Osteoporosis: Thinking outside the box Save

I recently attended a talk at RWCS by Dr. Gina Woods from UC San Diego on osteoporosis. As rheumatologists, most of us manage osteoporosis in some form every single day. If there is one constant in this space, it’s that osteoporosis care keeps evolving. We have newer agents, newer sequencing strategies, and an increasing number of patients asking for “less medicinal” options that go beyond a prescription. Dr. Woods opened by reframing osteoporosis as a comprehensive approach to bone and muscle health rather than a narrow discussion about a DEXA report. Her entire framework was built around four core principles—meals, movement, mindset, and medications.

She started with meals and the basics of nutrition, beginning with calcium. The target she recommended is the familiar 1,000 to 1,200 mg per day, but her emphasis was on practicality: get it through diet when possible—especially dairy and fortified foods—and use supplements simply to fill in the gaps. From there she moved to protein, and I appreciated how explicitly she linked this to the osteoporosis conversation. Protein needs increase with aging for bone and muscle health, and a useful goal is around 1 g/kg/day.

Dr. Woods then addressed dairy in a way that felt particularly relevant for rheumatology clinics. We get questions constantly about whether dairy is “inflammatory,” and we also face the reality of lactose intolerance. Her stance was straightforward: she recommends dairy, not only because it is rich in calcium and protein, but because of its food matrix—foods being more than a list of nutrients on a label. She described distinct structural characteristics that may influence how energy and nutrients are delivered and utilized. She also highlighted fermented dairy as an option with potential gut-health advantages due to its microbial content and, in many cases, better tolerability.

From nutrition she transitioned into movement and the concept of anabolic resistance—how older adults still generate a muscle protein synthesis response after a protein-rich meal, but that response is blunted compared with younger individuals. Clinically, this explains why “just eat more protein” can sometimes fall flat if we do not pair nutrition with an appropriate stimulus. One way to counter this is to increase protein targets in older adults toward 1.0 to 1.2 grams per kilogram per day, and even up to 1.5 grams per kilogram per day in those with chronic disease or individuals trying to regain muscle mass. But she also highlighted something that may be even more powerful: resistance training can improve the skeletal muscle anabolic response to a protein-rich meal in both younger and older adults. Movement does not simply build strength; it amplifies the body’s ability to use the nutrition we are recommending.

She then gave practical exercise targets for older adults that are easy to translate into clinic counseling. The aerobic foundation remains 150 minutes per week of moderate-intensity activity or 75 minutes per week of vigorous-intensity activity, but she emphasized that aerobic work is only part of fracture prevention. She recommended resistance training two or more days per week and balance-focused training two or more days per week, underscoring that the best osteoporosis therapy in the world cannot help if a patient falls. When she got more specific about resistance training, her advice was the kind that actually changes behavior: progressive resistance training using weights or resistance bands, at moderate intensity, where the last two reps of a ten-rep set should feel challenging. She also discussed progressive impact exercise—activities involving jumping or plyometrics—framed as a graded, progressive approach that promotes bone development through mechanical stress. Finally, she emphasized progressive balance training to reduce falls and fracture risk, citing approachable examples like tai chi and yoga.

When she moved into medications, she highlighted a study that made me rethink how we talk about dosing frequency and prevention. The trial looked at infrequent zoledronate in women aged 50 to 60, using three arms: two doses of placebo, zoledronate followed by placebo, and two doses of zoledronate, with doses separated by five years. The results were striking. Two doses of zoledronate five years apart led to a dramatic reduction in fracture risk compared with placebo, and even a single dose produced a noticeable reduction in fracture risk and a meaningful improvement in bone mineral density at the common sites we worry about. The larger message is that in the right population, we may be able to achieve durable benefit with far less frequent therapy than many patients assume, which has implications for adherence, convenience, and long-term planning.

She closed this part of the talk by stepping into one of the most clinically relevant—and guideline-dependent—areas: defining high risk versus very high risk osteoporosis. She acknowledged that societies and guidelines do not perfectly agree on what constitutes “very high risk,” which is why clinicians often feel like they are translating between definitions rather than following a single clean rule. Her working definition for high risk was practical: a T-score at or below -2.5, a history of hip or spine fracture, or FRAX thresholds that meet standard treatment cutoffs. For very high risk, she used the same basic classification but layered in the clinical features that signal imminent or profound fragility: severe or multiple vertebral fractures, or fracturing while on therapy. She also made a point that resonates with anyone who has tried to implement an “ideal” treatment pathway in the real world: labeling someone very high risk often pushes us toward starting with an anabolic agent, but the practical realities of cost, access, logistics, and patient preference matter. 

What I took away from Dr. Woods’ framework is that osteoporosis care works best when we stop treating it as a single-variable disease. Bone density is important, but muscle, fall prevention, nutrition, and the patient’s ability to execute a plan are just as critical. The “meals, movement, mindset, medications” structure gives us a way to organize that complexity into a clinic-ready approach. And in a world with expanding therapies and rising patient expectations, that kind of practical, integrated framework may be exactly what our osteoporosis patients need most.