Understanding Bone Health and Density

About a year ago, I participated in an online Pilates session that, well, stuck with me—not because of the workout itself, but because of an offhand remark the instructor made regarding bone density. She mentioned hers was exceptional, attributed to her Pilates practice, and casually moved on. It hit me, though—I realized I’d never really considered my bone health outside of being told to drink milk as a kid. It was a sudden wave of concern: when was the last time I had a glass of milk?

In the months that followed, “bone density” seemed to pop up everywhere—from social media platforms like TikTok and Instagram to casual conversations. Often, it was used in a familiar way, with people sharing workout routines or dietary tips that they insisted we should know. Rebekah Rotstein, who runs a bone-health exercise program called Buff Bones, thinks this rising interest in bone density is partly due to increased awareness of menopause—also linked to various businesses focused on menopause and perimenopause. “Midlife is definitely having its moment,” she noted. “People are starting to realize that bone loss is a silent issue associated with menopause—Osteoporosis is pretty much undetectable until a fracture occurs.”

From those various sources, I began to gather that weightlifting could improve my bone density. But, honestly, I was still a bit foggy on what bone density really was or how it pertained to me. Did I even need to worry about it? (Spoiler alert: yes, I definitely did.) A few experts helped clarify what bone density is and how we might maintain it, and I was surprised to find the answers both simpler and more whimsical than I’d expected. I’ll certainly never view my bones the same way again.

Bone density refers to how dense our bones actually are. But what does that even mean? Dr. Stella Bard, a clinical rheumatologist, likens bone to a honeycomb structure. “It’s a framework with empty spaces where bone has been resorbed,” she explains. This honeycomb structure undergoes constant remodeling. “Bone isn’t just sitting there; it’s dynamic,” she notes. Living cells within the bones, called osteoclasts and osteoblasts, play key roles: osteoclasts chew up old bone, while osteoblasts build new bone. A handy way to remember their functions, perhaps?

Dr. Vonda Wright, an orthopedic sports surgeon and author of a book on bone health, adds that bones are not just static structures; they act as metabolic organs as well. “Blood cells are produced in bones,” she clarifies, “They’re living entities that refresh themselves roughly every decade.” Healthy bone density indicates that our bones regenerate at a rate similar to how quickly they’re being broken down.

It’s worth noting that while bone density is a crucial part of bone health, it isn’t the only aspect to consider—it’s just the easiest to measure. According to Dr. Alana Serota, a specialist in metabolic bone disorders, we often overly simplify bone health by strictly focusing on density. “It’s not just about density; quality matters too,” she explains. Though bone density is pivotal, it’s just one factor among many that affect overall bone health.

Interestingly, bone density comprises about 60 to 70 percent of overall bone strength, says Rotstein. She elaborates that mineralization contributes to density, but a bone that’s overly dense might be brittle, which presents its own problems. You need a degree of resilience and flexibility in your bones too—that’s where collagen enters the equation.

When our osteoclasts overpower the osteoblasts, our bone density begins to decline, potentially leading to osteoporosis—characterized by weak and fragile bones. Referencing Bard’s honeycomb analogy: “A less supportive structure is prone to breakage,” she warns. When osteoporosis sets in, it translates to holes in the bones—literally and metaphorically. You become much more susceptible to fractures, and recovery becomes increasingly challenging.

Unfortunately, everyone is at some risk. Aging accelerates bone breakdown compared to how quickly they can be built up, particularly affecting those with ovaries after menopause. “We can lose up to 20 percent of our bone mass within the first five to seven years post-menopause,” Rotstein notes. With the decline of estrogen, which normally controls the bone-destroying osteoclasts, there’s often a discrepancy where more bone is lost than is made.

It’s also important to note that we don’t transition directly to osteoporosis. Rotstein advises keeping an eye out for osteopenia as well—an early warning sign—which affects a vast number of people, and is a precursor to more serious issues. “Over 80 percent of fragility fractures occur in those with osteopenia. It’s a solid reason to pay attention to your bone health,” she emphasizes.

The stakes are high when it comes to fractures. Dr. Serota explains that the risk of mortality following a hip fracture is reportedly greater than that of a heart attack. “We don’t tend to acknowledge that, probably because it lacks a catchy narrative,” she adds. The prevalence of osteoporosis is notably higher among people with female reproductive organs, partly due to hormonal changes and longer lifespans—about 50 percent are affected.

