Osteoporosis: The Complete Guide to Strong Bones, Fracture Prevention and Treatment

Osteoporosis is often called a “silent disease” because bones become weaker without any symptoms until one breaks. Worldwide, an osteoporotic fracture is estimated to occur every few seconds. Around one in three women and one in five men over the age of 50 will break a bone because of osteoporosis in their lifetime. Hip fractures alone affect well over a million people each year, and many never regain their previous independence.

Yet osteoporosis is preventable and treatable. The tragedy is that most people who have already had a fragility fracture are never assessed or offered treatment, even though one fracture greatly increases the risk of the next. This complete guide explains how bones work, who is at risk, how osteoporosis is diagnosed, what you can do for your bones at every age, which medicines work and what their real risks are, how to prevent falls, and how to recover after a fracture.

What is osteoporosis?

Osteoporosis means “porous bone”. It is a condition in which bones lose density and their internal structure deteriorates, making them fragile and more likely to break, even from a minor fall or everyday activities such as bending, lifting or coughing.

Bone is living tissue that is constantly being broken down and rebuilt in a process called remodelling. Cells called osteoclasts remove old bone, and cells called osteoblasts lay down new bone. In childhood and adolescence, bone is built faster than it is removed. Most people reach their “peak bone mass” by their late 20s. After about age 35 to 40, bone is gradually lost. In women, bone loss speeds up dramatically for several years after menopause, because oestrogen helps protect bone.

Osteoporosis develops when bone loss outpaces bone formation for long enough, or when peak bone mass was low to begin with. Osteopenia is a term used for bone density that is lower than average but not low enough to be called osteoporosis.

Fragility fractures: the real problem

Osteoporosis matters because of fractures. A fragility fracture is a broken bone resulting from a fall from standing height or less, or from no obvious injury. The most common sites are:

• The spine (vertebral fractures): the most common osteoporotic fracture. Many are not recognised, because they may cause only mild back pain or none at all. Over time they cause loss of height, a curved upper back (kyphosis), back pain and breathing or digestive difficulties.
• The hip: the most serious. Hip fractures almost always need surgery. Around a quarter or more of people die within a year of a hip fracture, often because of other health problems, and many lose the ability to live independently.
• The wrist: often the first fracture, typically in women in their 50s and 60s.
• The upper arm, pelvis and ribs.

Having one fragility fracture roughly doubles the risk of another, with the risk highest in the first one to two years afterwards. This period is often called “imminent fracture risk”. Any fragility fracture in someone over 50 should trigger an assessment for osteoporosis.

Who is at risk?

Risk factors you cannot change

• Age: risk rises steadily with age.
• Female sex: women have smaller, thinner bones and lose bone rapidly after menopause.
• Early menopause: before the age of 45, including after surgical removal of the ovaries.
• Family history: particularly a parent who broke a hip.
• Previous fragility fracture.
• Ethnicity: people of white European and Asian descent have higher average rates, but osteoporosis affects all ethnic groups, and people of African descent who have hip fractures often have worse outcomes.
• Small body frame.

Risk factors you can change

• Low body weight (a body mass index below about 19).
• Smoking.
• Heavy alcohol use (more than about three units a day).
• Physical inactivity and prolonged immobility.
• Low calcium intake and vitamin D deficiency.
• Eating disorders, especially anorexia nervosa.
• Falls risk, such as poor balance, poor eyesight and hazards at home.

Medical conditions and medicines

Many conditions and treatments increase bone loss. Common ones include:

• Long-term oral steroids, such as prednisolone at 5 milligrams or more a day for three months or longer. This is the most common medicine-related cause.
• Rheumatoid arthritis and other inflammatory conditions.
• Hormone deficiency: low oestrogen in women (including from absent periods due to excess exercise or low weight) and low testosterone in men.
• Breast cancer treatment with aromatase inhibitors and prostate cancer treatment with hormone therapy.
• Overactive thyroid, or taking too much thyroid hormone.
• Overactive parathyroid glands.
• Coeliac disease, inflammatory bowel disease and other conditions affecting absorption.
• Chronic kidney and liver disease.
• Type 1 and type 2 diabetes.
• Some anti-seizure medicines, long-term high-dose proton pump inhibitors, and some medicines for HIV, depression and diabetes.

