you

what it means to

Bone Health and

Osteoporosis

The Surgeon General’s Report on
This public document was originally prepared by the U.S. Department of Health and Human 

Services under the direction of the Office of the Surgeon General to make information 

in The 2004 Surgeon General’s Report on Bone Health and Osteoporosis available in 

plain language to improve health literacy on this topic. Health literacy is the ability of an 

individual to access, understand, and use health-related information and services to make 

appropriate health decisions.
S

trong bones begin in childhood. With good habits and 

medical attention when needed, we can have strong 

bones throughout our lives. People who have weak bones 

are at higher risk for fractures.

You can improve your bone health by getting enough calcium, 

vitamin D, and physical activity. If you have osteoporosis or 

another bone disease, your doctor can detect and treat it. This 

can help prevent painful fractures. 

Broken bones are very painful at any age. For older people, 

weak bones can be deadly. One in five people with a hip 

fracture dies within a year of their injury. One in three adults 

who lived independently before their hip fracture remains in a 

nursing home for a least a year after their injury. Many others 

become isolated, depressed, or frightened to leave home 

because they fear they will fall.

“

”

...with good 

habits and 

medical 

attention 

when needed, 

we can have 

strong bones 

throughout

our lives.

1
Why Healthy Bones Are 

Important to You

S

trong bones support us and allow us to move. They protect our heart, 

lungs, and brain from injury. Our bones are also a storehouse for vital 

minerals we need to live. Weak bones break easily, causing terrible 

pain. You might lose your ability to stand or walk. And as bones weaken, 

you might lose height.

Silently and without warning, bones may begin to weaken early in life if you 

do not have a healthy diet and the right kinds of physical activity. Many 

people already have weak bones and don’t know it. Others are making 

choices that will weaken their bones later.

“

Bones may 

begin to weaken 

early in life. 

Prevent this 

with a healthy 

diet and the 

right kinds 

of physical 

activity.”

Weak bones 

cause the 

spine to 

collapse.

2
There are several kinds of bone disease. The most common is osteoporosis. In 

this disease, bones lose minerals like calcium. They become fragile and break 

easily. With osteoporosis, your body’s frame becomes like the frame of a house 

damaged by termites. Termites weaken your house like osteoporosis weakens 

your bones. If you have severe fractures from osteoporosis, you risk never 

walking again. Weak bones can break easily. This can be fatal.

Fragile bones are not painful at first. Unfortunately, most people don’t realize 

they have weakened bones until one breaks. By that time, it is hard to make 

your bones strong again.

The good news is that you are never too old or too young to improve your bone 

health. There are many things you can do to keep bones strong and prevent 

fractures. At all ages, a diet with enough calcium and vitamin D, together with 

weight-bearing physical activity every day, can prevent problems later. You can 

work with your doctor to check out warning signs or risk factors. When you are 

older, you can have your bones tested and take medicine to strengthen them.

Osteoporosis causes weak bones.

Normal

Bone

Bone with

Osteoporosis

...you are

never too old 

or too young to 

improve your 

bone health.

“

”

3
Many types of physical activity can 

contribute to bone health, but most people 

are not active enough.

FAST FACT

Don’t Risk Your Bones

Many things weaken bones. Some are outside your control. If you 

have a family member who has bone problems, you could also 

be at risk. Some medical conditions can also make you prone 

to bone disease.

There are some things you can control:

■ Get enough calcium and vitamin D

in your diet at every age.

■ Be physically active.

■ Reduce hazards in your home that 

could increase your risk of falling 

and breaking bones.

■ Talk with your doctor about 

medicines you are taking that could 

weaken bones, like medicine for 

thyroid problems or arthritis. Also 

talk about ways to take medicines 

that are safe for bones. Discuss 

ways to protect bones while treating 

other problems.

■ Maintain a healthy weight. Being 

underweight raises the risk of 

fracture and bone loss.

■ Don’t smoke. Smoking can reduce 

bone mass and increase your risks 

for a broken bone.

