Approach to personalizing the treatment of osteoporosis.

A 58-year-old woman presented to the endocrinology clinic for osteoporosis. She had no history of adult fractures. Her only medical condition was hypothyroidism, for which she was treated with levothyroxine. She reported a long-term vegan eating pattern motivated by general health concerns. She took calcium and vitamin D3 supplements daily. For exercise, she attended OsteoStrong twice weekly and walked 3-4 miles daily. She reported no history of falls. Her last menstrual period was 4 years prior, and she continued to experience mild-to-moderate vasomotor symptoms. On physical examination, she appeared well, with normal gait and posture. Her height was 5′3″, weight 162 lb, and BMI 28.7 kg/m 2 . Laboratory results included normal calcium, phosphorous, creatinine, alkaline phosphatase, 25-hydroxyvitamin D, and TSH. DXA demonstrated a lumbar spine T-score of −2.0, left total hip T-score of −3.2, and left femoral neck T-score of −3.0. Trabecular bone score (TBS) was moderately degraded (1.253). She strongly preferred to avoid pharmacologic therapy and was interested exclusively in nutrition and exercise interventions to support bone health. Because osteoporosis was her primary health concern and her vegan diet was motivated by perceived health benefits, she was advised that incorporating dairy and/or other animal protein sources may better support bone health. She was counseled to consume protein with each meal, from a variety of whole food sources. She was advised that the evidence on the effectiveness of Osteostrong is inconsistent and low quality, and there is limited safety information ( 9 ). She was referred to a small group, in-person resistance and impact training program supervised by an exercise physiologist. Considering her total hip T-score of −3.2, treatment with romosozumab was recommended, but was not authorized by her insurance and she declined any alternative pharmacotherapy. One year later, she remained adherent to twice-weekly supervised resistance and impact exercise, continued calcium and vitamin D supplementation, and had added poultry and fish—but not dairy—to increase protein intake. Repeat DXA showed a significant 4.3% increase in lumbar spine BMD (T-score −1.6) and a nonsignificant 4.0% increase at the left total hip (T-score −3.0) and left femoral neck (T-score −2.8). After discussing bone health with peers in her exercise class, she inquired about menopausal hormone therapy (MHT) for vasomotor symptoms and skeletal protection. Despite some concerns about potential risks, she viewed MHT as a more natural approach that aligned with her healthcare preferences. In the absence of contraindications, transdermal estradiol and oral progesterone were initiated.

Consideration of patient's beliefs, values, and preferences is a cornerstone of evidence-based medicine ( 10 ), yet a review of English language clinical practice guidelines for osteoporosis found that less than half of guidelines reviewed (39%) mentioned patient beliefs, values, or preferences ( 11 ). We posit that anticipating, eliciting, and responding to these factors can facilitate more effective treatment plans.

Comprehensive osteoporosis care extends beyond pharmacologic therapy to include nutrition and exercise counseling. As with medications, patients may hold values and preferences that require individualized recommendations. Because behavior change is more likely when goals are specific and actionable, tailored guidance is essential. For example, in Case 2, a patient following a vegan diet was counseled to ensure adequate protein intake through consistent consumption of diverse protein sources at each meal ( 19 ). A specific action plan for this patient might look like: “I will eat two different protein-rich foods (how much), three times a day (how often), at breakfast, lunch, and dinner (when).” For both diet and exercise behaviors, some patients may be motivated to make substantial changes, where others may benefit from making small, attainable, and gradual changes, even if initial goals are below recommended ( 20 , 21 ). There is evidence that peer support and group-based physical activity programs can be effective for increasing physical activity ( 22 , 23 ). In the context of osteoporosis, peer support could influence medication taking decisions and reduce medication hesitancy as in Case 2. For many clinicians, formal training in nutrition has been limited, and counseling for osteoporosis often focuses primarily on calcium and vitamin D, an emphasis that is also reflected in current clinical practice guidelines. While it is true that many patients do not meet recommended intake levels of these 2 essential nutrients, this represents a narrow view of nutrition. Bone is a living tissue, and its growth and maintenance depend on adequate intake of a full range of essential nutrients. Furthermore, aspects of the whole diet influence bone health and whole-body health. For example, energy intake influences adiposity and obesity. Fiber intake influences gut health. Protein and amino acid intake influences acid–base balance. Nutrition plays an important role in the most prevalent chronic diseases, including