Warning signs

Most people have no symptoms until a fracture. Possible signs include:

• A fracture from a minor fall or bump.
• Loss of height of 4 centimetres or more.
• A curved upper back or stooped posture.
• Sudden back pain, especially after bending, lifting or coughing, which may indicate a vertebral fracture.
• The lower ribs getting closer to the top of the pelvis.

If you notice height loss or sudden back pain in later life, ask a healthcare provider whether a spine X-ray or bone assessment is needed.

How osteoporosis is diagnosed

Fracture risk assessment

Healthcare providers use tools such as FRAX, a widely used online calculator, to estimate a person’s 10-year probability of a major osteoporotic fracture and of a hip fracture. FRAX uses age, sex, weight, height, previous fracture, parental hip fracture, smoking, steroid use, rheumatoid arthritis, other causes of osteoporosis, alcohol intake and, if available, bone density. It is calibrated for many different countries. Other tools are used in some places.

Bone density scan (DXA)

Dual-energy X-ray absorptiometry (DXA) is a quick, painless scan that measures bone mineral density, usually at the hip and spine. It uses a very low dose of radiation. The result is given as a T-score, comparing your bone density with that of a healthy young adult:

• T-score of -1.0 or above: normal.
• Between -1.0 and -2.5: osteopenia (low bone mass).
• -2.5 or below: osteoporosis.

A Z-score compares your bone density with people of the same age and sex and is used for children, younger adults and premenopausal women. A low Z-score suggests another cause for bone loss should be looked for.

Importantly, many fractures occur in people with osteopenia rather than osteoporosis, because there are many more people in this group. That is why treatment decisions are based on overall fracture risk, not bone density alone. Someone who has already had a hip or spine fragility fracture may be diagnosed and treated for osteoporosis without a DXA scan.

Other tests

Blood tests check for underlying causes and make sure treatment is safe: calcium, vitamin D, kidney and liver function, thyroid function, full blood count, and sometimes parathyroid hormone, testosterone, coeliac antibodies and tests for myeloma. Spine X-rays or vertebral fracture assessment during DXA can identify silent vertebral fractures.

Building strong bones at every age

Childhood and adolescence

This is the most important time to build bone. Good nutrition with enough calcium, protein and vitamin D, plenty of active play and impact sports such as running, jumping, dancing and ball games, and avoiding smoking and excessive dieting help reach a high peak bone mass, which protects against osteoporosis later.

Young and middle-aged adults

Keep active with weight-bearing and muscle-strengthening exercise, eat a balanced diet, avoid smoking, limit alcohol, and maintain a healthy weight. Women with absent periods for more than a few months (other than in pregnancy) should seek advice, as this can harm bones.

Around menopause and beyond

Discuss your bone health with a healthcare provider, especially if you have risk factors or early menopause. Hormone therapy can help protect bones in some women around menopause.

Calcium and vitamin D

Calcium is a key building block of bone. Most adults need around 700 to 1,200 milligrams a day, depending on age and country guidelines. Good sources include milk, yoghurt and cheese; calcium-fortified plant milks; canned fish with soft bones such as sardines and salmon; tofu set with calcium; leafy green vegetables such as kale and okra (spinach contains calcium that is less well absorbed); beans; almonds; sesame seeds; and fortified foods. Getting calcium from food is preferred. Supplements may be recommended if dietary intake is low or alongside osteoporosis medicines. Very high-dose calcium supplements are not needed and may cause constipation and kidney stones.

Vitamin D helps the body absorb calcium. Most vitamin D is made in the skin from sunlight. People at risk of deficiency include those who are housebound or living in care homes, those who cover most of their skin, people with darker skin living in less sunny climates, and people living far from the equator during winter months. Many countries recommend a daily vitamin D supplement for some or all of these groups. Your healthcare provider can advise whether you need a supplement and at what dose.

Protein is also important for bone and muscle, especially in older adults. Aim to include a source of protein at each meal.

Exercise for bone health

Exercise is one of the best things you can do for your bones at any age. Bones respond to the forces placed on them by becoming stronger. Exercise also builds muscle strength and balance, which reduce the risk of falling.

• Weight-bearing impact exercise: brisk walking, stair climbing, dancing, jogging, skipping and hopping, at a level appropriate to your fitness and bone health. Short bursts of moderate impact are good for bones.
• Muscle-strengthening exercise: lifting weights, resistance bands, body-weight exercises such as squats and push-ups, at least two to three times a week. Progressive resistance training has good evidence for bone.
• Balance training: tai chi, yoga, standing on one leg, and specific balance exercises reduce falls.
• Posture exercises: strengthen back muscles and support good posture.

