Osteoporosis and Osteopenia: Integrative Care for Low Bone Density

Does vitamin D prevent fractures? What the trials show

Not on its own: in a 2019 meta-analysis in JAMA Network Open, vitamin D alone did not lower fractures in 11 trials (34,243 people), while daily vitamin D with calcium lowered any fracture by 6% and hip fracture by 16% in 6 trials (49,282 people) [4]. In the same meta-analysis, higher blood vitamin D was linked with fewer hip fractures in observational studies [4].

• Vitamin D for everyone: in the VITAL trial of 25,871 healthy adults not selected for low vitamin D or low bone density, 2,000 IU a day did not lower fractures over 5.3 years [5].
• Very large single doses: a single yearly dose of 500,000 IU raised falls by 15% and fractures by 26% in 2,256 women aged 70 and over [6]; the UK National Osteoporosis Guideline Group (NOGG) advises against routine large intermittent doses such as 60,000 IU or more [7].
• High daily doses: in a 3-year trial of 311 healthy adults aged 55 to 70 without osteoporosis, 10,000 IU a day led to more forearm bone loss than 400 IU a day (3.5% vs 1.2%), with no difference in bone strength [8].
• What this means for you: correct low vitamin D under supervision, take it every day rather than in large single doses, get enough calcium, and have calcium levels checked while on treatment.

What is osteoporosis? Osteopenia and T-scores

Osteoporosis is a bone disease that develops when bone mineral density and bone mass decrease, or when the structure and strength of bone change, according to the US National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) [9]. A T-score compares your bone density with that of a healthy young adult, in standard deviations, according to the NHS [1].

• How common: 18.3% of people worldwide in a 2021 meta-analysis of 86 studies [2]; in India, osteoporosis of the spine in 29% and osteopenia in 37% of postmenopausal women [3], and osteoporosis in 14.6% and osteopenia in 50.3% of healthy adult men [10].
• Fracture risk: NOGG advises a FRAX fracture-risk assessment for postmenopausal women and men aged 50 or over who have a risk factor for fragility fracture [7].
• Do you need medicine for osteopenia? NOGG bases treatment decisions on overall fracture risk measured with FRAX, not on the T-score alone [7], so some people with osteopenia need medicines and others do not.

What are the symptoms of osteoporosis?

Osteoporosis is called a “silent” disease because there are usually no symptoms until a bone breaks, according to NIAMS [9].

• Not usually painful: the NHS says osteoporosis is not usually painful until a bone is broken [1].
• Stooped posture: a stooped posture develops when bones in the spine have broken [1].
• Height loss: NOGG advises a spine fracture check for height loss of 4 cm or more, a curved upper back, or sudden back pain with risk factors [7].

What causes osteoporosis?

Bone loss after the menopause is a main cause in women, and other causes include an overactive thyroid, hyperparathyroidism, long-term high-dose steroid tablets, coeliac disease, rheumatoid arthritis, eating disorders, a BMI of 19 or less, and heavy drinking and smoking, according to the NHS [11].

• Steroid medicines: NOGG advises starting bone protection at the same time as steroids for postmenopausal women and men aged 50 or over taking 7.5 mg or more of prednisolone (or equivalent) a day for 3 months or longer [7]. See our Ankylosing Spondylitis and Rheumatoid Arthritis pages.
• Other causes NOGG lists: type 1 diabetes, untreated overactive thyroid, untreated low sex hormones or menopause before 45, malabsorption, chronic liver and kidney disease, and some medicines, including thyroid hormone excess, aromatase inhibitors and long-term acid-reducing medicines [7]. See our Hypothyroidism and Acidity & Hyperacidity pages.

What is the difference between osteoporosis, osteopenia, osteoarthritis and osteomalacia?

They are different conditions, according to the NHS: osteopenia is bone loss that has not reached the osteoporosis range [1], osteomalacia is the adult form of soft bones, usually caused by low vitamin D and calcium [12], and osteoarthritis is a condition that causes joints to become painful and stiff [13], not thinning of the bones; see our Osteoarthritis & Joint Pain and Knee Pain & Knee Arthritis pages.

How is osteoporosis diagnosed? DEXA, FRAX and blood tests

A doctor estimates fracture risk with a tool such as FRAX and may arrange a bone density (DEXA) scan, a short, painless scan that gives the T-score, according to the NHS [1]; NOGG lists blood tests to look for other causes, including PTH, thyroid function, a coeliac screen, testosterone and other hormones, vitamin D and a test for myeloma [7].

