Spring Cleaning for Clinical Practice: Time to Dust Off Osteoporosis Prevention Protocols

As spring ushers in renewal, it's the perfect time to refresh our approach to osteoporosis prevention. Despite significant advances in our understanding of bone health, osteoporosis remains underdiagnosed and undertreated, leading to preventable fractures that diminish quality of life and increase mortality risk. Let's dust off the evidence and revitalize our clinical protocols.

Calcium and Vitamin D: Evidence vs. Enthusiasm

For decades, calcium and vitamin D supplementation has been the cornerstone of osteoporosis prevention. But is this approach helping patients or merely creating false reassurance?

The landmark VITAL (Vitamin D and Omega-3 Trial) and DO-HEALTH trials analyzed by LeBoff et al. (2023) delivered compelling evidence that challenges conventional wisdom. These studies demonstrated that daily supplementation with 2000 IU of vitamin D in generally healthy, vitamin D-replete older adults did not significantly reduce fractures or falls, nor did it meaningfully improve bone mineral density or physical function compared to placebo.

The findings highlight several nuanced considerations:

• Vitamin D alone is insufficient: In the absence of deficiency, vitamin D supplementation by itself does not lower fracture risk.

• Target populations matter: Benefits may be limited to specific high-risk groups, particularly those with documented deficiencies or institutionalized elderly.

• Physiological context is crucial: The body's ability to utilize vitamin D depends on multiple factors including age, renal function, baseline status, and concurrent calcium intake.

While the VITAL trial showed no benefit in the general population, it's worth noting that participants had a mean baseline 25-hydroxyvitamin D level of 30.7 ng/mL, already within normal range. This suggests that supplementing those who are already replete provides little additional benefit and reinforces the importance of targeted rather than universal approaches.

The clinical takeaway? Assess vitamin D status individually rather than blanket-supplementing all older adults. Reserve supplementation for those with documented deficiencies or specific risk factors, and consider that over-supplementation carries both financial costs and pill burden without clear evidence of benefit.

The Exercise Equation: Stronger Than You Think

While supplements get significant attention in clinical conversations, physical activity—particularly resistance exercise—deserves elevated status in our prevention protocols.

Hong & Kim's (2018) comprehensive review established resistance exercise (RE) as the most osteogenic form of physical activity, enhancing both bone mineral density and bone quality. Their analysis revealed several critical insights:

• Mechanical loading principles: Bones respond to dynamic, high-magnitude forces applied at fast rates. This explains why resistance training outperforms activities like swimming or cycling for bone health.

• Site-specific adaptation: Exercise primarily benefits the bones directly loaded during activity, emphasizing the need for whole-body approaches focusing on fracture-prone areas.

• Intensity thresholds matter: To stimulate osteogenesis, resistance exercise must exceed the mechanical load of daily activities—suggesting that progressive overload principles are essential.

The research suggests optimal parameters for bone-building exercise:

• Intensity: High intensity (approximately 80-85% of one-repetition maximum) when feasible and safe

• Frequency: 2-3 sessions per week with 48 hours between sessions targeting the same muscle groups

• Exercises: Multi-joint, compound movements that load the axial skeleton and hip region, including squats, lunges, and stepping exercises

Light walking or swimming, while beneficial for cardiovascular health and overall well-being, simply doesn't provide sufficient mechanical stimulus to meaningfully improve bone health. This distinction is crucial when counseling patients who may believe their daily activities provide adequate bone protection.

Missed Opportunity in Middle Age?

Perhaps the most significant clinical oversight is waiting until "older age" to address osteoporosis prevention, missing a critical window for intervention.

The updated Clinician's Guide from the Bone Health and Osteoporosis Foundation (BHOF), highlighted by LeBoff et al. (2022), emphasizes early identification and intervention. Their research underscores several timely considerations:

• Fracture begets fracture: Any fracture at age 50+ signals imminent elevated risk for subsequent fractures, regardless of trauma severity.

• Timing is critical: Peak bone mass is largely determined by age 30, with accelerated loss occurring during perimenopause and early aging.

• Early intervention window: The first 1-2 years following an initial fracture represent a critical period when intervention may be most effective.

The guide specifically emphasizes that approximately 50% of women and 25% of men will experience an osteoporotic fracture in their lifetime, with mortality rates increasing significantly after hip fractures. Moreover, approximately 80% of patients who suffer a fracture never receive appropriate evaluation or treatment—representing a massive opportunity for improved care.

Most striking is the guide's assertion that "Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures." This challenges the common practice of dismissing fractures based on the presence of "significant trauma," suggesting instead that all fractures in midlife deserve thorough evaluation.

Conclusion: Preventing What's Preventable

It's time to reframe osteoporosis prevention as a proactive, not reactive, part of adult care. Current evidence demands we update our clinical pathways to include:

• Earlier risk assessment, starting in the perimenopausal period or age 50, whichever comes first

• Personalized supplementation based on documented deficiencies rather than age alone

• Prescriptive exercise focusing on progressive resistance training at appropriate intensities

• Early intervention at the first sign of bone loss or fragility fracture

The evidence is clear: fractures aren't inevitable consequences of aging—they're preventable when prevention isn't procrastinated. By dusting off and updating our osteoporosis prevention protocols based on current evidence, we can help patients maintain bone health and quality of life throughout their lifespan.

As clinicians, our spring cleaning task is clear: sweep away outdated approaches and polish our prevention protocols to reflect the best available evidence. Our patients' future independence may depend on it.

LeBoff MS, Greenspan SL, Insogna KL, Lewiecki EM, Saag KG, Singer AJ, Siris ES. The clinician's guide to prevention and treatment of osteoporosis. Osteoporosis International. 2022 Oct;33(10):2049-2102.

LeBoff MS, Chou SH, Ratliff KA, Cook NR, Khurana B, Kim E, Cawthon PM, Bauer DC, Black D, Gallagher JC, Lee IM, Buring JE, Manson JE. The Effects of Vitamin D Supplementation on Musculoskeletal Health: The VITAL and DO-Health Trials. The Journals of Gerontology: Series A. 2023 Jun;78(Suppl 1):73-78.

Hong AR, Kim SW. Effects of Resistance Exercise on Bone Health. Endocrinology and Metabolism. 2018 Dec;33(4):435-444.