What are the non-pharmacological approaches to managing osteoporosis?

Non-Pharmaceutical Management of Osteoporosis

All patients with osteoporosis should engage in a comprehensive non-pharmacological program including adequate calcium (1,000-1,200 mg/day) and vitamin D (800-1,000 IU/day) intake, a multi-component exercise regimen combining weight-bearing, resistance, balance, and flexibility training, smoking cessation, alcohol limitation, and fall prevention strategies. 1

Nutritional Interventions

Calcium and Vitamin D Supplementation

• Ensure daily calcium intake of 1,000-1,200 mg through diet or supplements if dietary intake is insufficient 1, 2
• Maintain vitamin D intake of 800-1,000 IU daily, targeting a serum 25-hydroxyvitamin D level ≥20 ng/mL (50 nmol/L) 1
• Vitamin D supplementation at these levels has been shown to reduce falls rate significantly (absolute risk reduction of 57.1% in post-hip fracture patients) 1
• If vitamin D deficiency is present, higher pharmacological doses may be required initially to achieve sufficiency 3

Protein and Balanced Diet

• Consume adequate protein at levels higher than the recommended daily allowance, as this benefits skeletal health 1
• Maintain a balanced diet, recognizing that vegetarian and vegan diets may potentially reduce bone mineral density 1
• Avoid severe caloric restriction, which is associated with lower bone mineral density 1

Exercise and Physical Activity

Multi-Component Exercise Program

• Engage in a combination of exercise types including weight-bearing exercise, resistance/progressive strengthening exercises, balance training, and flexibility/stretching exercises 1, 2
• Exercise should be performed at least 30 minutes daily or 3 times per week 4, 5
• Multi-component exercise approaches demonstrate significant bone mineral density benefits in middle-aged and older men 1
• Exercise reduces the risk of falls by 23%, which directly impacts fracture prevention 1

Tailored Exercise Prescription

• Exercise programs should be tailored according to individual patient needs and abilities 1
• Patients with gait or balance impairments should be offered medical rehabilitation 1
• Weight-bearing exercises combined with resistance training are particularly beneficial for bone health 4, 2

Lifestyle Modifications

Smoking and Alcohol

• Actively encourage smoking cessation, as smoking is a significant risk factor for osteoporosis 1, 2
• Limit alcohol consumption to a maximum of 1-2 drinks per day 1, 2, 6
• Both smoking and excessive alcohol consumption independently increase fracture risk 1

Fall Prevention Strategies

• Implement comprehensive fall prevention measures including balance training, home safety assessment, and vision checks 1, 4, 2
• Balance training exercises such as tai chi, physical therapy, and dancing should be specifically recommended 5
• Review medications that may affect balance or increase fall risk 5
• Address neurologic issues that may impair gait or balance 5

Multidisciplinary Care Coordination

Fracture Liaison Services

• Patients should be enrolled in coordinated multidisciplinary post-fracture care models (Fracture Liaison Services), which reduce re-fracture rates by approximately 30% 1
• These services effectively coordinate case finding, risk stratification, and secondary fracture prevention 1
• Orthogeriatric services delivering collaborative multidisciplinary care reduce in-hospital and long-term mortality compared with standard care 1

Medication Adherence Support

• Healthcare professionals should regularly evaluate and support adherence to prescribed anti-osteoporosis medications, as non-adherence rates are high (up to 64% by 12 months) and adversely affect outcomes 1, 4
• Interventions to improve adherence include patient education, less frequent dosing regimens, and pharmacist-delivered management services 1

Monitoring and Follow-Up

Bone Mineral Density Surveillance

• Repeat DXA scans every 2 years to assess treatment response and disease progression 4, 5
• More frequent monitoring (annually) may be indicated in high-risk patients or those on treatments causing rapid bone loss 4

Risk Reassessment

• Recalculate FRAX scores at each DXA scan to reassess the need for pharmacological intervention 4
• Lateral spine X-rays should be performed to identify existing vertebral fractures, which increase future fracture risk 5-fold for vertebral fractures and 2-fold for hip fractures 4

Special Considerations and Common Pitfalls

Cancer Survivors

• Cancer survivors, particularly those on aromatase inhibitors, GnRH agonists, or with chemotherapy-induced premature menopause, require more vigilant monitoring and may need earlier intervention 1, 4, 5
• Cancer treatments causing hypogonadism accelerate bone loss and should be factored into risk assessment 1, 4

Glucocorticoid Users

• Patients on chronic glucocorticoid therapy (≥3 months) should receive calcium and vitamin D supplementation and be considered for pharmacologic intervention at lower thresholds 1, 5
• Fracture risk should be adjusted upward if prednisone dose is >7.5 mg/day 4

Key Pitfalls to Avoid

• Do not rely solely on T-scores for treatment decisions; comprehensive fracture risk assessment using FRAX is essential 5, 2
• Avoid excessive calcium supplementation (>1,200 mg/day), which may increase cardiovascular risk 4
• Do not delay implementation of lifestyle modifications while waiting for the next DXA scan; these interventions should begin immediately 4
• Recognize that achieving normal bone mineral density does not cure osteoporosis; the diagnosis persists and ongoing monitoring remains necessary 6