■ Limit alcohol use. Heavy alcohol use 

reduces bone mass and increases 

your risk for broken bones.

“

Staying 

active helps 

strengthen 

bones.”

4
Bones Are Not What You 

Think They Are

When you think of bones, you might imagine a hard, brittle 

skeleton. In reality, your bones are living organs. They are 

alive with cells and flowing body fluids. Bones are constantly 

renewed and grow stronger with a good diet and physical activity.

The amount of calcium that makes up your bones is the measure of how strong 

they are. But your muscles and nerves must also have calcium and phosphorus 

to work. If these are in short supply from foods you eat, your body simply takes 

them from your bones.

Each day calcium is deposited and withdrawn from your bones. If you don’t 

get enough calcium, you could be withdrawing more than you’re depositing. 

Our bodies build up calcium in our bones efficiently until we are about 30 

years old. Then our bodies stop adding new bone. But healthy habits can 

help us keep the bone we have. Bone Growth/Loss

Active

Growth

Slow

Loss

Rapid

Loss

Less

Rapid

Loss

After your mid-30s, you begin to slowly lose bone mass. Women lose 

bone mass faster after menopause, but it happens to men too.

Weak bones 

cause the 

spine to 

collapse.

Age in Years

10 20 30 40 50 60 70 80 90

“

”

Do you

spend your

free evenings

on the sofa

or taking

a walk?

5
When Bones Break

There is some natural bone loss as women and men age. As we grow 

older, bones can break or weaken if we don’t take steps to keep them 

strong. The most common breaks in weak bones are in the wrist, 

spine, and hip.

Broken bones in your spine are painful and very slow to heal. People with 

weak bones in their spine gradually lose height and their posture becomes 

hunched over. Over time a bent spine can make it hard to walk or even sit up.

Broken hips are a very serious problem as we age. They greatly increase the 

risk of death, especially during the year after they break. 

People who break a hip might not recover for months or even years. Because 

they often cannot care for themselves, they are more likely to have to live in 

a nursing home.

“

The most 

common 

breaks in 

weak bones 

are in the 

wrist, spine, 

and hip.”

spine wrist

hip

6
Tips for keeping bones strong

■ Calcium is found in 

foods like milk, leafy 

green vegetables, 

and soybeans. Enjoy 

snacks of yogurt and 

cheese to increase 

your calcium. You can 

also take calcium 

supplements or eat 

food specially fortified 

with calcium.

■ Your body needs 

vitamin D to absorb 

calcium. Make sure 

you get enough 

vitamin D from your 

diet, sunlight, or 

supplements.

■ Even simple activities 

like walking and 

stair climbing will 

strengthen your 

bones. Get at least 

30 minutes of 

physical activity a 

day, even if it’s only 

10 minutes at a time. 

(Children should get 

at least 60 minutes 

a day.)

“

”

If you have 

any kind of

a fracture after 

age 50, talk to 

your doctor 

about getting 

your bone

density

checked.

You need more vitamin D as you get older.

Multivitamins typically provide

400 IU of vitamin D.

Daily vitamin D needs

in International Units (IU)

One cup of vitamin D-fortied

milk or juice provides 100 IU.

Age

0–12 months

Age

1–70

Over age

70

7
You Could Be at Risk

Too many of us assume we are not at risk for bone loss or fractures. 

We believe that if we haven’t had any signs of bone damage, then 

our bones are strong. Because there are no obvious warning signs, 

even doctors often miss signs of the problem. Most of us have our blood 

pressure and cholesterol checked for heart health. Testing bone density is 

an important way to check for bone health.

The risk of osteoporosis is highest among women. It is also higher for whites 

and Asians than other groups. However, it’s important to remember that it is 

a real risk for older men and women of all backgrounds.

Here are some clues that you are at risk:

■ Your older relatives have had fractures.

■ You have had illnesses or have been on medications that might weaken bones.

■ You are underweight.

That’s why it is important to know the risks for poor bone health at all ages. 

