Osteoporosis: The Evidence-Based Supplement Protocol

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Established osteoporosis (T-score ≤ -2.5 or fragility fracture) is treated with bisphosphonates, denosumab, or anabolic agents (teriparatide, romosozumab). Supplements have a foundational role in adequacy maintenance and a modest role in osteopenia/pre-osteoporosis where pharmacotherapy isn't yet indicated.

Calcium — To Meet, Not Exceed, the RDA

The RDA is 1,000 mg/day for adults under 50, 1,200 mg/day for women over 50 and men over 70. Achieve from diet first; supplement only the gap. WHI and meta-analyses found calcium supplementation above 1,000 mg/day was associated with small increased CV event and kidney stone risk with modest BMD benefit. Use citrate (better absorbed fasted or with PPI use) at ≤500 mg per dose. See calcium harm/benefit piece.

Vitamin D3 — Dose to Serum 25-OH-D 30–50 ng/mL

Vitamin D is essential for active intestinal calcium absorption and muscle function (fall prevention). Test and dose to target. Most adults need 1,000–4,000 IU daily; the VITAL trial showed routine vitamin D supplementation in already-replete adults did not reduce fracture risk — the benefit is specifically deficiency correction. See vitamin D piece.

Vitamin K2 (MK-7), 100–180 mcg Daily

K2 activates osteocalcin, the protein that directs calcium to bone matrix. The Knapen 2013 trial in postmenopausal women showed MK-7 180 mcg daily improved lumbar spine and femoral neck BMD over 3 years versus placebo. Cohort data (Rotterdam Study) shows inverse association between K2 intake and fracture risk. Avoid in adults on warfarin without anticoagulation team input.

Magnesium, 250–350 mg Elemental Daily

About 60% of body magnesium is stored in bone. Adequate intake supports osteoblast function and 1-alpha-hydroxylase activity. Glycinate or citrate forms. See magnesium glycinate piece.

Strontium and Boron — Not Recommended

Strontium ranelate (the European prescription) had positive BMD data but was withdrawn over CV and skin-toxicity signals. The supplement form (strontium citrate) has no equivalent fracture data and inflates DXA artifactually because strontium has higher atomic number than calcium. Boron has weak BMD signals at best.

What NOT to Take

Avoid strontium supplements — see above. Skip "bone-building" megaformulas — the studied components are the four above. Avoid bone broth as a primary intervention — collagen content does not improve BMD. Don't replace bisphosphonates, denosumab, or anabolic agents with supplements alone in established osteoporosis — supplement-only management does not prevent fractures at the same rate.

How to Run the Protocol

Get baseline DXA, 25-OH-D, calcium intake estimate. Resistance training is the single most effective non-pharmacological intervention — supplements support it but don't replace it. Achieve calcium RDA from diet + minimum gap supplementation. Vitamin D to 30–50 ng/mL serum. Add K2 + magnesium. Re-evaluate DXA every 2 years. For T-score ≤ -2.5, pharmacotherapy is first-line and supplement protocol is supportive. See the bone density stack.