Reviewed by a board-certified geriatrician
Osteopenia means your bones are thinner than average but not thin enough to be called osteoporosis. It's a good time to act. Many people already walk and get calcium. Here's what's happening inside your bones, and what else helps.
Your bones are always rebuilding
Bone is living tissue. Throughout life, cells called osteoclasts break down old bone and cells called osteoblasts build new bone in its place. When we're young, building wins, and bone mass peaks by our mid- to late 20s. After that, removal can slowly outpace building [1].
With age, bone loss speeds up and new bone forms more slowly. Lower estrogen after menopause speeds up the loss, and conditions that lower testosterone can do the same in men. Some medicines also add to bone loss, including long-term steroid pills (glucocorticoids), certain seizure medicines, some hormone-based cancer treatments, and possibly stomach-acid medicines (proton pump inhibitors) and some antidepressants (SSRIs) [2].
Tipping the balance: breakers and builders
Think of osteoclasts as the breakers and osteoblasts as the builders. Bone gets thinner when the breakers outwork the builders. You can push the balance back in two ways: slow the breakers, and give the builders a reason to work.
Estrogen keeps the breakers in check. When estrogen drops after menopause, the body makes more osteoclasts, and bone breakdown speeds up [9].
Load tells the builders to build. Cells buried inside bone, called osteocytes, sense the push and pull when you lift, jump or stomp. They normally send out a brake signal (sclerostin) that holds the builders back. When bone is loaded, that brake signal drops, and the builders get to work [10]. That fits what the exercise trial below found: heavier strength and impact work built bone, and gentle exercise did not [4].
Some things speed up the breakers. Long-term steroid pills, some other medicines, heavy drinking and smoking all tip the balance toward bone loss [2].
Medicines work on both sides. Some slow the breakers, such as bisphosphonates (like alendronate or zoledronic acid) and denosumab. Others boost the builders, such as teriparatide, abaloparatide and romosozumab [11]. Your doctor can explain which, if any, fits you.
The everyday steps below are about tipping that balance in your favor.
What else you can do
Add strength and impact work. Walking is good, but bones respond most to heavier loads. In a trial of women with low bone mass, supervised high-intensity strength and impact training twice a week for 8 months improved bone density at the spine and hip, and physical function too. The women in the control group, who did gentle home exercise, lost bone [4]. That program was carefully supervised and screened, so start with a physical therapist or trainer who works with bone health, especially if you've had a fracture.
Why it works: bones respond to the loads put on them. Apart from injuries, the biggest loads your bones feel every day come from your own muscles pulling on them [15]. When bone senses those loads, it strengthens itself, as described in the breakers and builders section above. Stronger muscles pull harder, so building muscle helps build bone. Muscle also releases chemical messengers (myokines) that help regulate bone [16].
Train your balance. Most broken hips come from falls. In U.S. data, falls caused 88% of hip fractures that led to an emergency visit or hospital stay [17]. Even strong bones can break in a fall, so falling less protects your bones. Balance and functional exercises lowered the rate of falls by about a quarter in older adults [5]. A physical therapist can show you which ones are safe for you.
Eat for your bones. Good food sources of calcium include milk, yogurt and cheese; canned salmon or sardines with the bones; tofu made with calcium; kale, broccoli and bok choy; and calcium-fortified soy or almond drinks [6]. How much calcium you need is less clear-cut than many people think. The U.S. recommends more for older adults than the UK does [6][18]. A large review found that people who got more calcium from food did not have fewer fractures, and that evidence for calcium supplements preventing fractures is weak and inconsistent [19]. Some of the countries with the highest calcium intake also have the most hip fractures, a reminder that calcium is only one piece of bone health [20]. So aim for a varied diet with some calcium-rich foods, and ask your doctor before adding a supplement. If you do take one, smaller doses are absorbed better [6]. For protein, a review found that plant protein such as soy and animal protein were both fine for bones, with neither better than the other [14].
Why calcium matters: bone is the body's calcium bank. When the calcium in your blood runs low, the parathyroid glands release a hormone (PTH) that makes bone release calcium into the blood [21]. Vitamin D is needed to absorb calcium from food [22]. Getting enough of both means your body doesn't have to keep drawing calcium out of your bones.
More than calcium: bones need other nutrients too [23]:
Vitamin D: fatty fish such as salmon, mackerel, tuna and sardines
Magnesium: spinach, okra, tomato products and potatoes
Potassium: sweet potatoes, papaya, oranges, bananas and tomato products
Vitamin C: peppers, broccoli, papaya, oranges and pineapple
Vitamin K: dark leafy greens such as kale, spinach and collard greens
Protein: many older adults don't get enough, which may be harmful to bones
Ask before taking vitamin D. In a large trial of nearly 26,000 midlife and older adults, vitamin D supplements did not lower fractures [7]. Ask your doctor whether you need one.
Limit alcohol and don't smoke. Heavy drinking is a major risk for bone loss, and smoking is linked to fractures [2][3]. Alcohol is toxic to the builders (osteoblasts), and the more you drink, the bigger the effect. Bone loss from alcohol comes mainly from building less new bone, not from more breakdown [24]. Smoking throws bone turnover off balance. It affects bone directly, including its blood supply, and indirectly through hormones that guard bone, such as the parathyroid hormone and vitamin D system and sex hormones [25].
Review your medicines. Ask your doctor whether any of your medicines could be affecting your bones, and whether there's an alternative [2].
Ask about your fracture risk, not just your score
A bone density scan gives a score, but your risk of breaking a bone also depends on age, past fractures, family history and other factors. Doctors often use a tool called FRAX to estimate it. It asks about your age, sex, weight and height, any past broken bone, whether a parent broke a hip, smoking, steroid use, rheumatoid arthritis, other conditions that thin bones, and heavy drinking. Your bone density result can be added but isn't required. It then estimates your chance of breaking a hip, or a major bone such as the spine, wrist or shoulder, over the next 10 years [12][13]. Two people with the same scan score can have very different risks. Decisions are made person by person, not on a single number [3].
For some people with osteopenia, medicine is worth considering. In a 6-year trial of women 65 and older with osteopenia, a bone-strengthening medicine given by infusion lowered fractures by about a third [8]. Whether that makes sense for you is a conversation with your doctor.
This article is for general education and isn't a substitute for advice from your own doctor.
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