There are many “red flags” that are signs that you are at risk for weak bones. 

(See page 19 for a checklist.) In addition, your calcium and vitamin D intake, 

level of physical activity, and medications should all be evaluated.

Why being active makes your 

bones strong

When you jump, run, or lift a weight, it puts stress on 

your bones. This sends a signal to your body that your 

bones need to be made stronger. New cells are added 

to strengthen your bones. If you are right-handed, the 

bones in your right arm are slightly larger and stronger 

from the extra use.

8
Bone Up on Your Diet

Calcium

To keep your bones strong, eat foods rich in calcium. Some people have 

trouble digesting the lactose found in milk and other dairy foods, including 

cheese and yogurt. Most supermarkets sell lactose-reduced dairy foods. 

Many nondairy foods are also calcium-rich.

Vitamin D

Vitamin D helps your body absorb calcium. As you grow older, your need 

for vitamin D goes up. Vitamin D is made by your skin when you are in the 

sun. For many, especially seniors, getting enough vitamin D from sunlight 

is not practical. Almost all milk and some other foods are fortified with 

vitamin D. If you are not getting enough calcium and vitamin D in your diet, 

supplements can be bone savers.

Food labels, like 

this skim milk 

label, tell you how 

much calcium and 

vitamin D you get 

per serving.

Your body needs calcium and vitamin D.

If this is your age, then you need this much calcium and vitamin D each day.

Calcium (mg) Vitamin D (IU)

Infants 0 to 6 months 200 400

Infants 6 to 12 months 260 400

1 to 3 years 700 600

4 to 8 years 1,000 600

9 to 13 years 1,300 600

14 to 18 years 1,300 600

19 to 30 years 1,000 600

31 to 50 years 1,000 600

51- to 70-year-old males 1,000 600

51- to 70-year-old females 1,200 600

>70 years 1,200 800

14 to 18 years, pregnant/lactating 1,300 600

19 to 50 years, pregnant/lactating 1,000 600

mg = milligrams; IU = International Units (40 IU = 1 mcg) 

Source: Food and Nutrition Board, Institute of Medicine, National Academy of Sciences, 2010.

9
Calcium-Rich Foods

Help your bones. Choose foods that are high in calcium. Here are some examples.

 

Tofu, firm, with calcium, 

1⁄2 cup, 204 mg

Fortified oatmeal, 

1 packet, 350 mg

Orange juice, fortified with 

calcium, 6 oz.,

200–260 mg (varies)

Ready-to-eat cereal, 

fortified with calcium, 1 cup, 

100–1,000 mg (varies)

Sardines, canned in oil, 

with edible bones, 3 oz.,

324 mg

Salmon, canned, with edible 

bones, 3 oz., 181 mg

Cheese pizza, 1 slice,

100 mg

Cheddar cheese, 

11⁄2 oz. shredded, 306 mg

Pudding, instant (chocolate, 

banana, etc.) made with 

2% milk, 1⁄2 cup,

153 mg

Fortified waffles (2),

100 mg

Milk, nonfat, 

1 cup, 302 mg

Baked beans, 1 cup,

142 mg

Turnip greens, boiled, 

1⁄2 cup,

99 mg

Milkshake, 1 cup,

300 mg

Cottage cheese,

1% milk fat, 

1 cup, 138 mg

Broccoli, raw, 1 cup, 

90 mg

Yogurt, plain, low-fat, 

1 cup, 300 mg

Spaghetti or lasagna, 

1 cup, 

125 mg

Ice cream, vanilla, 1⁄2 cup,

85 mg

Soybeans, cooked, 

1 cup, 261 mg

Frozen yogurt, vanilla,

soft-serve, 1⁄2 cup, 103 mg

Soy or rice milk, fortified 

with calcium, 1 cup,

80–500 mg (varies)

10
Protect Your Bones at Every Age

People of all ages need to know what they can do to have strong 

bones. You are never too old or too young to improve your 

bone health.

