Do I Really Need to Care About My Bone Density?
About a year ago, I took an online Pilates class that has haunted me ever since. The workout itself was fine, but it was an offhand comment the instructor made about bone density that got me. Hers, she said, was exceptionally good. She’d recently gotten a bone scan and had been told by her doctor that she had amazing bone density for her age (she is in her early 30s). She attributed her wonderful bones to Pilates and moved on, but I didn’t. We were all told as children to drink our milk for strong bones, but I’d never really thought about my bone health beyond that. Suddenly, I was worried that I’d been neglecting it. When was the last time you chugged a tall glass of milk?
In the following months, I began to see the term pop up more and more, usually in the context of fitness and exercise, on TikTok, on Instagram, and even in the occasional real-life conversation. It was always referenced casually and knowingly, with people offering workout routines or nutrition advice they claimed we should all be following. Rebekah Rotstein, who founded the bone-health exercise platform Buff Bones, attributes bone density’s newfound popularity, at least in part, to the boom in menopause awareness (which we can also trace to another boom, this one in menopause and perimenopause-related businesses in recent years). “Midlife is having a big moment now,” she says. “There’s a lot more attention to menopause, and one of the silent symptoms of menopause is bone loss. Osteoporosis is considered a silent disease in the sense that you have no sensation or feeling that you’re losing bone. It’s painless unless you’ve had a fracture.”
From social media, I eventually formed a vague understanding that lifting weights would make my bones … denser? Still, I didn’t totally understand what bone density was or how it was relevant to me. Was it even? (Spoiler: It absolutely was.) I spoke with four experts to answer these questions and all of our FAQs about what bone density is and how to maintain it. I’m happy to report that the answers were simpler and more whimsical than you may think — and, personally, I’ll never think of my bones the same way again.
So, what is bone density, and how does it relate to overall bone health?
It’s a pretty straightforward term; bone density is the density of your bones. But what does that look like, exactly? Dr. Stella Bard, a clinical rheumatologist, uses the analogy of a honeycomb to explain bone structure to her patients: It’s a latticelike network. “It has empty spaces where the bone was resorbed,” Bard explains. And that honeycomb is constantly remodeling itself. “Bone is not what you think it is,” she says. “You have living cells inside the bone called osteoclasts and osteoblasts. The way I remember it is the osteoclast chews — the C stands for “chewing,” and it chews up old bone. And then comes along an osteoblast that builds it back up.”
Dr. Vonda Wright, an orthopedic sports surgeon and researcher and the author of Unbreakable, says that, in addition to being the structure that gives shape to our muscles and organs, bone is itself a metabolic organ system. “Bone is where our blood cells are made,” she says. “We think of it as just dry bones, right? But it is a living dynamic organism that replaces itself every ten years.” If you have good bone density, it means that your bone structure is rebuilding itself at approximately the same rate as it is being resorbed.
Bone density isn’t the only component of your overall bone health, but it is the easiest to measure. “We talk about bone density as this discrete entity, but we know now that it’s not just about the density itself,” says Dr. Alana Serota, an internal medicine doctor who specializes in metabolic bone disorders, osteoporosis, and women’s health. “It’s not just the quantity, but the quality of the bone, which is a little more nebulous. So bone density is not the only factor, but it’s an important factor in bone health. It’s sort of a blunt instrument.”
And it accounts for about 60 to 70 percent of bone strength, says Rotstein. “The hard mineralization within bone is what makes it dense,” she explains. “But if bone is only that side of the scale, it also is problematic, and there’s pathologies when bones become too brittle. On the other side, you do want resilience and flexibility within the bone. That’s where collagen comes in. You want a good balance of these.”
When our osteoclasts are chewing up our bones more quickly than our osteoblasts can rebuild them, our bone density starts to lower — eventually leading to osteoporosis, a condition of weak and brittle bones. Going back to Bard’s honeycomb analogy, “With less of the lattice and architecture available, it’s more likely to shatter,” she says. “Like an eggshell — it’s very fragile and it’s very easy to crack and break. Osteoporosis really means holes in the bones. The bones already have holes in them; it just means more holes in the bones, bigger holes in the bones.” That means your bones are significantly more likely to break or fracture, and have a much harder time repairing themselves in the case of injury.
But am I at risk for osteoporosis and other bone-health issues?
Well, everyone is. As we age, we start breaking down bone faster than we’re building it. In particular, those of us born with ovaries are at a higher risk, especially once we hit menopause. “We lose up to 20 percent of our bone mass in the first five to seven years after menopause,” says Rotstein. “In menopause, we don’t have estrogen anymore; we’re still building bone through the osteoblast,” explains Wright. “Estrogen helps control the osteoclast, the bone-breakdown cell, and so there’s a mismatch and we’re breaking down more than we’re building.”
You don’t go straight to osteoporosis, though. Rotstein says we should also be looking out for its precursor, osteopenia. “More than 80 percent of fragility fractures actually occur in women with osteopenia,” she says. That’s at least partially because significantly more people have osteopenia than osteoporosis, but it’s worth paying attention to.
“The risk of death after a hip fracture is higher than the risk of death after a heart attack,” says Serota. “It’s just we don’t have a cute ribbon; we’re not good with our PR. It doesn’t seem as dramatic as it is.” And because of factors like menopause and longer lifespans, people with uteruses have a much higher incidence of osteoporosis, about 50 percent.
