Section 5: Non-pharmacological management of osteoporosis

Recommendations

Postmenopausal women, and men age ≥50 years, with osteoporosis or who are at risk of fragility fracture are recommended:

  1. A healthy, nutrient-rich balanced diet (Strong recommendation).
  2. An adequate intake of calcium (minimum 700mg daily) preferably achieved through dietary intake or otherwise by supplementation (Strong recommendation).
  3. To consume vitamin D from foods or be prescribed vitamin D supplements of at least 800IU/day if they have identified vitamin D insufficiency or risk factors for vitamin D insufficiency. Those who are either housebound or living in residential or nursing care are more likely to require calcium and vitamin D supplementation to achieve recommended levels of intake (Strong recommendation).
  4. A combination of regular weight-bearing and muscle strengthening exercise, tailored according to the individual patient’s needs and ability (Strong recommendation).
  5. Advice about smoking cessation if an individual is a smoker (Strong recommendation).
  6. Advice to restrict alcohol intake to ≤ 2 units/day (Strong recommendation).
  7. A falls assessment should be undertaken in all patients with osteoporosis and fragility fractures; those at risk should be offered exercise programmes to improve balance and/or that contain a combined exercise protocol (Strong recommendation).

Dietary modification

  1. A meta-analysis of observational studies examining different dietary patterns found a modest reduction in risk of low BMD and of hip fractures in subjects adhering to ‘healthy’ (high in fruit and vegetables, fish, poultry and whole grains) diets and a reduction in risk of low BMD in those with ‘milk/dairy’ diets. By contrast, those with a ‘meat/Western’ dietary pattern (high in processed and red meat, animal fat, refined sugar and soft drinks) saw a modest increase in risk of low BMD and of hip fractures. However, population heterogeneity with inclusion of subjects aged under 25 years in many dietary studies reduces generalisability 150; (Evidence level IIa). A randomised controlled trial of a ‘healthy diet’ consumed for 30 days, specifically a calcium-rich diet that emphasizes fruits, vegetables and low-fat dairy products (Dietary Approaches to Stop Hypertension (DASH)), resulted in reduction in bone turnover 151; (Evidence level Ib).
  2. Protein is an important constituent of bone and muscle tissue, and good dietary intake is necessary to maintain the health of the musculoskeletal system. Protein intakes higher than the recommended daily allowance (RDA) of 0.75g/kg body weight/day are associated with higher BMD at the neck of femur and total hip in one RCT, and in observational studies, has been associated with a reduced risk of hip fractures152,153; (Evidence levels Ib and IIa); however, in a meta-analysis of 30 interventional studies, no significant effects of protein supplementation on BMD were seen153; (Evidence level Ia). Post-operative protein supplementation in patients with a recent hip fracture has been shown to improve the subsequent clinical course by significantly lowering rates of infection and duration of hospital stay 154; (Evidence level Ib).
  3. Whilst there are inconsistencies in the evidence base for the associations between vegetarian and vegan diets and musculoskeletal health, consumption of a vegetarian or vegan diet has been associated with lower BMD at the lumbar spine and hip than an omnivore diet, and a vegan diet has been associated with higher fracture risk 155; (Evidence level IIa). A subsequent prospective cohort study of 65,000 people in the UK also identified lower BMD at the spine and hip in vegans and vegetarians, and higher hip fracture risk in vegans, attenuated in part by adjustment for calcium and/or protein intake 156; (Evidence level IIb).

Calcium and vitamin D

  1. At every stage of life, adequate dietary intakes of key bone nutrients such as calcium and vitamin D contribute to bone health. The UK Reference Nutrient Intake per day of calcium is 700mg for adults aged 19 years and older 157. Dietary calcium calculators are available to assess intake e.g., https://webapps.igmm.ed.ac.uk/world/research/rheumatological/calcium-calculator/. Whilst the Scientific Advisory Committee on Nutrition (SACN) recommends a reference nutrient intake (RNI) of 400 IU daily of vitamin D for adults of all ages 158, in the context of osteoporosis higher levels, specifically 800 up to 2,000 IU daily may be appropriate 159; (Evidence level IV).
  2. Most randomised controlled trials of anti-resorptive and anabolic drugs ( see Section 6) have included co-administration of calcium and vitamin D supplements. There have been many randomised controlled trials of either calcium alone, vitamin D alone or both in combination to examine whether use of these supplements alone reduces fracture risk. With respect to combined calcium and vitamin D supplements, meta-analyses have reported reduction in hip and non-vertebral fractures, and possibly also in vertebral fractures 160-162; (Evidence level Ia). Overall, there is little evidence that vitamin D supplementation alone reduces fracture incidence, although it may reduce falls risk 162,163; (Evidence level Ib). However, it is important for patients taking antiresorptive and anabolic osteoporosis drug therapies to be vitamin D replete. In clinical practice, dietary sources of calcium are the preferred option and calcium (combined with vitamin D) supplementation should be targeted to those who do not get sufficient calcium from their diet and who are at risk of osteoporosis and/or fragility fracture, such as older adults who are housebound or living in residential or nursing care 161, and those with intestinal malabsorption e.g. due to chronic inflammatory bowel disease, or following bariatric surgery. Calcium and vitamin D supplements may increase the risk of kidney stones, but not the incidence of cardiovascular disease or cancer 164; (Evidence level Ia). Routine intermittent administration of large doses of vitamin D e.g. ≥60,000 IU is not advised, based on reports of an associated increased risk of fracture and falls 165, 166; (Evidence level Ia).