Babies

Bone growth starts before babies are born. Premature and low-birth-weight 

infants often need extra calcium, phosphorus, and protein to help them 

catch up on the nutrients they need for strong bones. Breastfed babies 

get the calcium and nutrients they need for good bone health from their 

mothers. That’s why mothers who breastfeed need extra vitamin D. Most 

baby formula contains calcium and vitamin D.

Children

Good bone health starts early in life with good habits. While children 

and young adults rarely get bone diseases, kids can develop habits that 

endanger their health and bones. Parents can help by encouraging kids 

to eat healthful food and get at least an hour of physical activity every 

day. Jumping rope, running, and sports are fun activities that are great 

for building strong bones. Children need the amount of calcium equal to 

3 servings of low-fat milk each day. If your child doesn’t drink enough milk, 

try low-fat cheese, yogurt, or other foods that are high in calcium. If your 

child is allergic to milk or lactose intolerant, talk to your pediatrician about 

milk substitutes.

What if your toddler doesn’t 

like to drink milk?

■ Include some low-fat cheese chunks or 

yogurt for snacks.

■ Make a cheesy sauce for vegetables or for 

a dip.

■ Offer strawberry or chocolate milk as an 

afternoon treat.

11
Children should get at least an hour of physical 

activity every day. Adults should get at least 

30 minutes every day.

FAST FACT

Teens

Teens are especially at risk for not developing strong bones because 

their bones are growing so rapidly. Boys and girls from ages 9 to 18 need 

1,300 milligrams of calcium each day, more than any other age group. 

Parents can help teens by making sure they eat 4 servings of calciumrich and vitamin D-fortified foods a day. At least 1 hour a day of physical 

activities—like running, skateboarding, sports, and dance—is also critical. 

But take note: extreme physical exercise, when combined with undereating, 

can weaken teens’ bones. In young women, this situation can lead to a 

damaging lack of menstrual periods. Teens who miss adding bone to their 

skeletons during these critical years never make it up.

Adults

Adulthood is a time when we need to look carefully at our bone health. 

As adults, we need 1,000 to 1,200 milligrams of calcium, depending on 

our age, and at least 30 minutes of moderate physical activity every day. 

Activity that puts some stress on your bones is very important.

Many women over age 50 are at risk for bone disease, but few know it. 

At menopause, which usually happens in women over age 50, a woman’s 

hormone production drops sharply. Because hormones help protect bones, 

menopause can lead to bone loss. Hormone therapy was widely used to 

“

Your teen 

years are very 

important for 

strengthening 

bones through 

healthy eating 

and physical 

activity.”

12
You are 

buying lunch. 

Do you choose 

milk or a 

soft drink?

prevent this loss, but now it is known to increase other risks. Your doctor 

can help advise you on protecting bone health around menopause.

Seniors

Seniors can take steps to help prevent bone problems. Physical activity 

and diet are vital to bone health in older adults. Calcium, together with 

vitamin D, helps reduce bone loss. Activities that put stress on bones keep 

them strong. Find time for activities like walking, dancing, and gardening. 

Strengthening your body helps prevent falls. Protecting yourself against 

falls is key to avoiding a broken hip or wrist. All women over age 65 should 

have a bone density test.

Seniors should also know that recent studies conclude that anyone over 

age 50 should increase his or her vitamin D intake to 600 International 

Units (IU) per day. After age 70, 800 IU per day are needed.

Adults: Keep your 

bones strong with 

physical activity.

■ Physical activity at least 

30 minutes every day

■ Strength training 2 to 

3 times a week

■ Balance training once 

a week

“

”

13
Falls break bones

You can prevent most falls.

Falls are not just the result of getting older. But as you age, falls become more 

dangerous. Most falls can be prevented. By changing some of the things listed 

here, you can lower the chances of falling for you or someone you love.

1. Begin a regular exercise program.

Exercise is one of the most important ways to reduce your chances of falling. It 

makes you stronger and helps you feel better. Exercises that improve balance and 

coordination, like dancing and Tai Chi, are the most helpful. Consider joining an 

organized program at your local community center or gym.