There’s a range of other risk factors to think about, too, says Wright. “We build bone across our lifespan, and our peak bone mass is supposed to occur in our early 30s,” she explains. But many of her patients have had to take medications that break down bone throughout their lives, are smokers or vapers, have lived sedentary lifestyles, or were athletes who didn’t eat enough. A full list of risk factors can be found here. If any of them apply to you, it’s probably a good idea to get a bone scan early. Recommendations vary, but Wright says that you should get your first one by age 40.
Bottom line: “Everybody has the potential to lose bone,” says Wright. “Not everybody does lose bone, because you can get in front of this, which is what I want people to do.”
And what is a bone scan, exactly?
The longtime gold standard scan is a DEXA scan, which uses X-ray technology to measure bone density. Bard describes it as “the easiest test you’ll ever take.” It involves lying down on a table while a scanning arm scans your bones. “A lot of it depends on the machine that’s doing the scanning, and we tell people to pick a place that’s close to home, that’s convenient for you, because it’s better to use the same machine to scan you every two years,” says Bard. “Your insurance will normally pay for every two years unless you’re osteoporotic, in which case it might pay for annual bone-density screenings.”
There’s also the REMS scan, which uses ultrasound technology to evaluate bone density and bone quality, says Wright. But while there’s a lot of promising research for this type of scan, since it’s still very new, it’s not as widely recommended or widely used as of yet.
Bard, Wright, Serota, and Rotstein all recommend getting scanned early, while you have time to improve your bone density if your results aren’t what you expected. Wright says every patient who comes into her clinic gets referred for a bone scan, and they generally aren’t too difficult to come by — you can even pay to get one at some gyms. If you want your insurance to cover it, though, you will need a referral from your doctor.
Is there anything we can do to maintain bone density?
I’ll be honest: I was a little skeptical that Pilates was the key to my bone health, and at the idea that my workout routine (or lack thereof, most of the time) would affect my bones at all. On this, I was once again dead wrong.
There are three types of exercise most important for bone health. The first is the one you’ve probably heard about: weight-bearing exercise, which can mean anything from strength-based movements that take advantage of your body weight to lifting heavy in the gym. That could include Pilates. “I count Pilates as strength training,” Wright says. “You’re engaging your muscles, you are working on strength.” But while some recent studies indicate that Pilates can help improve your bone density, Serota, Wright, Bard, and Rotstein all say that lifting weights is the most effective, proven form of strength training you can do to target bone health.
More surprising for me was the importance of simply jumping around. Turns out being fun and whimsical has a side effect of increasing your bone density. “We must impact our bones,” says Wright. “Every jumping exercise that could possibly be will help build better bone: Jumping 20 times a day, or doing ten minutes of dedicated jumping, as simple as skipping, jumping rope, hopscotch, literally jumping up and down at your desk and landing hard with impact, can help build bone.” Rotstein says explosive movements that train your ability to rapidly produce force are also important: Kickboxing, medicine-ball throwing, and any performance or athletic training that involves speed would fall under this category.
The last expert-recommended form of exercise is not as directly related to building bone density but is essential for protecting your bones over time. That’s right, give it up for balance. The sooner you start thinking about it, the better. “You want to integrate balance into your life, because even the most elite athletes, an injury will undo their balance,” says Serota. “Stand at the sink and brush your teeth and stand on one leg. Make that part of your practice and your life.” If you’re looking to target your balance more intentionally, Rotstein says yoga, tai chi, and Pilates are all great options that will help with neuromuscular control, balance, proprioception, and fall prevention.
Ultimately, says Bard, “whatever exercises the muscle also exercises the bone and encourages bone building.” It’s not always realistic to maintain the perfect, multimodal fitness routine, but taking ten minutes to jump up and down or stand on one leg can make a difference. “The goal is,” Serota says, “you’re sweating more days of the week than not.”
“All the things that are good for your health anyway will be good for your bones,” Serota adds. That’s true for exercise and for nutrition, too. Most of us have heard our whole lives that calcium is essential for strong bones, but so is vitamin D (and K2 along with it). “Vitamin D is the vitamin that makes sure that calcium is pushed in and builds the bone,” Bard explains. But make sure you’re getting enough calcium for the vitamin D to do its work: “If you don’t provide your body with the brick, it’s not going to have the materials to build up the bone,” she says.
The ideal is always to get your nutrition through your diet, says Serota. “I always prefer that people eat rather than swallow.” To her, supplement mania is deeply troubling. “If you’re worried about Big Pharma, I’d like to introduce you to Big Vita,” she says. “They have a lot less skin in the game and less to prove, and they can kind of give you anything.” If you do need to take a supplement, though, she recommends the brands Solgar, Bluebonnet, and any others that have USP certifications, which basically means they undergo third-party testing.
When it comes to calcium supplements, make sure they’re actually necessary before you take them, since it is possible to get too much of it. “For younger people, it’s 1,000 mg a day for skeletal needs; for older people, it’s between 1,200 and 1,500,” says Serota. The best source is, as we all know, milk and other dairy products. But many people are lactose intolerant (including myself), and while there are plenty of plant-based foods that contain calcium, like leafy greens and tofu, Serota says those who don’t eat dairy should probably be taking a supplement. She recommends non-dairy milks and other drinks, like orange juice, that are supplemented with calcium or encapsulated calcium citrate.
“It’s better to prevent loss of bone than to treat loss of bone, but you can build bone at any age,” says Wright. So no matter what your bone-scan results are, there are steps you can take. As for me, I’ll be digging out my jump rope from the depths of my closet.