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Osteoporosis

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of osteoporosis.

Lifestyle Changes

Because osteoporosis affects such a considerable portion of the female population, total prevention may not be possible, particularly for high-risk groups. Once a woman goes through menopause and more rapid bone depletion occurs, the line between prevention and treatment blurs. Despite their lower risk for osteoporosis, men should also protect their bones with the same healthy lifestyle habits.

Exercise

Exercise is very important for slowing the progression of osteoporosis. Although mild exercise does not protect bones, moderate exercise (more than three days a week for more than a total of 90 minutes a week) reduces the risk for osteoporosis and fracture in both older men and women. Everyone who is in good health should aim for more. Exercise should be regular and life-long. Before beginning any strenuous exercise program, older patients, those at risk or those who have serious medical conditions, should talk to their doctors.

Specific exercises may be better than others, depending on the age group:

• Children should begin exercising before adolescence, since bone mass increases during puberty and reaches its peak between ages 20 and 30. Some evidence suggests that exercise may help develop bone mass in teenagers more effectively than high calcium intake. High-intensity exercises may be particularly bone-strengthening in young people. (Such regimes should not be confused with the athlete-triad -- intense competitive exercise, eating disorders, and menstrual irregularities -- that causes osteoporosis in young athletes.)
• Weight-bearing exercise applies tension to muscle and bone and, in young people, encourages the body to compensate for the added stress, increasing bone density by as much as 2 - 8% a year. In premenopausal women these exercises are very protective. (Young men need high-intensity exercises to increase bone mass.) Careful weight training is also very beneficial for elderly people, especially women.
• Regular brisk long walks improve bone density and mobility and may relieve osteoarthritic pain. High-impact exercises can be very bone-protective in young and middle-aged adults who have no precluding medical or physical conditions. Most older individuals should avoid high-impact aerobic exercises (step aerobics), which increase the risk for osteoporotic fractures. (Older people, particularly women who engage in jumping exercises should do so under supervision.) Although low-impact aerobic exercises such as swimming and bicycling do not increase bone density, they are excellent for cardiovascular fitness and should be part of a regular regimen.
• Exercises specifically targeted to strengthen the back help prevent fractures later on in life and can be beneficial in improving posture and reducing kyphosis (hunchback), even in people with existing severe conditions.
• Low-impact exercises that improve concentration, balance, and strength, particularly yoga and tai chi, have been found to decrease the risk of falling. In one study, tai chi reduced the risk of falling by almost half.

Calcium Supplements

For years, doctors have recommended that women take supplements of calcium plus vitamin D to help maintain bone density and reduce the risk for fractures. However, a 2006 New England Journal of Medicine study raised some questions about this approach. In the Women’s Health Initiative study, women were randomly assigned to receive either 1,000 mg of calcium carbonate plus 400 IU of vitamin D a day, or placebo. The results indicated that daily calcium and vitamin D supplements:

• Improve slightly (by 1%) hip bone density
• Prevent hip fracture, but only for women who consistently take the supplements. (Another 2006 study supported this finding.)
• Do not prevent spine or other types of fractures
• Produce a slight increase in the risk of kidney stones

The medical community has differing views on how to interpret these findings. Some doctors recommend that women over age 60 should still consider taking calcium and vitamin D for bone health. Other doctors feel that due to the risks of kidney stones, supplements are beneficial only for women (especially those over age 70) who do not get enough calcium in their diets. Ask your doctor whether you should take calcium supplements.

Appropriate Daily Doses. Evidence is unclear about the best dosage. In general the amount taken depends on age and risk factors:

• In young people, calcium intake should be 800 mg per day for children ages 3 - 8 and 1,300 mg per day for children and adolescents ages 9 - 17. Teenage girls who have a low intake of calcium in their diets should consider supplements, which can help build bone density during these critical years.
• The standard recommended dose for people over age 50 is about 1,200 mg per day, but may be higher or lower depending on risk factors. Even doses of 1,000 mg may help preserve bone in many postmenopausal women without osteoporosis, including during winter months (when bone loss is greatest). In women who have already experienced osteoporosis-related fractures, however, 1,000 mg daily may not add any protective benefits without bone-building medication.
• Some experts suggest that all pregnant women, adolescents, and those on corticosteroids take 1,000 - 1,300 mg of calcium every day.
• Breast-feeding women should have 2,000 mg per day.

