Osteoporosis: Prevention is better than treatment
Key ways to keep your bones strong and prevent osteoporosis:
Diet
The best diet for preventing or treating osteoporosis includes eating an adequate number of calories as well as calcium and vitamin D, which are essential in helping to maintain proper bone formation and density.
Calcium intake
Experts recommend that premenopausal women and men consume at least 1000 mg of calcium per day; this includes calcium in foods and drinks plus any calcium supplements. Postmenopausal women who do not take estrogen should consume 1500 mg of calcium per day. However, you should not take more than 2000 mg calcium per day due to the possibility of side effects.
The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, or hard cheese, and green vegetables, such as spinach and broccoli. A rough method of estimating dietary calcium intake is to multiply the number of dairy servings consumed each day by 300 mg. One serving is 8 oz of milk or yogurt, 1 oz of hard cheese, or 16 oz of cottage cheese.
Since it is difficult for most adults to take in enough calcium in their diet, we recommend supplements (calcium carbonate or calcium citrate.) Calcium doses greater than 500 mg/day should be taken in divided doses for good absorption (eg, once in morning and evening).
Vitamin D
Much research is going on that seems to link vitamin D deficiency to a host of future illnesses, from certain cancers to neurologic diseases, such as MS and Parkinson's Disease. We already know that vitamin D is necessary for strong bone development and preservation.
The FDA recommends that most people take a supplement of 1,000 International Units (IU) of vitamin D daily. This should reduce bone loss and fracture rate in older women when there is adequate calcium intake.
Milk is the primary dietary source of dietary vitamin D, containing approximately 100 IU per cup. It is not easy to take in enough milk to meet our needs, and since the main source of vitamin D comes from sun exposure, living in the Northeast makes this impossible for at least 6 months/year.
But it may not be sufficient to prevent other long-term illness. One way to determine if you are getting enough vitamin D (and if you are like me, living most of the year in the Northeast, where we absorb NO vitamin D for 6 months of the year), is to look carefully at your diet and family history. Consider getting a blood test to check your vitamin D level. While not yet routinely recommended as a preventive screening test, if you are not getting it in your diet, your environment, and you wear sunblock "vitamin D block" all spring and summer, you may be at risk for a correctable deficiency.
Protein supplements
Protein supplements may be recommended in some people to ensure sufficient protein intake. This may be particularly important if you have already had an osteoporotic fracture.
Alcohol, caffeine, and salt intake
We generally recommend limiting the amount of alcohol you drink, (sorry.) Drinking alcohol can increase the risk of fracture due to an increased risk of falling, poor nutrition, etc. It is not clear if restricting caffeine or salt is helpful; these measures have not been proven to prevent bone loss in people who consume an adequate amount of calcium.
Exercise
Weight-bearing exercises (on your feet), can improve bone mass in premenopausal women and help to maintain bone density for women after menopause. Physical activity reduces the risk of hip fracture in older women as a result of increased muscle strength. Most experts recommend exercising for at least 30 minutes three times per week. More is better, daily exercise is best.
The benefits of exercise are quickly lost if you stop exercising. A regular, weight-bearing exercise regimen that you genuinely enjoy improves the chances of continuing to follow the routine over the long term.
Stop Smoking (for every health reason you can think of!)
Cigarette smoking contributes to bone loss in several ways. The toxins use up your estrogen, shortening your hormonal benefits by about 5 years in average. In addition, the tissue of smokers does not get an adequate blood supply to promote healing.
Oxygen, which is carried by the blood and is necessary for healing is reduced in smokers. Several studies have shown that smokers who break hips, have surgical procedures or traumatic wounds often take much longer to heal than do non-smokers. Smoking also causes bronchospasm which reduces the amount of oxygen available in the bloodstream.
Preventing falls
Repeated falling may significantly increase the risk of osteoporotic fractures in older adults. Taking measures to prevent falls can decrease the risk of fractures. Such measures include the following:
Medication monitoring — Prolonged therapy with and/or high doses of certain medications can increase bone loss. The use of these medications should be monitored and decreased when possible. Such meds include:
Osteoporosis Medications
The non-drug measures above can help to reduce bone loss. A medication or hormonal therapy may also be recommended for certain men and premenopausal women who have or who are at risk for osteoporosis.