Besides gender, there are various risk factors to consider as well. According to Wright, while we’re meant to build bone through our lives, our peak bone mass typically occurs in our early 30s. Unfortunately, many of her patients have risk factors that contribute to bone loss—whether it’s medications, smoking, sedentary lifestyles, or a history of athleticism without adequate nutrition. A comprehensive list of these factors exists for further reference. If any align with your life, it’s wise to consider a bone scan as early as possible, ideally by age 40.

In essence, anyone can lose bone. “However, not everyone does; proactive steps can be taken,” Wright insists.

The go-to method for measuring bone density is the DEXA scan, using X-ray technology. “Believe me, it’s the simplest test you can take,” Bard shares, describing the process as lying on a table while a machine scans your bones. She advises choosing a facility nearby for consistency in your scans every two years, as insurance providers usually cover this unless osteoporosis is diagnosed, in which case more frequent scans might be needed.

An alternative is the REMS scan, which utilizes ultrasound technology and assesses bone density and quality, although it remains less common at this point. There’s quite a bit of promising research around it, but it hasn’t quite caught on as the norm.

The experts I spoke with all encourage early scans, ideally while there’s still time to enhance your bone density if needed. Wright mentions that everyone in her clinic is referred for a scan, which are generally accessible—even at some gyms for a fee. To have insurance cover it, however, you’ll typically need a doctor’s referral.

To be candid, I had my doubts about the role Pilates could play in my bone health and whether my workout routine—or lack thereof—had any effect on my bones. Turns out I was quite mistaken.

When it comes to exercise that can significantly support bone health, three categories stand out. The first is weight-bearing exercise, which includes everything from body-weight movements to heavier lifting. “Pilates definitely qualifies as strength training,” affirms Wright, noting that it helps engage muscles. While some recent studies suggest Pilates may improve bone density, all my consulted experts agree that traditional weightlifting is the most effective means to bolster your bones.

What surprised me most was learning how valuable simply jumping can be. Yes, that’s right—fun and playful actions, like jumping, genuinely promote bone density. “We need to apply impact to our bones,” shares Wright. Even simple activities, like jumping multiple times throughout the day or engaging in dynamic movements, can significantly enhance bone strength. Activities that foster explosive movement, such as kickboxing and medicine-ball workouts, also contribute positively.

The final exercise category, while not directly correlated with increasing bone density, is crucial for overall bone protection—balance. The sooner you start focusing on it, the better. “Injuries can derail even the most skilled athletes’ balance,” notes Serota. Incorporating balance exercises into routine activities, like standing on one leg while brushing your teeth, can be incredibly beneficial. Practices like yoga, tai chi, and Pilates can also enhance balance and overall bone health.

Ultimately, as Bard puts it, whichever exercises engage your muscles also benefit your bones. It might not always be feasible to maintain an all-encompassing workout routine, but even dedicating a few minutes to jump or practice balance can yield positive outcomes. “The goal should be to break a sweat several days a week,” says Serota.

Last but not least, everything good for your general health lends itself well to your bones too, according to Serota. This applies not only to exercise but also to nutrition. Calcium’s importance for strong bones is a well-known fact, but so is vitamin D—and K2, too. “Vitamin D is essential for calcium absorption,” explains Bard. “Without sufficient calcium, your body lacks the necessary material to build stronger bones.”

Serota emphasizes the importance of acquiring nutrients through diet rather than relying on supplements. “I really prefer that people eat rather than take pills,” she says. If supplements become necessary, she suggests reputable brands that undergo third-party testing.

When considering calcium supplements, do ensure they’re genuinely required, as excess can be problematic. “You need about 1,000 mg daily for younger individuals and between 1,200 and 1,500 mg for older adults,” notes Serota. While dairy remains the best calcium source, alternatives like fortified non-dairy milk or leafy greens may be viable options for those who are lactose intolerant.

“Preventing bone loss is better than trying to treat it, but remember, you can build bones at any age,” Wright reiterates. Regardless of your bone-scan results, there are proactive measures one can take. As for me, I’m planning to dig out my jump rope from the back of my closet.