Fracture Prevention: Calcium, Vitamin D, and Bone-Building Medications That Actually Work

Fractures don’t just happen to older people-they happen to people who’ve been told to take a calcium pill and a vitamin D capsule and think that’s enough. But here’s the truth: calcium and vitamin D alone won’t stop most fractures. If you’re over 65, have had a prior break, or were diagnosed with osteopenia or osteoporosis, you need more than supplements. You need the right combination, at the right dose, for your body. And if you’re still taking 400 IU of vitamin D and 1,000 mg of calcium because your doctor said "it can’t hurt," you might be wasting your time-and possibly putting yourself at risk.

Why Calcium and Vitamin D Alone Don’t Prevent Fractures

The idea that calcium and vitamin D are a magic shield against broken bones has been around for decades. But the science doesn’t back it up unless you’re severely deficient. A major 2019 analysis of over 34,000 people found that taking vitamin D by itself-no matter the dose-did nothing to lower the risk of hip or any other fracture. The same study showed that when calcium and vitamin D were taken together at low doses (400 IU vitamin D and 1,000 mg calcium), there was still no measurable benefit. That’s the exact dose most over-the-counter supplements provide.

The only time this combo works is when someone is truly deficient. Think nursing home residents with 25-hydroxyvitamin D levels below 12 ng/mL. In the landmark 1992 Chapuy trial, those people saw a 43% drop in hip fractures when given 800 IU of vitamin D3 and 1,200 mg of calcium daily. But for someone living at home, eating a decent diet, and getting a little sun? The benefit vanishes. The RECORD trial in 2005 showed no fracture reduction in community-dwelling older adults-even those with levels around 18.5 ng/mL, which many doctors still consider "low normal."

And here’s the catch: too much calcium can hurt you. The Women’s Health Initiative found that taking 1,000 mg of calcium daily increased the risk of kidney stones by 17%. It also raised the chance of heart problems by 17%. That’s not a small trade-off. The FDA warned about this in 2021. So if you’re not deficient, and you’re not at high fracture risk, you’re not helping yourself-you might be making things worse.

When Calcium and Vitamin D Actually Help

There are three groups where this combo makes a real difference:

• People with 25-hydroxyvitamin D levels below 20 ng/mL
• Those getting less than 700 mg of calcium per day from food
• Resident elderly in care homes or hospitals

If you fall into one of these groups, then 800-1,000 IU of vitamin D3 and 1,000-1,200 mg of calcium daily is backed by solid evidence. That’s not just any supplement-it’s a targeted, clinically proven dose. The 2019 meta-analysis showed a 16% drop in hip fractures and a 6% drop in all fractures with this regimen. But it only works if you take it consistently. Many people stop after a few months because they don’t feel any difference. That’s normal. Bone strength doesn’t improve overnight. It takes years.

Testing your vitamin D level is essential before starting. The Endocrine Society recommends checking 25-hydroxyvitamin D before any supplementation. If your level is below 20 ng/mL, you may need a high-dose course-like 50,000 IU of vitamin D2 once a week for 8-12 weeks-followed by a daily maintenance dose. After that, retest every 3-6 months. Too much vitamin D can cause hypercalcemia, which leads to nausea, confusion, and kidney damage. It’s rare, but it happens.

Bone-Building Medications: The Real Game Changers

If you’ve broken a bone after age 50, or if your FRAX score says you have a 20% or higher chance of a major fracture in the next 10 years, supplements aren’t enough. You need medication.

The most common are bisphosphonates-alendronate (Fosamax), risedronate (Actonel), and zoledronic acid (Reclast). These drugs slow down bone breakdown. In the Fracture Intervention Trial, alendronate cut vertebral fractures by 44%. Zoledronic acid, given as an annual IV infusion, reduced hip fractures by 41% over 18 months. That’s not a small win. That’s life-changing.

Then there’s denosumab (Prolia), a biologic injected every six months. It works differently than bisphosphonates and can be used if you can’t tolerate them. It reduces vertebral fractures by 68% and hip fractures by 40%. But if you stop it, you lose protection fast-bone loss can rebound. That’s why it’s not a "take when you feel like it" drug.

For the most severe cases, doctors now use anabolic agents like teriparatide (Forteo) and romosozumab (Evenity). These actually build new bone. Teriparatide reduces vertebral fractures by up to 65%. Romosozumab, approved in the U.S. in 2019, cuts vertebral fractures by 73% in the first year. But they’re expensive, require daily or monthly injections, and are limited to 1-2 years of use. After that, you switch to an antiresorptive like alendronate to hold the gains.

The Real Problem: People Stop Taking Their Medication

Here’s the ugly truth: even the best drugs fail if you don’t take them. A 2022 study in Osteoporosis International found that over half of people on oral bisphosphonates stop within a year. Why? Side effects. About 68% of patients report heartburn, stomach pain, or nausea. That’s why many switch to the yearly IV infusion of zoledronic acid-it’s easier. But even then, 30% still quit because they don’t feel different.

Doctors often don’t follow up. Patients aren’t told what to expect. If you’re on alendronate, you need to take it on an empty stomach with a full glass of water, stay upright for 30 minutes, and avoid food or coffee. Miss one dose? You might as well skip it for the month. Compliance is everything.

Successful treatment isn’t about the pill-it’s about the plan. A 2021 Mayo Clinic study followed 127 patients with prior fractures who were given vitamin D repletion plus alendronate. Their fracture rate dropped by 58%. Why? Because they had regular check-ins, education, and support. That’s the missing piece in most clinics.

What You Should Do Right Now

If you’re over 50 and haven’t had a fracture:

1. Ask your doctor for a 25-hydroxyvitamin D blood test.
2. If it’s below 20 ng/mL, get a bone density scan (DXA) and calculate your FRAX score.
3. If your FRAX score is above 20% (or 15% in the UK), talk about medication-not supplements.
4. If your vitamin D is normal and you eat dairy, leafy greens, or fortified foods, you likely don’t need extra calcium.

If you’ve already broken a bone:

• Stop relying on OTC vitamins.
• Ask your doctor if you’re a candidate for bisphosphonates, denosumab, or an anabolic agent.
• Get a dental check-up before starting any bone drug-some can cause jaw problems.
• Ask about the annual IV option if swallowing pills is hard.

And if you’re taking calcium and vitamin D because you "feel better"? That’s placebo. Bone health isn’t about how you feel-it’s about numbers: your vitamin D level, your T-score, your FRAX score. Those are the only things that matter.

The Future: New Drugs and Better Strategies

In 2023, the FDA approved abaloparatide-SC (Tymlos) for men with osteoporosis, expanding its use beyond women. The European Society for Clinical and Economic Aspects of Osteoporosis now recommends starting with anabolic drugs like teriparatide in the most severe cases, then switching to bisphosphonates. This "sequential therapy" cuts new fractures by 73% more than bisphosphonates alone.

The VITAL-DEP trial, currently recruiting 1,200 people in the U.S., is testing whether high-dose vitamin D (2,000 IU/day) helps prevent fractures in those with low vitamin D and depression-a group at higher fracture risk. Results are due in late 2025.

The market for osteoporosis drugs is growing fast-projected to hit $14.3 billion by 2028. But the real challenge isn’t developing new drugs. It’s getting people to use the ones we already have, the right way, for long enough to work.