• DEXA for density, X-rays for fractures: a DEXA scan measures bone density [1]; we use X-rays to see fractures and their healing.

How does Cure4Pain manage osteoporosis?

Cure4Pain manages osteoporosis and osteopenia with yearly DEXA scans, fracture-risk scores and blood tests, supervised vitamin D therapy, plant-based calcium and other bone nutrients, diet changes, strength and balance training and medicine review, under clinical guidance from Team Cure4Pain and in coordination with your existing consulting physician.

• Who we see: adults and young people aged 16 and over with osteopenia or osteoporosis: women after the menopause, men, younger people with low bone density, people on steroid medicines and people with autoimmune conditions. We do not treat fractures; after a fracture, we work with your orthopaedic doctor. We refer pregnant women to their obstetrician.

The plan includes:

1. Tests first: a DEXA scan once a year (arranged by you), a FRAX fracture-risk score, and our blood panel with calcium, PTH, phosphorus, alkaline phosphatase, thyroid tests, a coeliac screen and hormones (see below).
2. Vitamin D: supervised-dose vitamin D therapy (Coimbra Protocol-based methods), taken daily, with blood tests every 3 months including ionized calcium (see below).
3. Calcium: plant-based calcium from foods such as moringa and ragi, and from calcium bisglycinate supplements rather than calcium carbonate (see below).
4. Other bone nutrients: vitamin K2 (MK-7), magnesium, collagen, protein and omega-3, chosen for each person within official limits where one exists (see below).
5. Diet: salt, caffeine, alcohol and soft drinks restricted; raw milk avoided (see below).
6. Exercise and falls: supervised strength and impact training, balance work and yoga, exercises to avoid and falls prevention at home (see below).
7. Medicines: osteoporosis medicines and menopause hormone therapy prescribed and managed by Dr Krushal Pabari (see below).
8. Follow-up: blood tests every 3 months and a DEXA scan every year.

Our plan combines approaches tested separately in research; the combination is clinic practice, individual results vary, and further studies are needed.

What tests does Cure4Pain do for osteoporosis?

We start with a DEXA scan, a FRAX score and our blood panel of about 100 measures, adding the tests NOGG lists for other causes of bone loss [7]; the panel is our clinic protocol, not a guideline requirement.

• Bone tests: calcium and ionized calcium, phosphorus, alkaline phosphatase, PTH, vitamin D and kidney function.
• Causes of bone loss: thyroid tests, a coeliac screen and hormones (for example testosterone in men) [7].
• The rest of the panel: vitamin B12, iron studies, complete blood count, blood sugar and HbA1c, liver function, lipid profile, hsCRP and ANA by the IFA method; a positive ANA alone does not mean you have an autoimmune disease.
• DEXA once a year: NOGG says repeated bone density scans can be used to monitor the response to treatment [7]; asking for one every year is our clinic practice.

In India, the panel is available at a lower cost through our patient portal, with home collection across India. Outside India, the tests are done at a laboratory near you and reviewed with you in the consultation.

How does Cure4Pain use vitamin D therapy for osteoporosis?

At Cure4Pain we use supervised-dose vitamin D therapy (Coimbra Protocol-based methods) for osteoporosis, with the dose taken every day and set for each person, never as large single yearly or monthly doses, and with blood tests every 3 months including ionized calcium.

• What guidelines advise: NOGG suggests 800 to 2,000 IU a day may be appropriate in osteoporosis [7], and the upper limit for adults is 4,000 IU a day, according to the US National Institutes of Health [14].
• The studies that disagree: vitamin D alone did not lower fractures [4], 2,000 IU a day did not lower fractures in healthy adults [5], 10,000 IU a day for 3 years led to more forearm bone loss than 400 IU [8], and a single 500,000 IU yearly dose raised falls and fractures [6].
• Our approach: doses in Coimbra Protocol-based methods can be above the standard upper limit, and too much vitamin D can raise blood calcium, according to the US National Institutes of Health [14], so they are used only under supervision with calcium checks every 3 months. We found no trial of Coimbra Protocol-based methods for bone density or fractures; this is clinic practice, individual results vary, and further studies are needed.
• Never on your own: please do not take high doses of vitamin D without medical supervision and regular blood tests.

How much calcium do you need for osteoporosis, and from which sources?

