab, and for severe osteoporosis anabolic agents such as teriparatide and romosozumab. All are prescription-only, chosen on calculated risk, and require monitoring.

Menopausal hormone therapy preserves bone mass and reduces fracture risk, but it is prescribed primarily for menopausal symptoms and with attention to timing — generally within the first 10 years after the final period.

What does not work: collagen as an osteoporosis treatment, silicon, the "alkaline diet", or cutting protein to de-acidify the body. None of these ideas is supported by fracture data.

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Men too#

Roughly one osteoporotic fracture in five occurs in men, and one-year mortality after hip fracture is higher in men than in women. Yet men are screened less often, and the diagnosis usually arrives only once a fracture has happened.

Their risk factors are the same plus some specific ones: low testosterone, long-term glucocorticoids, heavy alcohol use, and androgen deprivation therapy for prostate cancer. Screening is recommended from 70, and earlier with risk factors.

The bottom line#

Osteoporosis develops across decades and stays silent until the first fracture. Prevention splits into two distinct phases: before thirty, build the highest peak bone mass you can; after that, slow its expenditure and reduce the risk of falling.

Of all the measures available, progressive resistance training, impact loading, balance work and adequate calcium and protein have the strongest support. DXA is indicated for women from 65 and men from 70, and earlier with risk factors — with treatment decided on overall risk rather than a single T-score.