In the U.S., the National Osteoporosis Foundation (NOF) recommends use of a medication to treat postmenopausal women (and men ≥ 50) with a history of hip or vertebral fracture or with osteoporosis based on T-score ≤-2.5 on bone mineral density testing.
In addition, the NOF recommends meds for people with osteopenia (T-score between -1.0 and -2.5) as well as one of the following risk factors:
Bisphosphonates — Bisphosphonates are meds that slow the breakdown and removal of bone (ie, resorption). They are used for the prevention and treatment of osteoporosis in postmenopausal women. These drugs need to be taken first thing in the morning on an empty stomach with a full 8 oz glass of plain (not sparkling) water. The person must then wait:
Side effects of bisphosphonates — Most people who take bisphosphonates do not have any serious side effects related to the medication. However, it is important to closely follow the instructions for taking the medication; lying down or eating sooner than the recommended time after a dose increases the risk of stomach upset.
The risk of this problem is small in people who take bisphosphonates for osteoporosis prevention and treatment. However, there is a slightly higher risk of this problem when higher doses of bisphosphonates are given intravenously during cancer treatment.
Dental Work. Experts do not think that it is necessary for most people to stop bisphosphonates before invasive dental work (eg, tooth extraction or implant).
However, people who take a bisphosphonate as part of a treatment for cancer should consult their doctor before having invasive dental work.
Alendronate: Fosamax reduces vertebral and nonvertebral fractures, and decreases the loss of height associated with vertebral fractures. It is available as a pill that you take once per day or once per week.
Risedronate: Actonel is approved for both prevention and treatment of osteoporosis. It can be taken once per day, once per week, or once per month. Risedronate reduces the risk of both vertebral and hip fractures.
Ibandronate : Boniva can be used for prevention and treatment of osteoporosis. It is available as a pill that you take every day or once per month. It is also available as an injection that is given into a vein once every three months.
Although ibandronate reduces the risk of bone loss and spine fractures, there is no proof that it reduces the risk of hip fractures.
Yearly intravenous zoledronic acid can improve bone density, decrease the risk of spine and hip fractures, and decrease the risk of recurrent fractures in high-risk patients with recent hip fx.
Side effects of zoledronic acid can include flu-like symptoms within 24 - 72 hours of the first dose. This may include a low grade fever, muscle, and joint pain. Treatment with a fever-reducing medication (ibuprofen or acetaminophen) generally improves the symptoms. Subsequent doses of ZA typically cause milder symptoms.
Intravenous ZA is an appealing alternative for people who cannot tolerate oral bisphosphonates or who prefer a once yearly to a monthly, weekly, or daily regimen. However, the ideal duration of therapy and long-term safety (>3 years) have not been established.
"Estrogen-like" medications — Certain medications, known as selective estrogen receptor modulators (SERMs) produce some estrogen-like effects in the bone. These medications provide protection against postmenopausal bone loss. In addition, SERMS decrease the risk of breast cancer in women who are at high risk.
Currently available SERMs include raloxifene (Evista), tamoxifen and osphena. Raloxifene can be used for the prevention and treatment of osteoporosis in postmenopausal women, although it may be less effective in preventing bone loss than bisphosphonates or estrogen. SERMs are not recommended for premenopausal women.
Newest SERM: osphena: has been approved as a treatment for dryness, but as it is a SERM (selective-estrogen receptor modulator) it turns on receptors in bone, theoretically reducing bone loss, it turns off estrogen receptors in the breast, which should decrease estrogen stimulation to breast, while remaining neutral to the uterus. At this time, osphena is not recommended for breast cancer survivors, but time will tell.
Key ways to keep your bones strong and prevent osteoporosis:
- healthy diet
- weight-bearing exercise
- stop smoking
Diet
The best diet for preventing or treating osteoporosis includes eating an adequate number of calories as well as calcium and vitamin D, which are essential in helping to maintain proper bone formation and density.
Calcium intake
Experts recommend that premenopausal women and men consume at least 1000 mg of calcium per day; this includes calcium in foods and drinks plus any calcium supplements. Postmenopausal women who do not take estrogen should consume 1500 mg of calcium per day. However, you should not take more than 2000 mg calcium per day due to the possibility of side effects.
The main dietary sources of calcium include milk and other dairy products, such as cottage cheese, yogurt, or hard cheese, and green vegetables, such as spinach and broccoli. A rough method of estimating dietary calcium intake is to multiply the number of dairy servings consumed each day by 300 mg. One serving is 8 oz of milk or yogurt, 1 oz of hard cheese, or 16 oz of cottage cheese.