People with osteoporosis can and should exercise, including those who have had vertebral fractures. Earlier advice to avoid activity has been replaced with guidance to stay active safely. Avoid sudden, forceful forward bending and twisting of the spine, particularly with heavy loads, and learn safe lifting techniques. A physiotherapist can design a safe programme.

Swimming and cycling are excellent for fitness and joints but do not load bones as much, so combine them with weight-bearing and strengthening exercises.

Lifestyle changes that protect bones

• Stop smoking: smoking reduces bone density and increases fracture risk.
• Limit alcohol: keep within recommended limits, as heavy drinking weakens bones and increases falls.
• Maintain a healthy weight: both underweight and severe obesity can increase fracture risk.
• Limit caffeine to moderate amounts.
• Review medicines that increase bone loss or falls risk with your healthcare provider.

Medicines for osteoporosis

When fracture risk is high, medicines significantly reduce the chance of fractures, typically by around 30 to 70 percent for spine fractures and 20 to 40 percent for hip fractures, depending on the medicine. Treatment is offered based on fracture risk, not bone density alone.

Bisphosphonates

Bisphosphonates slow down bone removal. They are usually the first-line treatment in most countries.

• Alendronate and risedronate are taken as tablets, usually once a week. They must be taken correctly: first thing in the morning on an empty stomach, with a full glass of plain water, while sitting or standing upright, and you must stay upright and not eat, drink anything other than water or take other medicines for at least 30 minutes (60 minutes for some products). This prevents irritation of the oesophagus and ensures absorption.
• Ibandronate may be taken monthly by mouth or every three months by injection.
• Zoledronic acid is given as an intravenous infusion once a year. It avoids the need for tablets and is useful after a hip fracture or for people who cannot take tablets correctly. Flu-like symptoms are common for a day or two after the first infusion.

Bisphosphonates are usually taken for five years (tablets) or three years (zoledronic acid), followed by a review. Many people can then take a “drug holiday”, because the medicine continues to work for some time after stopping. People at very high risk may continue longer.

Denosumab

Denosumab is an injection given under the skin every six months. It strongly reduces bone removal. It is effective, but it must not be stopped or delayed without a plan. When denosumab is stopped, bone loss can rebound quickly and the risk of multiple vertebral fractures rises. If stopping, another medicine, usually a bisphosphonate, should be given to protect bone. Keep injections on schedule.

Bone-building (anabolic) medicines

• Teriparatide and abaloparatide are daily injections that stimulate new bone formation. They are usually given for up to two years to people at very high risk, such as those with severe osteoporosis or multiple vertebral fractures, followed by a medicine that slows bone removal.
• Romosozumab is a monthly injection given for 12 months that both builds bone and slows bone removal. It is not used in people who have had a recent heart attack or stroke.

For people at very high risk, starting with a bone-building medicine and then switching to a bisphosphonate or denosumab gives the greatest gain in bone strength.

Hormone-related treatments

• Hormone replacement therapy (HRT) prevents bone loss and reduces fractures in women around menopause. It is often a good option for women under 60 with menopausal symptoms, after discussing benefits and risks.
• Raloxifene, a selective oestrogen receptor modulator, reduces spine fractures and breast cancer risk but increases the risk of blood clots and hot flushes.
• Testosterone may be used in men with low testosterone levels.

Understanding the real risks of osteoporosis medicines

Fear of side effects is the most common reason people decline or stop osteoporosis medicines. Two rare side effects receive a lot of attention:

• Osteonecrosis of the jaw: an area of exposed jawbone that does not heal, usually after a tooth extraction. In people taking osteoporosis doses of bisphosphonates or denosumab, it is very rare, estimated at around 1 in 10,000 to 1 in 100,000 patient-years. It is more common in people receiving much higher doses for cancer. Good dental hygiene and regular dental check-ups reduce the risk. Tell your dentist you take these medicines, but do not avoid needed dental treatment.
• Atypical femoral fractures: unusual fractures of the thigh bone. They are rare and the risk increases with longer duration of bisphosphonate use, which is one reason treatment is reviewed after three to five years. Warning signs include new aching pain in the thigh or groin; report this to your healthcare provider.

For people at high fracture risk, the number of fractures prevented by these medicines far outweighs the number of rare side effects caused. More common side effects of bisphosphonate tablets include indigestion and heartburn, which can usually be avoided by taking them correctly.