osteoporosis, but there is a great time lag before benefits or harms of dietary choices surface in these long latency diseases. Thus, good nutrition is important for prevention and rarely serves as a silver bullet to “cure” a disorder. Expert panels recommend food before supplements to achieve adequate nutrient intake ( 24 ). Patients should be counseled to choose a dietary pattern that meets their nutrient requirements, with an emphasis on nutrient-dense foods ( Table 2 ) ( 25 ). Key nutrition talking points for osteoporosis care Start with food first . Nutrient-dense foods give your body a full package of vitamins, minerals, protein, and other natural compounds that work together to support bone health. Include calcium-rich foods daily. Aim for 1000-1200 mg of calcium per day, preferably from food. Three servings of dairy typically meet this goal without the need for supplements. For plant-based diets, calcium-fortified soy milk is a well-absorbed option, while other plant-based milks vary in calcium content and absorption has not been studied. Prioritize high-quality protein at most meals. Protein is essential for bone strength—about half of bone is made of protein. What is “high-quality” protein? High-quality proteins contain all the building blocks your body needs (called essential amino acids) and are easy to absorb. These proteins are especially effective at supporting muscle and bone. If you follow a vegetarian or vegan diet, you can still meet your protein needs for bone health. Plant-based foods often contain lower amounts of protein, so paying attention to your total protein intake is important. Plant proteins may not provide the full complement of essential amino acids, so combining different sources across the day helps ensure you’re getting everything your bones need. Aim for a mix of soy foods (tofu, tempeh, edamame), beans, lentils, nuts, seeds, whole grains, and—if you’re a lacto-ovo vegetarian—eggs and dairy. Keep salt intake on the lower side. Too much salt can increase calcium loss from bones and raise blood pressure. Cooking at home and choosing less-processed foods helps. Use supplements when food isn’t enough. If you’re low in calcium, vitamin D, or other nutrients, supplements can help fill the gap—but they work best alongside a healthy diet, not instead of one. Remember that supplements don’t provide fiber. Fiber from plant foods supports a healthier gut microbiome, which plays a role in overall health—including bone health. Patients are bombarded with marketing claims about dietary supplements and bone health, largely without evidence for benefits or risks. Dietary supplements are recommended when patients are unable to meet their nutrient requirements through food alone. Supplements generally deliver one or a limited number of nutrients, in contrast to whole foods, which provide a diverse matrix of vitamins, minerals, and bioactive compounds that may contribute to bone health. A recent review concluded that few micronutrients or bioactive compounds have evidence comparable to calcium (particularly from dairy) and exercise for supporting bone health ( 26 ). Unlike whole foods, dietary supplements lack the food matrix and dietary fiber that promote calcium absorption and gut health through fermentation and production of short-chain fatty acids ( 27 ). The standard of care for nutritional advice for patients with osteoporosis has been to take calcium and vitamin D supplements. If the patient avoids dairy products that are rich in calcium and vitamin D (not fortified in all countries), supplementation is likely to be necessary to meet the recommendations for the general population of 1000 mg calcium/day for men aged 51-70 years or 1200 mg calcium/day for men over 70 years and women over age 50 years and 15 ug (600 IU)/day vitamin D for adults increasing to 20 µg (800 IU)/day after age 71 years ( 24 ). Earlier Endocrine Society guidelines recommended 1500-2000IU/day of vitamin D for individuals at risk for osteoporosis ( 28 ). However, subsequent large trials found no skeletal benefit from supplementation ( 29 , 30 ), prompting debate regarding optimal vitamin D levels ( 31 ). Current guidance does not recommend routine screening or specific intake targets ( 32 ). When recommending calcium or vitamin D supplements, there is a wide variety of choices that can accommodate patient preferences. For calcium, calcium carbonate is the least expensive salt and most concentrated. Calcium is better absorbed in divided doses of less than 500 mg. For those following a vegan eating pattern, Vitamin D 2 can be recommended. Adequate vitamin D status facilitates calcium absorption, but this occurs well before current recommendations for vitamin D. Because vitamin D-mediated calcium absorption involves gene activation, which takes time, the 2 nutrients do not have to be coingested. Other micronutrients are needed for bone tissue maintenance and repair, but the evidence base is much less for the benefit of micronutrient supplements ( 33 ). The evidence for bioactive foods and ingredients remains limited and is largely focused on prevention or attenuation of bone loss rather than treatment of established osteoporosis. Polyphenol-rich