At least 700 mg a day, preferably from food: NOGG advises at least 700 mg of calcium a day, preferably from the diet, with supplements for people who do not get enough from food [7], and the NHS says adults need 700 mg a day [15].

• Plant foods we use: ragi (finger millet) has about 364 mg of calcium per 100 g, and drumstick (moringa) leaves about 314 mg per 100 g, according to the Indian Food Composition Tables 2017 [16]. The US National Institutes of Health notes that calcium from some plants is absorbed much less well, because they contain compounds that bind it [17].
• Leafy greens: in this osteoporosis plan we allow leafy greens such as kale and broccoli.
• Milk: as clinic practice we remove raw (unpasteurised) milk; the US Centers for Disease Control and Prevention says pasteurised milk offers the same nutritional benefits without the infection risks of raw milk [18]. Other milk products are allowed. In a meta-analysis of 195,102 women, milk intake was not linked with hip fracture either way [19].
• Calcium bisglycinate instead of calcium carbonate: as clinic practice we use calcium bisglycinate, because we find calcium carbonate less well absorbed.
• What the research shows: calcium carbonate was poorly absorbed on an empty stomach by people with very low stomach acid, but normally with a meal [20], and in 37 healthy adults it was absorbed as well as calcium citrate when taken with food [21]. We found no published human study of calcium bisglycinate on absorption, bone density or fractures, so further studies are needed.
• Supplements, stated plainly: in a 2015 BMJ meta-analysis of 59 trials, calcium from food or supplements raised bone density by only 0.6% to 1.8% [22]; calcium supplements without vitamin D were linked with more heart attacks in a 2010 BMJ meta-analysis [23], while NOGG concludes they may increase kidney stones but not heart disease [7]. The upper limit is 2,000 to 2,500 mg of calcium a day for adults [17].

Do vitamin K2 (MK-7), magnesium, collagen, protein and omega-3 help bones?

The evidence is mixed in the studies below; we use these nutrients as clinic practice, within official limits where one exists, and state the research for each.

• Vitamin K2 (MK-7): in a 3-year trial of 244 healthy postmenopausal women, MK-7 slowed bone loss at the lower spine and the hip neck, but not at the whole hip [24]; a 2022 meta-analysis of 16 trials found better spine bone density, with fewer fractures only after one study was left out [25], and a long-term review found more (non-serious) side effects [26].
• Blood thinners: vitamin K can interact with warfarin and similar medicines, and people taking them need a steady vitamin K intake, according to the US National Institutes of Health [27]. Tell us if you take one.
• Magnesium: a meta-analysis in the journal Bone linked higher magnesium intake with higher hip bone density in older adults, with no link to fractures found [28]; the upper limit from supplements is 350 mg of elemental magnesium a day for adults [29].
• Collagen: in a 12-month trial of 131 postmenopausal women, specific collagen peptides raised spine and hip-neck (femoral neck) T-scores slightly more than placebo [30]; one author works at a collagen research institute.
• Protein: a National Osteoporosis Foundation meta-analysis found a small benefit of higher protein intake for spine bone density and no adverse effects [31]; NOGG notes that protein supplements did not change bone density in 30 trials [7].
• Omega-3: in a 2019 meta-analysis of 28 trials, low-quality evidence suggested a possible small rise in spine bone density, but the result was uncertain and there were no fracture data [32].

What is the best diet for osteoporosis? Salt, caffeine, alcohol and soft drinks

NOGG advises no more than 2 units of alcohol a day and stopping smoking [7]; as clinic practice we also restrict salt, caffeine and soft drinks, alongside our usual home-cooked diet with no processed foods.

• Alcohol and smoking: the NHS advises no more than 14 units of alcohol a week and links smoking with a higher risk of osteoporosis [15].
• Soft drinks: in the Framingham Osteoporosis Study, women who drank cola daily had 3.7% lower bone density at the hip neck than those who drank less than one a month; other fizzy drinks showed no link [33].
• Salt and caffeine: NOGG does not include salt or caffeine in its advice [7]; restricting them is our clinic practice, individual results vary, and further studies are needed.

What exercise is best for osteoporosis? Strength, impact and balance

NOGG advises a combination of regular weight-bearing and muscle-strengthening exercise suited to each person, with balance exercise for people at risk of falls [7], and supports the Strong, Steady and Straight expert consensus on exercise for osteoporosis [34].