Because of potential side effects with high amounts of calcium, an upper limit of 2,500 mg is recommended.

Forms of Calcium Supplements. Calcium supplements exist in different compounds, such as calcium carbonate (Caltrate, Os-Cal, Tums), calcium citrate (Citracal), calcium gluconate, and calcium lactate. Although all of these provide calcium, they have different calcium concentrations, absorption capabilities, and other actions. Their value in preserving bones depends on many different factors:

• Calcium Concentrations. Forty percent of calcium carbonate is actually calcium, whereas calcium citrate is 24% calcium, and calcium gluconate is only 9% calcium.
• Calcium Absorption Capabilities. The calcium must also be absorbed from the stomach into the bloodstream. Calcium citrate is better absorbed than many other calcium compounds. It was reported to be the first calcium supplement to preserve bone density after menopause. (Calcium citrate also increases iron absorption. Milk and other calcium compounds tend to reduce iron absorption.) One simple method for testing the absorbency of a particular brand of calcium tablet is to place it in a glass of white vinegar at full strength and check to be sure that it breaks up within 30 minutes. Taking large amounts of antacids can impair calcium absorption. Supplements should be taken after meals.

Side Effects. Calcium supplements, even at normal doses of about 1,000 mg a day, can increase the risk for kidney stones. People should be careful not to exceed the upper limit of 2,500 mg per day. (Because many commercial foods are now fortified with calcium, this upper limit may be easier to reach than people think.) Calcium may boost the effects of drugs used to treat osteoporosis.

Although not a specific side effect of calcium, there has been much public concern about reports of a small amount of lead in calcium supplements. Although exposure to high levels of lead can cause health problems, the amount in such supplements is very small, and experts believe the amount poses no hazard.

Vitamin D and Other Vitamins

Vitamin D. Vitamin D is necessary for the absorption of calcium in the stomach and gastrointestinal tract and is the essential companion to calcium in maintaining strong bones. Vitamin D protects against osteoporosis only in combination with calcium.

Vitamin D is manufactured in the skin using energy from the ultraviolet rays in sunlight. It can also be obtained from dietary supplements. As a person ages, vitamin D levels decline. They also fall during winter months and when people have inadequate sunlight. Pollution may also contribute to less sunlight and declining vitamin D levels.

Current adult guidelines recommend:

• 400 IU (10 mcg) for people between ages 50 and 60.
• 600 IU (15 mcg) for those over age 70 who do not have sufficient exposure to sunlight. (Some evidence suggests that higher doses of vitamin D -- up to 800 IU per day -- may help prevent fractures in people with osteoporosis.)

Sufficient sunlight exposure and drinking milk fortified with vitamin D supply most people’s normal needs for vitamin D. One cup of whole milk provides about 100 IU of vitamin D. Oily fish (sardines especially, also salmon, fresh tuna, mackerel) are also important dietary sources of vitamin D. Wild salmon has a much higher vitamin D content than farmed salmon.

Vitamin D is toxic in high doses. In people without vitamin D deficiencies, adding the vitamin to calcium supplements does not add any additional protection. No one should exceed the recommended daily intake of vitamin D except under the direction of a doctor.

There is some concern that many people may be deficient in vitamin D as more individuals avoid sunlight to prevent skin cancers and increase their intake of milk products, such as yogurt and skim milk, which may have little vitamin D. Such individuals may need to take supplements. People with darker skin are at higher risk for deficiencies than those with lighter skin.

Vitamin D derivatives are being investigated for treating osteoporosis. Calcitriol (Calcijex, Rocaltrol), for example, is a prescription-form of vitamin D that can increase bone mass and decrease the rate of spinal fractures. However, calcitriol increases the risk for high blood calcium levels (hypercalcemia) and requires frequent monitoring. Other vitamin D analogues under investigation include doxercalciferol (Hectorol), 22-oxacalcitriol (Maxacalcitol), cholecalciferol, and alfacalcidol.

Vitamin K. Vitamin K has properties that protect bone and prevent fracture. Intestinal bacteria produce vitamin K, and the vitamin is found in leafy vegetables, so deficiencies are rare, although there is some evidence that people may not be consuming enough of this nutrient. Vitamin K affects blood clotting, and supplements are not recommended without specific doctor instruction. Vitamin K2 (menatetrenone), a form of vitamin K, may help prevent fractures in people with osteoporosis.