foods such as prunes, soy, tea, and blueberries are among the more promising candidates, but optimal dosing, duration, and target populations remain to be established. A framework outlining the evidence needed to support health recommendations for bioactive foods has been published ( 33 ), and a similar framework for bioactive supplements is currently under review. Exercise supports fracture prevention through 2 primary mechanisms: reducing falls and maintaining or improving bone mineral density. Accordingly, effective programs typically include balance or functional training (or Tai Chi) and resistance training, often combined with impact exercise. There is high-certainty evidence that exercise can prevent falls (rate ratio 0.77, 95% confidence interval (CI) 0.71-0.83), 59 studies, 12 981 participants, and there is some evidence, albeit lower certainty, that exercise interventions may prevent fractures (risk ratio or RR 0.62; 95% CI 0.42-0.90) ( 34-37 ). When it comes to the types of exercise programs, analyses from systematic reviews suggest that exercise programs targeting training of balance, functional tasks (including gait), and coordination, sometimes combined with other types of exercise such as resistance training are effective for reducing falls, as is Tai Chi, whereas the evidence for other types of exercise, such as walking, dance, or resistance exercise alone, is less certain ( 36 ). Balance and functional training programs often target specific aspects of balance, such as anticipatory control, dynamic stability, functional stability limits, reactive control, and joint mobility (eg, ankles, hips) ( 38 ). Exercise program delivery by a healthcare professional (eg, physical therapist) may be more effective than programs delivered by individuals who are not healthcare or exercise professionals because they are tailored to be sufficiently challenging and address an individual's impairments or activity limitations ( 39 ). While physical activity guidelines often recommend balance exercise specifically for older adults ( 40 ), that may be because fall prevention is rarely studied in middle-aged adults, so there is no evidence on which to base guidelines. Because of the relevance of falls in fracture prevention, balance and functional training should be recommended to all adults at risk of fractures. In addition, fall risk assessment is associated with a reduction in fracture risk and should be performed alongside fracture risk assessment to further tailor interventions ( 35 ). Fall risk assessment algorithms have been proposed ( 41 , 42 ), and start with basic fall risk screening questions ( 41 ). Impact exercise, resistance exercise, or both in combination may maintain or increase BMD, and are thought to increase the forces on bone via ground reaction forces or muscle pull on bone ( 43-46 ). Weight-bearing or impact are terms often used interchangeably to describe exercise that is osteogenic but refer to a range of activities that may have variable efficacy. For example, walking or dancing are low-impact activities, whereas drop or depth jumps are high-impact activities. Walking is often recommended as weight-bearing or impact exercise, but in people with low bone mass, walking was reported to have no effect on total hip or femoral neck BMD, and a modest effect on spine BMD (mean difference 0.02 g/cm 2 , 95% CI [0.00, 0.03], 341 participants) ( 47 ). Many trials that examine the effects of impact exercise on bone often combine it with other types of exercise, most often resistance training, which may be the best option if: (1) the goal is to maintain/increase BMD and (2) the individual can tolerate progressive impact exercise. In addition, it has been proposed that low-intensity resistance or impact exercise may not be enough of a stimulus, and moderate- or high-intensity exercise is effective for improving BMD ( 48 , 49 ). There is evidence from meta-analyses of randomized controlled trials in postmenopausal women that resistance training (often with impact exercise) may improve BMD at the lumbar spine, hip and femoral neck ( 48 ). There are fewer trials in individuals with low bone mass, but one meta-analyses reported that resistance training may increase femoral neck (mean difference 0.02 g/cm 2 ; 95% CI = 0.01-0.03; 521 participants, 5 studies) but not lumbar spine BMD or total hip BMD ( 44 ); there is a need for more trials of resistance and impact training in people with low bone mass to address the low precision in existing meta-analyses. To preserve both muscle and bone, one might recommend resistance training aligned with what is reported to be best for muscle strength outcomes in that the 2026 American College of Sports Medicine Position Stand on Resistance Training: resistance training using higher intensity loads (≥80% one-repetition maximum), through a complete range of motion, for 2-3 sets, at the beginning of training sessions (ie, resistance training first, not other types of training), and ≥2 sessions per week ( 50 ). Wearing weighted vests (during daily activities or exercise) does not improve bone strength when compared to control or exercise alone ( 51 , 52 ). Research on the efficacy of