2. Make your home safer.

■ Remove things you can trip over from 

stairs and places where you walk.

■ Remove all small rugs.

■ Don’t use step stools. Keep items you 

need within easy reach.

■ Have grab bars put in next to your toilet 

and in the bathtub or shower.

■ Use nonslip mats in the bathtub and 

shower.

■ Use brighter light bulbs in your home.

■ Add handrails and light in all staircases.

■ Wear shoes that give good support and 

have nonslip soles.

3. Ask a health care professional to review your medicines.

Ask your doctor, nurse, pharmacist, or other health care professional to review all 

the medicines you are taking. Make sure to mention over-the-counter medicine, 

such as cold medicine. As you get older, the way some medicines work in your 

body can change. Some medicines, or combinations of medicines, can make you 

drowsy or light-headed, which can lead to a fall.

4. Have your vision checked.

Poor vision increases your risk of falling. You could be wearing the wrong glasses 

or have a condition such as glaucoma or cataracts that limits your vision.

14
“

”

It’s never

too late or

too early to 

improve your 

bone health.

Live Well, Live Strong, 

Live Long

The average American eats too little calcium. And nearly half 

of us do not get enough physical activity to strengthen 

our bones.

The same healthy lifestyle that strengthens your bones strengthens your 

whole body. You might not hear as much about bone health as other health 

concerns. But healthy habits are good for all your organs, including your bones.

■ Be physically active every day—at least 60 minutes for children, 

30 minutes for adults. Do strength-building and weight-bearing activities to 

build strong bones.

■ Eat a healthy diet. Educate yourself on proper nutrition. Be aware that 

certain foods are naturally rich in calcium and vitamin D. Get 

the recommended amounts of calcium and vitamin D daily.

■ Reduce your risks of falling. Check your home for loose rugs, poor 

lighting, etc. Take classes that increase balance and strength—like Tai Chi 

or yoga. Make stretching a part of your workout.

Even people who know better don’t always do what’s good for their bones. 

Make yourself an exception. Be aware of your risks and work to reduce 

them. Get help from your family and friends and your doctor, nurse, 

pharmacist, or other health care professional. Building healthy bones 

begins at birth and lasts your whole life.

15
Your Doctor Can Help Protect 

Your Bones

Talk to your doctor about bone health. Together you can evaluate your 

risks. Some things to discuss include your current health, your diet 

and physical activity levels, and your family background.

Your doctor can look at your age, weight, height, and medical history. From 

that he or she can determine if you need a bone density test. Broken bones 

are a “red flag” for your doctor. If you break a bone after the age of 50, talk to 

your doctor about measuring your bone density. Even if you broke a bone in an 

accident, you might have weak bones. It is worth checking.

Your doctor might recommend a medical test called a bone mineral density 

test. Bone density tests use x-rays or sound waves to measure how strong 

your bones are. These tests are quick (5 to 10 minutes), safe, and painless. 

They will give you and your doctor an idea of how healthy your bones are. All 

women over age 65 should have a bone density test. Women who are younger 

than age 65 and at high risk for fractures should also have a bone density 

test.

Your doctor might also want to do a blood test to check for a vitamin D 

deficiency or abnormal calcium levels.

If your doctor finds that your bones are becoming weaker, there are things you 

can do to make them stronger. You can be more physically active, change your 

diet, and take calcium and vitamin D supplements. If your bones are already 

weak, there are medicines that stop bone loss. They can even build new bone 

and make it less likely that you will suffer a broken bone.

Your doctor might suggest medications to help you build stronger bones. To 

reduce the chance that you might fall, have your vision checked. When you 

speak to your doctor, be prepared with a list of questions and concerns. The 

list on the next page should help get you started.

“

All women

over age 65 

should have

a bone

density test.”

16
See Your Doctor

Although osteoporosis is the most common disease that harms 

bones, certain other conditions can also be harmful. Your 

doctor can help you learn if you are at risk and can help you treat 

these conditions.