Vitamin B12. One study reported that in people with osteoporosis and pernicious anemia, taking vitamin B12 (which is used to treat the anemia) also increased bone density.

Vitamin C and E. There has been some positive association between vitamin C and E intake and bone density. For example, a 2001 study reported better bone health in women who were taking estrogen therapy as well as calcium and vitamin C. More evidence is needed, however, to prove any direct benefits.

Vitamin A. High amounts of dietary vitamin A reduce bone density and may even increase the risk for fracture in postmenopausal women. (A form of vitamin A, retinoic acid, has been found to stimulate bone breakdown.)

Dietary Recommendations

The DASH Diet and Low Sodium. Perhaps a good general approach for people at risk for osteoporosis (or almost any adult) is the DASH diet plus sodium (salt) restriction. The DASH (Dietary Approaches to Stop Hypertension) diet is used to help people with hypertension maintain healthy blood pressures. A 2003 study also reported that it might help protect bones and improve cholesterol levels. This diet not only is rich in important nutrients and fiber but also includes foods that contain far more potassium, calcium, and magnesium, than are found in the average American diet. All of these minerals are important for bone protection. The dietary recommendations are as follows:

• Avoid saturated fat (although include calcium-rich dairy products that are no- or low-fat). When choosing fats, select monounsaturated oils, such as olive or canola oils. These fats are also found in some fish. Although no one wants to be overweight, even a slight excess of fat helps protect bones. In fact, in one 2000 study, women who ate more fat in their diet were, on average, better able to absorb calcium than were women who had been put on a low-fat, high-fiber diet.
• Choose whole grains over white flour or pasta products. Include nuts, seeds, or legumes (dried beans or peas) daily.
• Choose fresh fruits and vegetables every day. Many of these foods are rich in potassium, magnesium, and other minerals that are important for bone (as well as heart) protection.
• Choose protein preferably from fish, poultry, or soy products. Soy in combination with fiber-rich foods or supplements may have specific benefits. Oily fish may also be particularly beneficial. They contain omega-3 fatty acids, which have been associated with heart and nerve protection.

Salt Restriction. Reducing salt may protect both the heart and the bones. High sodium intake interferes with calcium retention. Note: Fast foods and commercial snacks are usually high in sodium and have been linked with weak bones.

Dairy Products and Calcium-Rich Foods. Although some studies have reported that dairy products benefit the bones, it is not entirely clear if high-calcium diets reduce the risk for fractures compared to adequate intake of vitamin D. Until more is known, people should be sure their diets have sufficient calcium. Dietary calcium is available from many good sources.

• Milk and Dairy Products. The best source of calcium in the diet is from milk fortified with vitamin D. Four glasses of milk provide about 1,200 mg of calcium. (Skim milk and yogurt products, unfortunately, are often low in vitamin D, which is important for calcium absorption.) According to a 2003 study, girls who have low milk intake increase their risk for fracture in adulthood. One report even suggests that milk proteins actually slow bone break down. It is not clear, however, if drinking milk after menopause offers any significant bone protection.
• Other Calcium-Rich Foods. Other calcium-rich foods include shrimp, canned salmon or sardines, black strap molasses, calcium-fortified tofu, and almonds. A number of commercial foods, including orange juice and some cereals, are now calcium fortified. Dark green vegetables (broccoli, kale, turnip greens) are rich in calcium but little of it is absorbed (kale is best).

Mineral-Rich Fruits and Vegetables .

• Potassium. Potassium may be very important for strong bones and may help counteract negative effects of high-protein diets. Potassium-rich fruits include bananas, oranges, prunes, and cantaloupes, and vegetables that contain potassium include carrots, spinach, celery, alfalfa, mushrooms, lima beans, potatoes, avocados, and broccoli.
• Magnesium. Some studies have observed that low levels of magnesium may contribute to thinning bones. Some studies suggest that magnesium supplements help suppress the cycle that leads to bone loss. Experts recommend 350 mg a day for supplements. However, excessive magnesium may be harmful in people with diabetes or kidney disease. Foods rich in magnesium include dairy products, spinach, potatoes, beets, nuts, sole, and halibut.
• Other Minerals. Phosphorous, boron, and zinc have also been associated with bone protection.