• Supervised strength and impact training: in the LIFTMOR trial of 101 postmenopausal women with low bone mass, 8 months of supervised high-intensity strength and impact training raised spine bone density by 2.9% (compared with a 1.2% fall with home exercise), with one minor adverse event [35].
• Falls: in a Cochrane review of 108 trials (23,407 people), exercise lowered the rate of falls by 23%, and balance and functional exercise by 24% [36].
• Exercises to avoid: NOGG advises care with repeated forced forward bending of the spine [7]; we adapt yoga and avoid sudden forward bending and twisting for people with a weak spine.
• At Cure4Pain: supervised strength and impact training, balance work, adapted yoga and falls prevention at home are part of the plan; individual results vary, and further studies are needed.

What medicines and injections treat osteoporosis?

Medicines lower fracture risk: in a Cochrane review of 11 trials (12,068 women), alendronate lowered spine fractures by 45%, and hip fractures by 53% in women who had already had a fracture [37]; NHS options include bisphosphonates, denosumab, romosozumab, hormone therapy, teriparatide and raloxifene [38]. Bisphosphonates are taken as tablets or as a yearly zoledronate infusion; denosumab, teriparatide and romosozumab are given as injections.

• At Cure4Pain: Dr Krushal Pabari prescribes and manages osteoporosis medicines, including bisphosphonates, denosumab and teriparatide, under clinical guidance from Team Cure4Pain, in coordination with your existing consulting physician.
• How long: NOGG advises oral bisphosphonates for at least 5 years and zoledronate for at least 3 years before fracture risk is reassessed [7].
• Denosumab: never stop or delay it without a follow-on medicine: in an analysis of the FREEDOM trial, spine fractures rose from 1.2 to 7.1 per 100 people a year after stopping, often several at once [39], and NOGG says it must not be stopped without an alternative treatment [7].
• Rare side effects: NOGG reports jaw osteonecrosis (10 to 100 per 100,000 person-years with bisphosphonates) and unusual thigh fractures (3.2 to 50 per 100,000 person-years); report any unexplained thigh, groin or hip pain [7]. We explain these before treatment.

Does hormone therapy help bones after menopause?

Hormone therapy protects bone but has other risks: in the Women’s Health Initiative trial of 16,608 women, estrogen plus progestin lowered fractures by 24% and raised hip bone density by 3.7%, but the overall balance of benefits and risks showed no net benefit, even in women at high fracture risk [40].

• Guideline view: NOGG advises starting hormone therapy for osteoporosis mainly in younger postmenopausal women (aged 60 or under) at low risk of its side effects [7].
• At Cure4Pain: Dr Krushal Pabari considers and prescribes menopause hormone therapy in-house, after weighing the benefits and risks for each woman.

What happens after an osteoporosis fracture?

We do not treat fractures. After a fracture, we work with your orthopaedic doctor on bone health, tests and medicines, because a fragility fracture is a key reason NOGG gives for assessing and treating osteoporosis [7].

How long does it take to improve bone density?

Bone density changes slowly: meaningful change on DEXA is usually seen only after 6 to 9 months and can take up to 2 years. This is a clinic observation; individual results vary, and further studies are needed. We repeat blood tests every 3 months and ask for a DEXA scan every year.

• What the research shows: the LIFTMOR trial measured change after 8 months [35], and the K2 trial over 3 years [24].

When should I get urgent help?

Get urgent medical care for sudden severe back pain, especially after a fall or lifting, or for pain and difficulty moving after a fall, because these can be signs of a fracture; NOGG advises a spine fracture check for sudden back pain in people with risk factors [7]. Call 112 in India, 911 in the US or 999 in the UK if you cannot move or the pain is severe. Cure4Pain does not treat sudden or severe pain.

Does Cure4Pain work with my own doctor?

Yes. We work alongside your existing consulting physician, orthopaedic doctor, endocrinologist or gynaecologist, share our findings with them, and any change to medicines is made under clinical guidance from Team Cure4Pain, in coordination with them.

What happens at an osteoporosis consultation?

After your DEXA scan and blood tests, your first consultation (in Mumbai or online) covers your history, fractures, falls, medicines, menopause, diet, activity and test results. You then receive a written plan for vitamin D, calcium and other nutrients, diet, exercise and medicines. We see adults and young people aged 16 and over. Follow-up reviews with blood tests are planned every 3 months. Individual results vary, and further studies are needed.