Osteostrong is primarily observational, with inconsistent findings that are very low certainty, and evidence on safety is very limited ( 9 ). Some clinicians or patients are concerned about exercise-related injuries, especially if patients are designing their own programs and performing them without guidance on form or tailoring to fall or fracture risk or physical functioning. Giving restrictive nonspecific advice (eg, don’t bend, don’t lift more than 5 lbs) creates fear and is a disincentive to physical activity. Instead, for high-risk individuals, discuss the types of movements that may need to be performed with caution eg, rapid, repetitive, weighted, sustained, or end-range lateral or forward flexion or twisting movements ( 53 ). Individuals should include, or progress to, moderate-impact (eg, hopping) or high-impact (eg, drop/depth jumps) exercise only if appropriate in the context of their fracture risk or other health conditions. For example, individuals with very high fracture risk (eg, history of hip or vertebral fracture) or certain health conditions may not be able to tolerate (or may not want to risk) doing impact exercise or heavy external loads; examples include spondyloarthropathy, arthritis in the lower extremities, pelvic organ prolapse, disc herniation, or stress incontinence. They could pursue alternative options that involve moderate-to-high muscle forces without impact or heavy external loads, such as power training, or strategic exercise selection where one increases difficulty without adding weight by altering position of the body relative to gravity, the number of limbs involved, or other factors. It is ideal if patients have access to or are willing to pay for exercise program design and instruction on form and progression by a certified exercise physiologist, strength and conditioning coach, or physical therapist with expertise in strength and impact training and osteoporosis. If they do not, they could consider lower-cost options if available, such as small group in-person training (which is lower cost than 1:1 training), reputable online resources ( Fig. 2 ), or paying for a few sessions with an exercise physiologist to design a program they can follow independently. BoneFit™ is a continuing education program that trains exercise professionals in osteoporosis-specific exercise prescription, and patients may benefit from working with a BoneFit™-trained provider. Table 3 summarizes selected exercise resources clinicians can recommend. In general, the benefits of having a larger proportion of the population participating in resistance and balance training outweigh the risks, so clinicians should encourage participation and ensure that patients leave with a plan to start balance, strength, and, if appropriate, impact exercise that is aligned with their fall or fracture risk, preferences, and needs. Evidence-based exercise recommendations to help reduce the risk of fractures. Reprinted with permission from Osteoporosis Canada. Evidence-based patient education resources to support exercise and nutrition in osteoporosis The principles discussed above can be integrated into a personalized treatment framework that combines fracture risk assessment with evidence-based lifestyle interventions, pharmacologic therapy, and patient preferences. Figure 3 summarizes a practical approach to individualized osteoporosis management that can be adapted according to fracture risk, treatment goals, and patient values. Personalized treatment approach to postmenopausal osteoporosis. Clinical risk assessment integrates fracture history, bone mineral density, and other risk factors to guide treatment selection. Foundational therapy—including nutrition, exercise, and patient-centered communication using shared decision-making principles—applies across all risk categories. For individuals at low fracture risk, management focuses on lifestyle optimization, periodic reassessment, and preventive pharmacotherapy when aligned with patient values and preferences. Patients at high fracture risk generally require antiresorptive therapy in addition to foundational measures, whereas those at very high fracture risk should be considered for upfront anabolic therapy or a potent antiresorptive agent. Treatment intensity and selection should be individualized and adjusted to align with patient goals and preferences. Sequential antiresorptive therapy is recommended following anabolic treatment to maintain skeletal benefits and reduce fracture risk. Aging and the hormonal changes of menopause are primary drivers of bone loss, yet despite the predictable decline in bone density across the menopausal transition ( 54 ), few women are offered pharmacologic therapy for osteoporosis prevention. The FDA has approved 3 classes of medications for prevention—estrogen, SERMs, and bisphosphonates—but they are infrequently prescribed for this purpose. More proactive strategies, including appropriate use of preventive medications, could meaningfully reduce the burden of osteoporosis and fractures among postmenopausal women. The 2024 ASBMR/BHOF Task Force position statement on goal-directed osteoporosis therapy recommends selection of osteoporosis therapy based on an