Since it is difficult for most adults to take in enough calcium in their diet, we recommend supplements (calcium carbonate or calcium citrate.) Calcium doses greater than 500 mg/day should be taken in divided doses for good absorption (eg, once in morning and evening).
Vitamin D
Much research is going on that seems to link vitamin D deficiency to a host of future illnesses, from certain cancers to neurologic diseases, such as MS and Parkinson's Disease. We already know that vitamin D is necessary for strong bone development and preservation.
The FDA recommends that most people take a supplement of 1,000 International Units (IU) of vitamin D daily. This should reduce bone loss and fracture rate in older women when there is adequate calcium intake.
Milk is the primary dietary source of dietary vitamin D, containing approximately 100 IU per cup. It is not easy to take in enough milk to meet our needs, and since the main source of vitamin D comes from sun exposure, living in the Northeast makes this impossible for at least 6 months/year.
But it may not be sufficient to prevent other long-term illness. One way to determine if you are getting enough vitamin D (and if you are like me, living most of the year in the Northeast, where we absorb NO vitamin D for 6 months of the year), is to look carefully at your diet and family history. Consider getting a blood test to check your vitamin D level. While not yet routinely recommended as a preventive screening test, if you are not getting it in your diet, your environment, and you wear sunblock "vitamin D block" all spring and summer, you may be at risk for a correctable deficiency.
Protein supplements
Protein supplements may be recommended in some people to ensure sufficient protein intake. This may be particularly important if you have already had an osteoporotic fracture.
Alcohol, caffeine, and salt intake
We generally recommend limiting the amount of alcohol you drink, (sorry.) Drinking alcohol can increase the risk of fracture due to an increased risk of falling, poor nutrition, etc. It is not clear if restricting caffeine or salt is helpful; these measures have not been proven to prevent bone loss in people who consume an adequate amount of calcium.
Exercise
Weight-bearing exercises (on your feet), can improve bone mass in premenopausal women and help to maintain bone density for women after menopause. Physical activity reduces the risk of hip fracture in older women as a result of increased muscle strength. Most experts recommend exercising for at least 30 minutes three times per week. More is better, daily exercise is best.
The benefits of exercise are quickly lost if you stop exercising. A regular, weight-bearing exercise regimen that you genuinely enjoy improves the chances of continuing to follow the routine over the long term.
Stop Smoking (for every health reason you can think of!)
Cigarette smoking contributes to bone loss in several ways. The toxins use up your estrogen, shortening your hormonal benefits by about 5 years in average. In addition, the tissue of smokers does not get an adequate blood supply to promote healing.
Oxygen, which is carried by the blood and is necessary for healing is reduced in smokers. Several studies have shown that smokers who break hips, have surgical procedures or traumatic wounds often take much longer to heal than do non-smokers. Smoking also causes bronchospasm which reduces the amount of oxygen available in the bloodstream.
Preventing falls
Repeated falling may significantly increase the risk of osteoporotic fractures in older adults. Taking measures to prevent falls can decrease the risk of fractures. Such measures include the following:
- Remove loose rugs and electrical cords or any other loose items in your home that could lead to tripping, slipping, and falling.
- Ensure that there is adequate lighting in all areas inside and around the home, including stairwells and entrance ways.
- Avoid walking on ice, wet or polished floors, or other potentially slippery surfaces.
- Avoid walking in unfamiliar areas outside.
- Review medications. Because certain drugs may increase the risk of falls, drug regimens should be reviewed on a regular basis.
- Correct your vision
- For more information on fall prevention, see stopfalls.org
Medication monitoring — Prolonged therapy with and/or high doses of certain medications can increase bone loss. The use of these medications should be monitored and decreased when possible. Such meds include:
- Glucocorticoid medications (steroids)
- Proton-pump inhibitors for gastric reflux (such as omeprazole, pantoprazole...)
- Heparin, used to prevent and treat abnormal blood clotting
- Vitamin A and certain synthetic retinoids
- Anti-depressants (selective serotonin reuptake inhibitors)
- Certain antiepileptic drugs (eg, phenytoin, carbamazepine, primidone, phenobarbital…)
Osteoporosis Medications
The non-drug measures above can help to reduce bone loss. A medication or hormonal therapy may also be recommended for certain men and premenopausal women who have or who are at risk for osteoporosis.
