by Dr. David Borenstein M.D, updated by Dr. C.H. Weaver M.D. 4/2021
Osteoporosis is a disease of the bones that is characterized by reduced bone mass and bone quality.In other words osteoporosis is characterized by weak, deteriorating bones. Osteoporosis increases the risk of fractures, notably at the hip, spine, and wrist.Osteoporosis is often associated with aging. Medical experts, however, increasingly believe that osteoporosis is not an unavoidable part of aging and that it is largely preventable. Moreover people already affected by osteoporosis may be able to take steps to slow its progress and reduce risk of fractures.
Who is affected by osteoporosis?
Men and women can both develop osteoporosis, though it occurs more frequently in women. According to the National Institutes of Health, of the 44 million Americans affected by osteoporosis, 68 percent are women. Osteoporosis is most common in Caucasian postmenopausal women. To a lesser degree, Asian, Hispanic, and African-American women are at risk of fractures.
How does bone deteriorate?
Throughout an individual’s lifetime, bone undergoes a continuous process of removal of old bone (called resorption) and addition of new bone (called formation). This process makes bones larger, heavier, and denser. Peak bone mass is reached around age 30. After age 30, bone resorption begins to outpace bone formation—meaning bone is removed at higher rate than it is replaced. Osteoporosis is a condition associated with an increased risk of bone fracture. The increased risk is related to a decrease in the amount of calcium in bones causing a weakening of bone structure. With decreased bone quality, individuals are at increased risk of spontaneous fractures as well as those associated with falls. A primary location for fracture is the lumbar and thoracic spine. Other skeletal structures at risk include the hips, pelvis, and wrists.Osteoporosis is a serious medical condition. In the year following a hip fracture, up to 20% of patients die. Rehabilitation care is required for another 20% and 50% of individuals never fully recover.
Signs & Symptoms of Osteoporosis
The majority of osteoporotic individuals are asymptomatic because bone loss without fracture is a painless process. The first symptom of osteoporosis may be a fracture or collapsed vertebrae. Otherwise, the disease causes no symptoms and is therefore often called a “silent disease”. A collapsed vertebra may cause severe back pain, loss of height, or spinal deformities such as stooped posture. Loss of bone can result in microfractures that do not result in change in the shape of the bones. An ache or pain however can be associated with this change in bone structure.Bone is living tissue that is constructed like a building. Buildings have an internal framework, girders, that are surrounded by cement to form rooms. The equivalent in bone for girders is collagen and for cement is calcium and phosphorus. Bone is constantly being remodeled; osteoclast cells that excavate and resorb, and osteoblasts form new bone. This process supplies a constant source of calcium that supports essential bodily function. When younger, the balance is in favor of osteoblasts that make bone. As we age, the balance shifts to the osteoclasts that hasten bone loss. As calcium is lost from bone, the architecture is altered with cross struts supporting weight being lost. The result is weakened bone with increased fracture risk.1-3
Causes of Osteoporosis
Though osteoporosis tends to affect older individuals, it may be caused during childhood and adolescence—if bones don’t grow adequately early in life, optimal peak bone mass is never reached. Less than optimal bone mass increases risk for osteoporosis later in life.Hormonal changes later in life also contribute to bone loss. This is especially true for women, who experience a decrease in estrogen production when menopause occurs. Estrogen may be decreased by natural menopause, surgical removal of the ovaries, or chemotherapy and radiation treatments for cancer. Men also experience a decline in sex hormone (testosterone) levels that can contribute to bone loss, but the decline is not as pronounced as it is in women. (1-3) Some health conditions, as well as the medications used to treat them, can cause bone loss as a side effect.
Medications That Can Cause Bone Loss
- Corticosteroids Women who have arthritis or asthma may lose bone mass as a result of avoiding weight-bearing exercise because it’s painful or can trigger an attack. Also, medications often used to treat these conditions—corticosteroids such as prednisone (Deltasone® and Orasone®) and dexamethasone (Decadron® and Hexadrol®)—cause bone loss by inhibiting new bone formation and interfering with the body’s absorption of calcium. According to the American College of Rheumatology, anyone who takes corticosteroids (also called glucocorticoids) for more than three months is at risk of osteoporosis.4 Conditions such as lupus and inflammatory bowel disease may be treated with long-term corticosteroids, as well.
- Proton pump inhibitors (e.g., Aciphex,® Nexium,® and Prilosec®), used to treat gastrointestinal reflux, and selective serotonin reuptake inhibitors (e.g., Prozac,® Paxil,® and Zoloft®), used to treat depression—may increase the risk of hip fracture, especially when they are taken for a long time.5,6 Further research is needed on the fracture risks posed by these commonly prescribed medications.