individual's fracture risk, with the overarching goal of achieving a T-score target > −2.5 within a reasonable time frame ( 55 ). Current guidelines stratify patients into high-risk and very-high-risk categories, with up-front anabolic therapy recommended for those at very high risk ( 56 ). Although there is no universally accepted definition of “very high fracture risk,” factors such as T-scores below −3.0, recent fractures, fractures while on approved osteoporosis medication, multiple fractures, fracture while taking medication known to cause skeletal harm, or very high FRAX scores (>30% major osteoporotic or > 4.5% hip fracture risk) are cited ( 57 ). In practice, however, treatment selection is shaped by far more than clinical risk alone; cost, insurance coverage, access to care, and patient values and preferences all influence the final therapeutic plan ( 58-60 ). Unlike therapies for many other chronic diseases, most osteoporosis treatments are not typically continued indefinitely. It is therefore striking that age and life expectancy have not been incorporated into postmenopausal osteoporosis treatment guidelines. The ASBMR/BHOF position statement, for example, outlines treatment sequences expected to allow more than 50% of women to achieve a T-score above −2.5 within approximately 3 years ( 55 ). For a woman with a total hip T-score of −3.1 or a lumbar spine T-score of −3.7, the recommended sequence of goal-directed therapy is romosozumab followed by denosumab. Although this sequence was highly effective in the FRAME trial and associated with continued gains in bone mineral density ( 61 ), its long-term implications warrant consideration in younger women who may have a life expectancy of 30 years. We have a decade of safety data for denosumab ( 62 ), yet concerns persist about the implications of longer-term use, including the potential risk for jaw osteonecrosis and uncertainty about longer-term efficacy. An alternative approach for women with longer life expectancy may be to use sequential anabolic therapy, followed by a bisphosphonate, for those with very low baseline T-scores. Although evidence remains limited, repeat courses of teriparatide or romosozumab can be considered (abaloparatide is still capped at 24 months), with the ASBMR/BHOF position statement noting that a second anabolic course may be appropriate for individuals who remain at or return to very high fracture risk. A small study showed that repeat courses of romosozumab produced additional gains in bone density at the spine and hip when the interval therapy was a bisphosphonate or teriparatide; patients bridged with denosumab experienced gains at the spine only ( 63 ). These observations highlight the need for treatment algorithms that explicitly incorporate life expectancy and support more flexible, individualized sequencing across the multi-decade course of osteoporosis care. One additional consideration for younger postmenopausal women is the potential role of menopause hormone therapy. Menopause hormone therapy is approved for prevention, but not for the treatment of osteoporosis. In the Women's Health Initiative, estrogen therapy was associated with significant reductions in hip, spine, wrist, and total fractures, with consistent effects observed in both the estrogen-alone and estrogen-plus-progestin arms, despite participants not being selected for low BMD or high fracture risk ( 64 ). Estrogen also produced approximately 3-5% increases in bone mineral density at the hip and spine over 3-6 years ( 65 ). Many postmenopausal women are diagnosed with osteoporosis before age 60, even though routine screening is not recommended until age 65. For these younger postmenopausal women, who have lower absolute fracture risk by virtue of age, menopause hormone therapy may represent a reasonable off-label treatment option in the absence of contraindications, with the added potential benefit of alleviating menopausal symptoms that are common in this age group ( 66 ). Selective estrogen receptor modulators (SERMs) are another option in this population. Raloxifene is FDA-approved for the treatment of osteoporosis, reducing vertebral fracture risk and lowering breast cancer risk in women at elevated risk ( 67 ). Bazedoxifene combined with conjugated equine estrogen is FDA-approved for osteoporosis prevention and the treatment of vasomotor symptoms ( 68 ); this combination does not increase mammographic breast density ( 69 ), and clinical trials evaluating its effects on other markers of breast cancer risk are ongoing ( 70 ). Implementing comprehensive, patient-centered osteoporosis care is limited by time constraints, gaps in clinician training, limited multidisciplinary integration, and inadequate access to long-term lifestyle interventions. Patient-level barriers, including health literacy, socioeconomic factors, and time constraints, further complicate implementation. This manuscript focuses on postmenopausal osteoporosis and does not address osteoporosis in men or secondary osteoporosis. Future efforts should prioritize multidisciplinary training, practical clinical tools, and accessible care models to support personalized osteoporosis care. In the cases above, 