Exercise to improve or maintain bone density

  1. Exercise has beneficial effects on BMD 167(Evidence level Ia); however, clear evidence for a reduction in fracture risk is wanting. The effect of exercise on different skeletal sites varies. Combination exercise programmes, which include weight-bearing and resistance strengthening exercise, are effective at reducing bone loss in the femoral neck and lumbar spine in post-menopausal women 167,168; (Evidence level Ia). Similarly, upper body resistance exercise increases forearm bone mass 169; (Evidence level Ia). A meta-analysis of the effects of exercise interventions on BMD in men found only three studies and identified a significant but moderate improvement in BMD at the femoral neck and a trend towards increased BMD at the lumbar spine 170; (Evidence level Ia).
  2. The effect of exercise varies with intensity and duration. Strengthening (resistance) exercise may be more effective if supervised. People at risk of falls, or with vertebral fractures, may need more specific advice and assessment before increasing exercise intensity 171 ( see Section 8 ). The NOGG supports the Royal Osteoporosis Society Strong, Steady and Straight Expert Consensus Statement, which offers advice on intensity and duration and linked patient information videos and factsheets 171.
  3. In people with osteoporosis, repetitive forced spinal forward flexion exercises should be undertaken with care as this specific movement may be associated with an increased risk of new vertebral fractures 172; (Evidence level Ia). However, in general people with osteoporosis can safely participate in exercise because the risk of serious adverse events is very low 172; (Evidence level Ia).

Falls interventions

  1. The majority of non-vertebral fractures are preceded by a fall. Exercise can significantly reduce the risk of falls and, perhaps the risk of subsequent fractures, by maintaining or restoring muscle strength, balance and posture, improving confidence and reaction times. However, two recent large randomised controlled trials have not demonstrated an effect of multi-disciplinary interventions, targeted at falls, on fracture reduction, when combined with screening for falls risk in primary care 173,174 ; (Evidence level Ib), a recent Cochrane review of falls prevention exercise programmes, and two previous meta-analysis demonstrated, albeit with low certainty, evidence of a reduction in fall-related fractures (or falls resulting in fractures) in those living in the community 168,175, 176;(Evidence level Ia).
  2. Exercise interventions to reduce falls in people with osteoporosis and/or at high risk of falling, have been found to be safe 177 ; (Evidence level Ia).
  3. Programmes that involve balance training and/or a combined exercise protocol are more effective in those who have risk factors for falling 175,177; (Evidence level Ia). Combined exercise protocols may include resistance training, balance challenging, aerobic exercise and impact exercise. Interventions of 3 hours per week or more are most effective 178; (Evidence level Ia). Interventions of short duration (less than 6 months) have found to be effective, and good compliance with exercise interventions has been reported 177; (Evidence level Ia).
  4. Home safety interventions (best delivered by an occupational therapist) have been shown to reduce the risk of falls in people living in the community 179; (Evidence level Ia). Furthermore, whole body vibration has been demonstrated to reduce fall rate but does not increase BMD 180; (Evidence level Ia).

Lifestyle measures

  1. Other measures to improve bone health include optimisation of body mass index if under or overweight, stopping smoking and reducing alcohol intake. Smoking cessation has been demonstrated to reduce the risk of vertebral and hip fractures in women 181,182; (Evidence levels Ilb and IIa). However, risk of hip fracture was reduced in those who had stopped smoking, compared with current smokers, only after 5 years. Furthermore, pre-operative smoking cessation is associated with fewer post-operative complications 183; (Evidence level Ia). Currently minimal evidence is available on the fracture risk associated with vaping/e-cigarette use; one cross-sectional study has identified elevated risk of self-reported fragility fracture in electronic cigarette users 184; (Evidence level Ic). In men with previous alcohol dependence, BMD is significantly lower than controls, but improves following 3-4 years of abstinence 185; (Evidence level IIa). National guidelines recommend alcohol intake is limited to ≤ 2 units/day for women and men 186.