Evidence: key studies

Who treats you

• Dr Krushal PabariMD, PGCP - Rheumatic & Musculoskeletal Diseases. Assistant Professor, Cooper Hospital; Guest Professor, CMP Homoeopathic Medical College.
• AT. Chintan Dalal, N.D.BNYS, R.AP. Functional nutrition and Coimbra Protocol practitioner.

Consultations look at the whole person: alongside the medical and nutritional plan, we bring a strong interest in behavioural science to counselling on stress, sleep and lasting lifestyle change.

How consultations work: Mumbai or online worldwide

Book through our patient portal. You can see us in person at our clinic in Malad West, Mumbai, or online from anywhere. Your first consultation reviews your history and tests; we then agree a plan together and set the monitoring schedule.

Related conditions and articles

• Osteoarthritis & Joint PainHip, hand and joint pain from osteoarthritis, treated without surgery.
• Knee Pain & Knee ArthritisKnee pain, stiffness and osteoarthritis, treated without surgery.
• Ankylosing SpondylitisInflammatory back pain and stiffness, often with HLA-B27.
• Hypothyroidism (Underactive Thyroid)Underactive thyroid; vitamin D, B12, iron, diet and thyroid care.

• Back, neck and joint pain
• Coimbra Protocol

This page is for education and does not replace medical advice. Do not start, stop or change any medicine or supplement without medical guidance.

References

1. NHS. Osteoporosis. nhs.uk/conditions/osteoporosis

2. Salari N, et al. The global prevalence of osteoporosis in the world: a comprehensive systematic review and meta-analysis. J Orthop Surg Res 2021;16(1):609. doi:10.1186/s13018-021-02772-0

3. Anupama DS, et al. Burden of Osteopenia and Osteoporosis Among Postmenopausal Women in India: A Systematic Review and Meta-Analysis. J Midlife Health 2022;13(2):107-114. doi:10.4103/jmh.jmh_207_21

4. Yao P, et al. Vitamin D and Calcium for the Prevention of Fracture: A Systematic Review and Meta-analysis. JAMA Netw Open 2019;2(12):e1917789. doi:10.1001/jamanetworkopen.2019.17789

5. LeBoff MS, et al. Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults. N Engl J Med 2022;387(4):299-309. doi:10.1056/NEJMoa2202106

6. Sanders KM, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA 2010;303(18):1815-22. doi:10.1001/jama.2010.594

7. Gregson CL, et al. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos 2022;17(1):58. doi:10.1007/s11657-022-01061-5

8. Burt LA, et al. Effect of High-Dose Vitamin D Supplementation on Volumetric Bone Density and Bone Strength: A Randomized Clinical Trial. JAMA 2019;322(8):736-745. doi:10.1001/jama.2019.11889

9. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), US National Institutes of Health. Osteoporosis. niams.nih.gov/health-topics/osteoporosis

10. Raj M, et al. Prevalence of osteoporosis in healthy adult males in India measured by dual-energy-X-ray absorptiometry: A systematic review and meta-analysis. Indian J Med Res 2026;164(4):575-583. doi:10.25259/IJMR_552_2026

11. NHS. Osteoporosis: causes. nhs.uk/conditions/osteoporosis/causes

12. NHS. Rickets and osteomalacia. nhs.uk/conditions/rickets-and-osteomalacia

13. NHS. Osteoarthritis. nhs.uk/conditions/osteoarthritis

14. Office of Dietary Supplements, US National Institutes of Health. Vitamin D: Fact Sheet for Health Professionals. ods.od.nih.gov/factsheets/VitaminD-HealthProfessional

15. NHS. Osteoporosis: prevention. nhs.uk/conditions/osteoporosis/prevention

16. Longvah T, et al. Indian Food Composition Tables 2017. National Institute of Nutrition, Indian Council of Medical Research. The values on this page come from a digitised copy of IFCT 2017, not from the book itself. nin.res.in/ebooks/IFCT2017.pdf

17. Office of Dietary Supplements, US National Institutes of Health. Calcium: Fact Sheet for Health Professionals. ods.od.nih.gov/factsheets/Calcium-HealthProfessional

18. US Centers for Disease Control and Prevention (CDC). Raw Milk. cdc.gov/food-safety/foods/raw-milk.html

19. Bischoff-Ferrari HA, et al. Milk intake and risk of hip fracture in men and women: a meta-analysis of prospective cohort studies. J Bone Miner Res 2011;26(4):833-9. doi:10.1002/jbmr.279