2 women in their 50's presented with DXA-defined osteoporosis (T-scores <–3) without prior fractures. Neither met recommended calcium intake, and both were engaging in exercise approaches with limited evidence for skeletal benefit, despite strong motivation to improve bone health through lifestyle change. In Case 1, early surgical menopause, a major osteoporosis risk factor, had not prompted preventive pharmacotherapy. Given their very low BMD and a treatment goal of achieving a T-score >−2.5, up-front anabolic therapy was recommended in both cases. In Case 1, the patient elected to proceed with anabolic therapy and achieved substantial gains in BMD. She also increased her dairy intake and transitioned from walking and hiking to resistance and impact training, sustaining a minor exercise-related injury that underscored the value of supervised instruction. Case 1 demonstrates substantial BMD gains with sequential anabolic therapy aligned with her goals. In Case 2, the patient modified her long-term vegan diet to include lean meats after counseling regarding fracture risk and found support through a group exercise program, which helped reduce her medication hesitancy. Despite initial reluctance and insurance barriers, she ultimately initiated menopausal hormone therapy. Although estrogen alone was unlikely to achieve a target T-score >−2.5 given her very low hip BMD, meaningful gains in BMD were expected, and the approach aligned with her preferences. Case 1's treatment selection and sequencing were perhaps more aggressive than current guidelines, while Case 2's approach was more conservative. Yet both women remained engaged in their treatment plans and remained fracture-free during follow-up—underscoring how individualized, preference-sensitive care can support positive outcomes across a range of therapeutic strategies. In the current clinical environment, endocrinologists are increasingly expected to address a broad range of patient concerns, including questions about nutrition, exercise, and health information encountered online. This requires active listening, eliciting patient values and preferences alongside assessing medical risk, and translating this into personalized, comprehensive treatment plans that integrate lifestyle and pharmacologic therapies within a time-limited clinical setting. A proposed framework for integrating fracture risk assessment, foundational therapy, pharmacologic treatment, and patient preferences is shown in Fig. 3 . By adopting this more comprehensive approach to bone health and by eliciting and responding to patient beliefs, values, and preferences, we can facilitate more effective treatment plans, improve patient engagement in osteoporosis care, and ultimately reduce fracture risk.

Strategies from motivational interviewing can help to guide discussions about treatment recommendations, alternative options, and problem-solving barriers ( 18 ). Motivational interviewing is a collaborative, person-centered communication style designed to strengthen a person's own motivation and commitment to making behavior change. We describe a selection of motivational interviewing strategies that may be particularly amenable to osteoporosis care. These strategies can be used when discussing medication, nutrition, and exercise; however, examples pertaining to medication are provided here. The OARS framework—using o pen-ended questions, a ffirmations, r eflective listening, and s ummaries—can be used to understand patient perspectives. Open-ended questions are intended to invite patients to share their perspective without being limited to a specific direction, eg, “What have you heard about bone health?” Affirmations are statements that recognize patients' strengths and efforts, eg, “You’ve done a lot of research on this, I can see the dedication you have to your health.” Reflective listening, is meant to foster trust and ensure understanding, eg, “It sounds like you’ve heard some really scary things about medications.” Summaries are similar to reflective listening and often pull together several points, eg, “It sounds like you really want to improve your bone density but are worried about the side-effects of medications. You’re not sure what to do. Did I leave anything out?” Providing information effectively can be done through asking permission (eg, “can I share some information about side-effects with you? Or “Is it OK if I share some of the concerns I have with that plan?”), and following an elicit-provide-elicit sequence (eg, “What do you know about osteoporosis?,” “The most effective way to increase bone density is through a combination of medication and health behavior change,” “What are your thoughts about that?”). A final motivational interviewing strategy that may be helpful is decisional balancing, or reviewing the pros and cons, from the patient's perspective, of 2 options. In osteoporosis care, this tool may help to highlight that not taking medications (or another behavior) also comes with risks. Table 1 shows common concerns and example responses using motivational interviewing and other strategies for effective communication. Common concerns and example responses using effective communication strategies