Osteoporosis and osteopenia are conditions that affect bone strength, but they aren’t the same thing. Both involve reduced bone mineral density (BMD), making bones weaker and more prone to fractures, but they differ in severity. While osteoporosis is more advanced and significantly raises the risk of fractures, osteopenia is the earlier stage, a warning sign that bones are starting to lose strength.

Let’s dive into what these conditions are, why they happen, and the latest evidence on the best ways to manage them—especially through conservative methods like exercise, diet, and lifestyle changes.

What Are Osteopenia and Osteoporosis?

• Osteopenia: This is when bone mineral density is lower than normal but not low enough to be classified as osteoporosis. It’s often seen as a precursor to osteoporosis and signals that bones are becoming weaker.

• Osteoporosis: Osteoporosis is a more serious condition where bone density is so low that bones are fragile and more likely to break. Fractures from osteoporosis can happen even from minor falls or, in severe cases, from something as simple as coughing or bending over.

Understanding Bone Pathology

Our bones are constantly changing through a process called remodeling—old bone tissue gets broken down, and new bone is formed. In younger people, bone formation outpaces breakdown, but as we age, bone loss starts to happen faster than bone formation. This imbalance is what leads to lower bone density over time.

With osteopenia and osteoporosis, the trabecular (spongy) bone becomes thinner, and the cortical (hard) bone becomes more porous. Over time, the bones become less dense, weaker, and more prone to fractures. The inside of healthy bone has small spaces, like honeycomb. As bone density decreases, the size of these spaces increases, causing the bone to lose strength.

Risk Factors and Causes

The causes of osteoporosis and osteopenia are multifactorial, with many risk factors that can contribute to reduced bone density:

• Age: Bone density naturally declines as we age, especially after menopause in women, due to a drop in oestrogen levels, which play a key role in maintaining bone mass.

• Gender: Women are at higher risk, particularly post-menopause, but men can develop osteoporosis too, often later in life.

• Genetics: A family history of osteoporosis increases your risk.

• Diet and Nutrition: A diet low in calcium and vitamin D can weaken bones over time. Excessive alcohol and caffeine can also impair bone health.

• Physical Inactivity: Regular weight-bearing exercise is crucial for maintaining bone density. Sedentary lifestyles can lead to weaker bones.

• Medications: Long-term use of corticosteroids, some anticonvulsants, and certain cancer treatments can accelerate bone loss.

• Smoking: Smoking has been shown to reduce bone density and increase the risk of fractures.

Diagnosis of Osteopenia and Osteoporosis

Diagnosing osteopenia and osteoporosis is typically done using a dual-energy X-ray absorptiometry (DEXA) scan. This scan measures bone mineral density, and the results are given as a T-score and a Z-score. T-scores compare bone density with that of a healthy person, whereas Z-scores use the average bone density of people of the same age, sex, and size as a comparator:

• T-score -1.0 to -2.5: Indicates osteopenia.

• T-score below -2.5: Indicates osteoporosis.

Best Conservative Treatment Options for Improving Bone Density

Fortunately, there are several effective ways to manage osteopenia and osteoporosis, especially when caught early. While medications are often prescribed for more severe cases, conservative management can significantly improve bone health and even reverse bone loss in some cases.

1. Exercise for Bone Health

Exercise is one of the most powerful tools for improving bone density. When we exercise, we place stress on our bones, which stimulates the bone-building process. If you are going to incorporate exercise into your bone density strategy (which we highly recommend), it’s important to ensure that you have the right “prescription” - the correct type of exercise, weight, load and reps. Here’s what the latest guidelines say about the best types of exercises for maintaining and improving bone density:

• Weight-bearing aerobic exercises: Activities like walking, jogging, dancing, and hiking require your body to work against gravity, which helps strengthen bones. Walking, for example, has been shown to improve bone density in the hips and spine.

• Resistance training: Strength training exercises, like lifting weights or using resistance bands, apply tension to muscles and bones, encouraging bone growth. This is particularly effective for strengthening the spine and improving overall bone health.

• High-impact exercises: For those able to perform more intense activities, exercises like jumping, stair climbing, or skipping are highly effective at building bone density. However, if you already have osteoporosis, high-impact exercises may not be recommended due to the risk of fractures.

• Balance and coordination exercises: Improving balance through exercises like tai chi, yoga, or Pilates can help prevent falls, which is crucial for avoiding fractures in people with low bone density.

According to best practice guidelines, a combination of weight-bearing aerobic activity and resistance training, performed 2–3 times per week, is ideal for improving bone health. It’s also important to progressively increase the intensity over time to continue challenging the bones. Having an individualised plan that suits your body, history of injury and current fitness level is particularly important to decrease your risk of injury while exercising.

2. Nutritional Support

Calcium and vitamin D are essential for bone health. Calcium is a building block for bones, while vitamin D helps the body absorb calcium. Most adults need about:

• 1,000–1,200 mg of calcium per day.

• 600–800 IU of vitamin D per day (this may vary depending on individual needs and sun exposure).

If you’re not getting enough from food, supplements can be required (especially in places like Ballarat!), but it’s always best to get nutrients from whole foods when possible. Dairy products, leafy greens, fortified plant-based milks, and fatty fish are great sources of calcium and vitamin D.

3. Lifestyle Modifications

Small changes to your daily routine can also help reduce your risk of bone loss and fractures:

• Quit smoking: Smoking can accelerate bone loss, so quitting is key for bone health.

• Limit alcohol and caffeine: Both of these can interfere with your body’s ability to absorb calcium.

• Fall prevention: In people with osteoporosis, falls are a major cause of fractures. Keeping the home clear of tripping hazards, using non-slip mats, and improving balance and strength through exercise are important for reducing fall risk. Our Exercise Physiologist can help with Falls Prevention.

Medications: When Necessary

In some cases, especially when osteoporosis is advanced or there's a high risk of fractures, medications may be prescribed. These include:

• Bisphosphonates (e.g., alendronate, risedronate): These drugs slow bone loss and can even increase bone density over time.

• Denosumab (eg Prolia): An injection that helps prevent the body from breaking down bone.

• Hormone Replacement Therapy (HRT): Particularly in post-menopausal women, HRT can help maintain bone density by replacing oestrogen in the body.

The Bottom Line

Osteopenia and osteoporosis are conditions that affect millions of people worldwide, particularly as we age. While they can lead to fractures and reduced quality of life, early diagnosis and conservative management can significantly improve bone health. Exercise—especially weight-bearing and resistance exercises—along with proper nutrition, lifestyle changes, and sometimes medication, are the cornerstones of treatment.

If you’re concerned about your bone health, it’s a good idea to chat to your GP to get a DEXA scan to check your bone density. From there, you can take proactive steps to strengthen your bones and prevent future fractures. Our clinicians can work with you to design an evidence based exercise program to maintain or improve your bone strength. Click here to book with one of our physiotherapists, exercise physiologists or osteopaths.

References:

• Turner, C. H., & Robling, A. G. (2003). Designing exercise regimens to increase bone strength. Exercise and Sport Sciences Reviews, 31(1), 45-50.

• Weaver, C. M., Gordon, C. M., Janz, K. F., Kalkwarf, H. J., Lappe, J. M., Lewis, R., ... & Zemel, B. S. (2016). The National Osteoporosis Foundation's position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations. Osteoporosis International, 27(4), 1281-1386.

• Khan, K. M., McKay, H. A., Kannus, P., Bailey, D. A., & Wark, J. D. (2001). Physical activity and bone health. Human Kinetics.