20. Recker RR. Calcium absorption and achlorhydria. N Engl J Med 1985;313(2):70-3. doi:10.1056/NEJM198507113130202

21. Heaney RP, et al. Absorption of calcium as the carbonate and citrate salts, with some observations on method. Osteoporos Int 1999;9(1):19-23. doi:10.1007/s001980050111

22. Tai V, et al. Calcium intake and bone mineral density: systematic review and meta-analysis. BMJ 2015;351:h4183. doi:10.1136/bmj.h4183

23. Bolland MJ, et al. Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ 2010;341:c3691. doi:10.1136/bmj.c3691

24. Knapen MH, et al. Three-year low-dose menaquinone-7 supplementation helps decrease bone loss in healthy postmenopausal women. Osteoporos Int 2013;24(9):2499-507. doi:10.1007/s00198-013-2325-6

25. Ma ML, et al. Efficacy of vitamin K2 in the prevention and treatment of postmenopausal osteoporosis: A systematic review and meta-analysis of randomized controlled trials. Front Public Health 2022;10:979649. doi:10.3389/fpubh.2022.979649

26. Zhou M, et al. Efficacy and safety of vitamin K2 for postmenopausal women with osteoporosis at a long-term follow-up: meta-analysis and systematic review. J Bone Miner Metab 2022;40(5):763-772. doi:10.1007/s00774-022-01342-6

27. Office of Dietary Supplements, US National Institutes of Health. Vitamin K: Fact Sheet for Health Professionals. ods.od.nih.gov/factsheets/VitaminK-HealthProfessional

28. Groenendijk I, et al. Impact of magnesium on bone health in older adults: A systematic review and meta-analysis. Bone 2022;154:116233. doi:10.1016/j.bone.2021.116233

29. Office of Dietary Supplements, US National Institutes of Health. Magnesium: Fact Sheet for Health Professionals. ods.od.nih.gov/factsheets/Magnesium-HealthProfessional

30. König D, et al. Specific Collagen Peptides Improve Bone Mineral Density and Bone Markers in Postmenopausal Women-A Randomized Controlled Study. Nutrients 2018;10(1). doi:10.3390/nu10010097

31. Shams-White MM, et al. Dietary protein and bone health: a systematic review and meta-analysis from the National Osteoporosis Foundation. Am J Clin Nutr 2017;105(6):1528-1543. doi:10.3945/ajcn.116.145110

32. Abdelhamid A, et al. The Relationship Between Omega-3, Omega-6 and Total Polyunsaturated Fat and Musculoskeletal Health and Functional Status in Adults: A Systematic Review and Meta-analysis of RCTs. Calcif Tissue Int 2019;105(4):353-372. doi:10.1007/s00223-019-00584-3

33. Tucker KL, et al. Colas, but not other carbonated beverages, are associated with low bone mineral density in older women: The Framingham Osteoporosis Study. Am J Clin Nutr 2006;84(4):936-42. doi:10.1093/ajcn/84.4.936

34. Brooke-Wavell K, et al. Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. Br J Sports Med 2022;56(15):837-846. doi:10.1136/bjsports-2021-104634

35. Watson SL, et al. High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. J Bone Miner Res 2018;33(2):211-220. doi:10.1002/jbmr.3284

36. Sherrington C, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev 2019;1(1):CD012424. doi:10.1002/14651858.CD012424.pub2

37. Wells GA, et al. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev 2008(1):CD001155. doi:10.1002/14651858.CD001155.pub2

38. NHS. Osteoporosis: treatment. nhs.uk/conditions/osteoporosis/treatment

39. Cummings SR, et al. Vertebral Fractures After Discontinuation of Denosumab: A Post Hoc Analysis of the Randomized Placebo-Controlled FREEDOM Trial and Its Extension. J Bone Miner Res 2018;33(2):190-198. doi:10.1002/jbmr.3337

40. Cauley JA, et al. Effects of estrogen plus progestin on risk of fracture and bone mineral density: the Women’s Health Initiative randomized trial. JAMA 2003;290(13):1729-38. doi:10.1001/jama.290.13.1729

41. Sakhaee K, et al. Meta-analysis of calcium bioavailability: a comparison of calcium citrate with calcium carbonate. Am J Ther 1999;6(6):313-21. doi:10.1097/00045391-199911000-00005