Protein. Both low and high protein intake has been associated with bone loss. Protein deficiencies appear to trigger hormonal changes that increase bone breakdown. Protein may also be important for frail older people for improving muscle strength. On the other hand, high protein intake increases urinary calcium loss, which can impair bone density in people with low calcium diets. High protein diets, however, do not appear to cause bone loss if calcium intake is also high. The bottom line, then, is to have sufficient protein but to balance this with plenty of calcium- and other mineral-rich foods.

The protein source (meat, soy, or fish) may have some effect on bone density, although the effects are not clear. Studies are mixed on whether protein from meat has a positive or negative effect on bone loss. A 2003 study found no differences in bone calcium levels between women on high- or low-meat diets. In any case, the best sources of protein for bone protection may be from oily fish or soy.

• Choosing protein from fish (especially oily fish such as salmon, mackerel, fresh tuna, herring) may be a good option. Oily fish are high in vitamin D, which is bone protective. (Note: American brands of canned tuna generally contain no significant amounts of vitamin D.) Such fish are also heart protective.
• Studies on soy have suggested some modest protection against bone loss. Soy is high in estrogen-like plant chemicals called isoflavones , which may actually improve bone health in older women. (However, other studies indicate that soy has no effect on bone density in healthy premenopausal women.) Soy food products, such as tofu, that also contain calcium may be particularly beneficial. In such cases, 3 oz of tofu supply 60% of daily calcium requirements.

Alcohol. Alcohol has different effects on bones depending on how much is consumed. A 2000 study found that women older than age 65 who drank one to two drinks (1 - 2 oz) of alcohol weekly had higher bone density than non-drinkers. Alcohol in moderate amounts may reduce parathyroid hormone and increase estrogen levels. Excessive drinking, however, has been associated with brittle bones.

Cola, Coffee, Tea and Caffeine. A 2002 study suggested that drinking tea regularly may help protect bones. Nevertheless, there has been some concern that caffeine consumption, particularly from coffee, may increase calcium levels in urine and reduce levels in the body. In one trial, consumption of lots of coffee, (9 or more cups per day, was associated with an increased risk of hip fractures in women, but not in men. However, not all studies support a risk. Some evidence, in fact, suggests that caffeine may pose a danger for bone loss only in elderly thin women -- but not in those who have normal or high weight. Drinking carbonated beverages, particularly cola, may increase the risk for bone fractures in people with low bone density.

Oral Contraceptives

The effect of OCs on bone density is unclear and may depend on dosage levels, the specific formulas, and timing. A Canadian study that followed a group of young women found that OCs resulted in lower bone density and higher risk for fractures, possibly because taking OCs at younger ages interferes with achieving peak bone mass. Some evidence suggests, however, that low-dose OCs may protect against bone loss in women during the perimenopausal period. In addition, specific progestins (such as norethindrone or norgestimate) may be bone protective.

Quit Smoking

Everyone who smokes should quit. The risk for osteoporosis from smoking appears to diminish after quitting.

Preventing Falls and Fractures

An important component in reducing the risk for fractures is preventing falls. Risk factors for falling include:

• Slow walking
• Inability to walk in a straight line
• Certain medications (such as tranquilizers and sleeping pills)
• Low blood pressure when rising in the morning
• Poor vision

Recommendations for preventing falls or fractures from falls in elderly people include:

• Exercise to maintain strength and balance if there are no conflicting medical conditions. In one study of older people, this was the single best intervention for preventing falls.
• Do not use loose rugs on the floors.
• Move any obstructions to walking, such as loose cords or very low pieces of furniture, away from traveled areas.
• Rooms should be well lit.
• Have regular eye checkups.
• Try wearing hip pads. Hip pads are specially designed to protect hipbones against falls and are worn under clothing. Evidence on their protection against fractures is weak, however, particularly since compliance is poor. Nevertheless, newer hip pads that are thinner and made with newer materials may be helpful and more appealing.
• Wear thinner, hard-soled shoes. Studies indicate these shoes are just as comfortable as the popular resilient-soled footwear, but they may be difficult to find. Soft-soled high-resilient so-called athletic footwear may contribute to impaired balance and dangerous falls, in part, because these cushioned shoes offer less stability.

• Review Date: 10/18/2006
• Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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