Preventing falls

Most hip and wrist fractures happen because of a fall. Preventing falls is as important as strengthening bones. Steps include:

• Strength and balance exercise, such as tai chi or a structured falls prevention programme, which can reduce falls by around a quarter or more.
• A medicine review, especially for sleeping tablets, sedatives, some antidepressants, blood pressure medicines that cause dizziness, and taking many medicines at once.
• Eye checks and up-to-date glasses. Take care with multifocal lenses when walking outdoors or on stairs.
• Home safety: remove loose rugs and clutter, improve lighting (including night lights), install grab rails in bathrooms and handrails on stairs, use non-slip mats, and keep frequently used items within reach.
• Footwear: well-fitting shoes with good grip, and avoid walking in socks or loose slippers.
• Treating dizziness and low blood pressure on standing. Get up slowly from lying or sitting.
• Managing continence to reduce rushing to the toilet, especially at night.
• Hearing checks, as hearing loss is linked to falls.
• Personal alarms for people who live alone.

Hip protectors, padded garments worn over the hips, may reduce hip fractures in care home residents who wear them consistently.

Living with vertebral fractures and back pain

Vertebral fractures can cause acute pain lasting weeks, and some people develop long-term back pain, height loss and changes in posture. Management includes pain relief, gentle movement and physiotherapy, posture and breathing exercises, heat, and sometimes a short period of support. Most acute vertebral fracture pain improves over six to twelve weeks. Procedures that inject cement into the fractured vertebra are used in selected cases. Treating the underlying osteoporosis is essential to prevent further fractures.

After a fracture: recovery and fracture liaison services

Every fragility fracture is an opportunity to prevent the next one. Many hospitals now have fracture liaison services, often led by specialist nurses, that identify people over 50 with fragility fractures, assess their bone health and falls risk, start treatment and follow them up. Studies show these services increase treatment rates and reduce further fractures. If you have had a fracture after a minor fall, ask whether you have been assessed for osteoporosis.

After a hip fracture, early surgery, early mobilisation, good nutrition, preventing delirium, rehabilitation and starting bone treatment all improve recovery. Families can help by encouraging movement, ensuring good nutrition and hydration, and supporting the person through rehabilitation.

Osteoporosis in men

Osteoporosis is often thought of as a women’s disease, but men account for around a third of hip fractures worldwide, and men who break a hip have higher death rates than women. Common causes in men include low testosterone, long-term steroid use, heavy alcohol use, smoking and prostate cancer treatment. Men with fragility fractures or risk factors should be assessed and treated in the same way as women.

Osteoporosis in younger people

Osteoporosis in younger adults usually has an underlying cause, such as an eating disorder, absent periods, coeliac disease, inflammatory bowel disease, long-term steroid use, hormone problems or genetic conditions. Treating the cause is the priority. Pregnancy- and breastfeeding-associated osteoporosis is a rare condition that can cause vertebral fractures in new mothers and needs specialist assessment.

A note for nurses and healthcare workers

Nurses play a central role in osteoporosis care: running fracture liaison services, delivering falls prevention programmes, teaching correct bisphosphonate technique, administering infusions and injections, keeping denosumab on schedule, supporting people after hip fracture, and identifying risk factors such as long-term steroid use in patients they see for other reasons. Simple questions, such as “Have you broken a bone in a minor fall since you turned 50?” or “Have you lost height?”, can identify people who need assessment. Nurses who work in care homes, emergency departments and community settings are especially well placed to spot those at risk.

Common myths about osteoporosis

• “Osteoporosis only affects women.” Men are affected too, and often have worse outcomes after hip fracture.
• “It’s just a normal part of ageing.” Bone loss happens with age, but osteoporosis and fractures can be prevented and treated.
• “If I drink milk, I won’t get osteoporosis.” Calcium helps, but many other factors affect bone health.
• “People with osteoporosis shouldn’t exercise.” Appropriate exercise is safe and recommended.
• “Osteoporosis medicines are more dangerous than the disease.” For people at high risk, the benefits far outweigh the rare risks.

Steroid-induced osteoporosis

Long-term oral corticosteroids, such as prednisolone, are the most common medicine-related cause of osteoporosis. Bone loss is fastest in the first three to six months of treatment, and fracture risk rises even at relatively low doses and even before bone density falls much. Anyone expected to take oral steroids for three months or more, especially at 5 milligrams of prednisolone a day or more, should have their bone health considered at the start of treatment, not years later.