In the U.S., the National Osteoporosis Foundation (NOF) recommends use of a medication to treat postmenopausal women (and men ≥ 50) with a history of hip or vertebral fracture or with osteoporosis based on T-score ≤-2.5 on bone mineral density testing.
In addition, the NOF recommends meds for people with osteopenia (T-score between -1.0 and -2.5) as well as one of the following risk factors:
- High risk of bone loss long-term use of steroids
- High risk based on history of fracture with minimal force (eg, fall from standing.)
- Estimated 10-year risk of hip or osteoporosis-related fracture ≥3 or ≥20 percent respectively.
Bisphosphonates — Bisphosphonates are meds that slow the breakdown and removal of bone (ie, resorption). They are used for the prevention and treatment of osteoporosis in postmenopausal women. These drugs need to be taken first thing in the morning on an empty stomach with a full 8 oz glass of plain (not sparkling) water. The person must then wait:
- At least half an hour with alendronate and risedronate
- At least one hour with ibandronate
- before eating or taking any other meds, to reduce side effects and potential complications.
Side effects of bisphosphonates — Most people who take bisphosphonates do not have any serious side effects related to the medication. However, it is important to closely follow the instructions for taking the medication; lying down or eating sooner than the recommended time after a dose increases the risk of stomach upset.
The risk of this problem is small in people who take bisphosphonates for osteoporosis prevention and treatment. However, there is a slightly higher risk of this problem when higher doses of bisphosphonates are given intravenously during cancer treatment.
Dental Work. Experts do not think that it is necessary for most people to stop bisphosphonates before invasive dental work (eg, tooth extraction or implant).
However, people who take a bisphosphonate as part of a treatment for cancer should consult their doctor before having invasive dental work.
Alendronate: Fosamax reduces vertebral and nonvertebral fractures, and decreases the loss of height associated with vertebral fractures. It is available as a pill that you take once per day or once per week.
Risedronate: Actonel is approved for both prevention and treatment of osteoporosis. It can be taken once per day, once per week, or once per month. Risedronate reduces the risk of both vertebral and hip fractures.
Ibandronate : Boniva can be used for prevention and treatment of osteoporosis. It is available as a pill that you take every day or once per month. It is also available as an injection that is given into a vein once every three months.
Although ibandronate reduces the risk of bone loss and spine fractures, there is no proof that it reduces the risk of hip fractures.
Yearly intravenous zoledronic acid can improve bone density, decrease the risk of spine and hip fractures, and decrease the risk of recurrent fractures in high-risk patients with recent hip fx.
Side effects of zoledronic acid can include flu-like symptoms within 24 - 72 hours of the first dose. This may include a low grade fever, muscle, and joint pain. Treatment with a fever-reducing medication (ibuprofen or acetaminophen) generally improves the symptoms. Subsequent doses of ZA typically cause milder symptoms.
Intravenous ZA is an appealing alternative for people who cannot tolerate oral bisphosphonates or who prefer a once yearly to a monthly, weekly, or daily regimen. However, the ideal duration of therapy and long-term safety (>3 years) have not been established.
"Estrogen-like" medications — Certain medications, known as selective estrogen receptor modulators (SERMs) produce some estrogen-like effects in the bone. These medications provide protection against postmenopausal bone loss. In addition, SERMS decrease the risk of breast cancer in women who are at high risk.
Currently available SERMs include raloxifene (Evista), tamoxifen and osphena. Raloxifene can be used for the prevention and treatment of osteoporosis in postmenopausal women, although it may be less effective in preventing bone loss than bisphosphonates or estrogen. SERMs are not recommended for premenopausal women.
Newest SERM: osphena: has been approved as a treatment for dryness, but as it is a SERM (selective-estrogen receptor modulator) it turns on receptors in bone, theoretically reducing bone loss, it turns off estrogen receptors in the breast, which should decrease estrogen stimulation to breast, while remaining neutral to the uterus. At this time, osphena is not recommended for breast cancer survivors, but time will tell.
|
Susan Malley, MD
Pediatric, Adolescent & Adult Gynecology |
Summit Health
3030 Westchester Avenue Purchase, NY 914.848.8800 |
Summit Health
1 Theall Road Rye, NY 914.848.8800 |
"Courage doesn't always roar. Sometimes courage is the little voice at the end of the day that says I'll try again tomorrow." MA Radmacher