■ Rickets and osteomalacia—Too little 

vitamin D causes these diseases in 

children and adults. They can lead to 

bone deformities and fractures.

■ Kidney disease—Renal 

osteodystrophy can cause fractures.

■ Paget’s disease of bone—Bones 

become deformed and weak, which 

can be caused by genetic and 

environmental factors.

■ Genetic abnormalities—Disorders 

like osteogenesis imperfecta cause 

bones to grow abnormally and break 

easily.

■ Endocrine disorders—Overactive 

glands can cause bone disease.

17
What to discuss with your doctor

Talk with your doctor, nurse, or other health care professional about your 

bone health. Use this checklist to start your discussion.

£ Ask to check your risk for bone disease.

£ Discuss your need for a bone density test.

£ Talk about any fall, even ones in which you were not hurt. Tell him or her 

about any broken bones you’ve had.

£ If you have fallen, ask about the need for a full evaluation. Tests include 

vision, balance, walking, muscle strength, heart function, and blood 

pressure.

£ Go over all the medications you are taking (including over-the-counter 

ones). Do this at least once a year. This helps avoid dangerous drug 

interactions and taking higher doses of drugs than you need, which can 

lead to falls.

£ Ask if your doctor checks vision. Annual vision checks can help eliminate 

bone-breaking falls.

£ Know your calcium and vitamin D intake. Report your totals to your doctor.

£ If you would like to try a new physical activity, ask about the best choices 

for you.

“

A 50-year-old 

woman breaks 

her wrist when 

she trips on 

a rug. Should 

she ask for a 

bone density 

test even if her 

doctor doesn’t 

bring it up? 

YES!”

Bone disease is often a “silent” disorder 

until it causes a fracture.

FAST FACT

18
Are you at risk for weak bones?

Check any of these that apply to you.

£ I’m older than 65.

£ I’ve broken a bone after age 50.

£ My close relative has osteoporosis or has broken 

a bone.

£ My health is “fair” or “poor.”

£ I smoke.

£ I am underweight for my height.

£ I started menopause before age 45.

£ I’ve never gotten enough calcium.

£ I have more than two drinks of alcohol several 

times a week.

£ I have poor vision, even with glasses.

£ I sometimes fall.

£ I’m not active.

£ I have one of these medical conditions:

£ Hyperthyroidism

£ Chronic lung disease

£ Cancer

£ Inflammatory bowel disease 

£ Chronic hepatic or renal disease 

£ Hyperparathyroidism 

£ Vitamin D deficiency

£ Cushing’s disease 

£ Multiple sclerosis

£ Rheumatoid arthritis

£ I take one of these medicines:

£ Oral glucocorticoids (steroids) 

£ Cancer treatments (radiation, chemotherapy)

£ Thyroid medicine 

£ Antiepileptic medications 

£ Gonadal hormone suppression 

£ Immunosuppressive agents

If you have any of these “red flags,” you could be at 

high risk for weak bones. Talk to your doctor, nurse, 

pharmacist, or other health care professional.

19
Resources

For more information:

For more information on your bone health, talk to your doctor, nurse, 

pharmacist, or other health care professional.

More information about the reports of the Surgeon General is available 

on the Surgeon General’s website at:

www.surgeongeneral.gov/library/reports

Medicare offers bone mass measurement (bone density) for Medicare 

beneficiaries who meet certain eligibility requirements and conditions 

for coverage.

www.medicare.gov/coverage/bone-density.html

If you need more information about available resources in your language 

or in another language, please contact:

National Institutes of Health Osteoporosis and Related Bone Diseases

National Resource Center

2 AMS Circle

Bethesda, MD 20892–3676

Phone: 202–223–0344 

Toll free: 800–624–BONE (2663)

TTY: 202–466–4315

Fax: 202–293–2356

Email: NIHBoneInfo@mail.nih.gov

www.bones.nih.gov

20

You are never too old or too young to

 improve your bone health.

NIH Publication No. 15–7827

December 2015