Protective steps include using the lowest effective steroid dose for the shortest time, considering steroid-sparing treatments, ensuring adequate calcium and vitamin D, staying active, and, for many people, starting a bone-protecting medicine such as a bisphosphonate at the same time as the steroid. People over 65 or with a previous fragility fracture who are taking long-term steroids are usually offered bone protection straight away. Never stop prescribed steroids suddenly, because this can be dangerous; ask your healthcare provider about bone protection instead.

Bone health with diabetes and kidney disease

Both type 1 and type 2 diabetes increase fracture risk. In type 2 diabetes, bone density may be normal or even high, yet bone quality is reduced and falls are more common because of nerve damage, poor vision, low blood sugar episodes and some medicines. Tools such as FRAX may underestimate risk in people with diabetes, so healthcare providers may adjust their assessment. Good blood sugar control, avoiding low blood sugar, foot and eye care, and falls prevention all help.

Chronic kidney disease affects how the body handles calcium, phosphate and vitamin D, and can cause a complex bone condition. Some osteoporosis medicines need dose adjustment or are not suitable in advanced kidney disease. People with kidney disease should have bone treatment decisions made with their kidney team.

Calcium for every kind of diet

Not everyone eats dairy, and calcium needs can be met in many ways:

• Lactose intolerance: many people can tolerate yoghurt, hard cheese and lactose-free milk, which contain plenty of calcium.
• Vegan or plant-based diets: choose calcium-fortified plant milks and yoghurts (shake the carton, as calcium settles), calcium-set tofu, fortified breakfast cereals and breads, almonds, tahini (sesame paste), beans, chickpeas, figs and leafy greens such as kale, bok choy and collard greens.
• Traditional diets in many regions: small whole fish eaten with their bones (such as sardines, anchovies, kapenta, dried fish and whitebait), leafy vegetables such as amaranth, moringa and baobab leaves, millet and sorghum, and sesame seeds are valuable calcium sources.

Spreading calcium across the day helps absorption. Too much salt, very high caffeine intake and fizzy cola drinks in large amounts may slightly reduce bone health, so keep these moderate.

Moving safely in daily life

For people with osteoporosis, especially after vertebral fractures, small changes to how everyday tasks are done reduce strain on the spine:

• Lifting: bend at the hips and knees rather than the waist, keep your back straight, hold the load close, and avoid twisting while lifting. Split heavy shopping into lighter bags.
• Bending: use a long-handled reacher or grabber for items on the floor, and a long-handled shoehorn and sock aid for dressing.
• Getting out of bed: roll onto your side, bend your knees, and push up with your arms as your legs go over the edge of the bed.
• Coughing and sneezing: support your back by pressing a hand against your lower back or stand upright.
• Housework and gardening: use long-handled tools, kneel on a padded cushion rather than stooping, and take frequent breaks.
• Posture: sit with your back supported, keep screens at eye level, and do gentle back-extension exercises as advised by a physiotherapist.

Monitoring your treatment

Once you start osteoporosis treatment, follow-up helps make sure it is working and safe. Typical follow-up includes checking that you are taking medicines correctly and without side effects, reviewing calcium and vitamin D, blood tests for kidney function and calcium (especially before zoledronic acid and denosumab), and a repeat DXA scan after two to five years in many cases. Bone density may rise only modestly on treatment, but fracture risk falls substantially even when the scan changes are small. A treatment review after three to five years of bisphosphonate use decides whether to continue, take a break or switch.

Supporting a family member after a hip fracture

A hip fracture is a turning point for many older people and their families. Practical ways to help during recovery include:

• Encouraging the person to get up and walk with the physiotherapy team as early as advised, as early movement improves recovery.
• Bringing in familiar items, glasses and hearing aids, and helping with orientation, because delirium (sudden confusion) is common after hip fracture.
• Making sure they eat and drink enough, as poor nutrition slows healing.
• Helping arrange home adaptations before discharge, such as a raised toilet seat, a perching stool, rails and removal of trip hazards.
• Asking the team whether bone treatment has been started or planned.
• Watching for low mood and loss of confidence, and encouraging continued exercise and social contact.

Osteoporosis around the world

As populations age, the number of hip fractures worldwide is expected to rise sharply over the coming decades, with the greatest increases in Asia, Latin America and the Middle East. Access to DXA scanning is limited in many countries, and medicines may be costly. Even where scans are unavailable, fracture risk tools such as FRAX can be used without bone density, and inexpensive measures such as falls prevention, exercise, adequate calcium and vitamin D, and generic bisphosphonates can prevent many fractures. Community health workers and nurses are central to delivering these measures at scale.

Questions to ask your healthcare provider

• What is my 10-year risk of a major fracture and a hip fracture?
• Do I need a bone density scan, a spine X-ray or blood tests?
• Is there an underlying cause of my bone loss that should be treated?
• Which medicine do you recommend, and why that one?
• How should I take it, and how long will I need it?
• What are the realistic benefits and risks for someone like me?
• Can I be referred to a falls prevention or exercise programme?
• Should I tell my dentist anything before starting treatment?

Osteoporosis and emotional wellbeing

A diagnosis of osteoporosis, or a fracture, can shake a person’s confidence. Many people become afraid of falling, start avoiding outings, stairs and exercise, and become less active, which in turn weakens muscles and bones and increases the risk of falling. Fear of falling is common and treatable. Strength and balance programmes, gradual practice of everyday activities with support, and talking about worries with a nurse or physiotherapist can rebuild confidence. Chronic back pain and changes in body shape after vertebral fractures can also affect self-image and mood. Support groups run by osteoporosis charities in many countries connect people with others who understand, and can be a valuable source of practical tips and encouragement.

Bone health for the next generation

Because peak bone mass is built in childhood and adolescence, protecting bones is a family project. Encouraging children and teenagers to play actively outdoors, take part in sports that involve running and jumping, eat calcium-rich foods, get safe sunlight, and avoid smoking and extreme dieting sets them up for strong bones for life. Teenage girls are a particular focus, as many do not get enough calcium or vitamin D during the years when bone building is fastest. Parents who look after their own bones also model healthy habits.

A simple bone health checklist

• Do you know whether you have had a fragility fracture since age 50?
• Have you lost height or developed a stoop?
• Do you take long-term steroids or other medicines that affect bone?
• Do you get enough calcium from food every day?
• Do you need a vitamin D supplement where you live?
• Do you do weight-bearing and strengthening exercise at least twice a week?
• Have you had your falls risk, eyesight and medicines reviewed in the last year?
• Are you a non-smoker who drinks within recommended limits?

If any of these raise a concern, or you are not sure of the answer, it is worth raising with a nurse or healthcare provider at your next visit.

Frequently asked questions

Can osteoporosis be reversed?

Medicines can increase bone density and reduce fracture risk significantly. Bone-building medicines can lead to substantial gains. Osteoporosis is usually managed long term rather than cured.

Does osteoporosis cause pain?

Osteoporosis itself is painless. Pain usually comes from fractures.

When should I have a bone density scan?

Recommendations differ between countries. Generally, scans are recommended for women aged 65 and over, younger postmenopausal women and men with risk factors, and anyone with a fragility fracture or long-term steroid use.

Should I take a calcium supplement?

Only if your dietary calcium intake is low or your healthcare provider recommends it alongside osteoporosis medicine. Food sources are preferred.

How long do I need to take osteoporosis medicine?

It depends on the medicine and your risk. Bisphosphonates are usually reviewed after three to five years. Denosumab should not be stopped without a plan for follow-on treatment.

Can I still lift my grandchildren?

Many people can, using safe lifting techniques: bend at the knees, keep your back straight, hold the child close to your body and avoid twisting. A physiotherapist can advise you.

But what if I am afraid of the medicines?

This is very common and understandable. Ask your healthcare provider to explain your personal 10-year fracture risk and how much treatment would reduce it, compared with the very small risks of rare side effects. Ask about different options: a yearly infusion instead of tablets, or a six-monthly injection. Many people decide that preventing a hip fracture, with all it can mean for independence, is worth it. Whatever you decide, focus on exercise, nutrition and falls prevention, and review your decision if your risk changes.

Related: Osteoporosis risk and prevention: quick guide · Healthy ageing: the complete guide

Sources: International Osteoporosis Foundation, World Health Organization (bone density definitions and FRAX), Royal Osteoporosis Society, Bone Health and Osteoporosis Foundation, National Institute for Health and Care Excellence (NICE) osteoporosis guidance, Endocrine Society guidelines, Cochrane reviews on exercise and falls prevention.