- Anti seizure medications
- Hyperparathyroidism increase the risk of secondary osteoporosis.
- Kidney disease
- Crohn;s disease
- Anorexia nervosa
Risk Factors for Osteoporosis
There are risk factors that increase and individual’s likelihood of developing osteoporosis. Some of the risk factors cannot be changed however others can be modified to reduce risk.
Risk factors that cannot be changed
- Gender—Women are at greater risk than men.
- Age—Risk increases with age, as bones become thinner and weaker.
- Body size—People (women, in particular) with small, thin bones are at greater risk.
- Ethnicity—White women and Asian women are at highest risk. Risk is lower but significant in African-American and Hispanic women.
- Family history—A family history of fractures (specifically, in one’s parents) may increase risk.
Risk factors that can be changed with medical treatment and lifestyle measures
- Sex hormones—Estrogen deficiency resulting from abnormal absence of menstrual periods and menopause (natural or due to surgical removal of ovaries or medical treatments) can contribute to osteoporosis in women; Low testosterone levels can increase a man’s risk.
- Anorexia nervosa—This eating disorder (irrational fear of weight gain) increases risk.
- Calcium and vitamin D intake—A diet low in these nutrients increases risk.
- Medication use—Certain medications increase risk (anti-inflammatory drugs known as glucocorticoids and anticonvulsants, or anti-seizure medications, for example).
- Lifestyle—People with an inactive lifestyle or those on extended bed rest may have weaker bones.
- Cigarette smoking—Smoking, which harms the heart and lungs, is also bad for bone health.
- Alcohol intake—Excessive consumption of alcohol can increase bone loss and risk for fractures.
Men and Osteoporosis
Osteoporosis is less common in men than women. Men have more bone than women to start. Bone loss starts later in life. Bone loss does occur in men as testosterone levels decrease. The ability to absorb calcium is decreased with age. The risk for fractures also increases with the tendency to fall more often. In men, hormone ablation therapy for prostate cancer can result in an increased risk. By age 75, 25% of men are osteoporotic.
The process of diagnosing osteoporosis will begin with a physical exam. X-rays may also be taken to detect skeletal problems such as fractures. In the absence of a fracture, bone mineral density (BMD) can be used to diagnose osteoporosis. Individuals should be prepared to discuss the following with their doctor.
- Family History
- Previous fractures
- Current medication use
- Exercise and activity
- Menstrual cycle history
Bone Mineral Density:
A bone mineral density test is like an X-ray of your bones. It usually measures the density of bone at the hip, in the spine, and sometimes in the wrist. It is recommended that all women 65 and older get their bone density tested (the test is covered by Medicare). Younger women should be tested if they are at high risk of bone loss (for example, because they smoke, have a family history of osteoporosis, or use medications that promote bone loss).
If you break a bone after age 50, talk to your doctor about getting a bone density test. The BMD test produces a measurement called a T-score, which compares an individuals bone density to optimal bone density. A negative score indicates low bone mass. The World Health Organization (WHO) defines osteoporosis as a T score < -2.5 standard deviations below the mean value of peak bone mass. Osteopenia is a BMD score between -1 and -2.5.In addition, there are laboratory tests (using blood or urine samples) that assess the process of bone breakdown and formation as well as identify conditions that may contribute to bone loss. Testing may include: blood calcium and vitamin D levels, thyroid function, measurement of estrogen levels in women and testosterone levels in men, and measurement of follicle stimulating hormone in women to establish menopausal status.
Prevention & Treatment of Osteoporosis
The increased risk of osteoporosis is related to a decrease in the amount of calcium in bones causing a weakening of bone structure. With decreased bone quality, individuals are at increased risk of spontaneous fractures as well as those associated with falls. A primary location for fracture is the lumbar and thoracic spine. Other skeletal structures at risk include the hips, pelvis, and wrists.The first step in treating osteoporosis is to prevent it by taking measures to avoid bone loss and maintain strong bones. The following measures may contribute to long-term bone health: (1-3)
Weight-bearing exercising, like walking, is essential to increasing or maintaining bone mineral density at any age. Also, impact or resistance exercise, such as lifting weights, is positive for bone health. These efforts will blunt bone loss but will not fully prevent it.
- Exercise and Move More to Improve Bone Health
- Exercises for Building Bone Density
- Plant Based Foods to Improve Your Bone Health
Calcium and Vitamin D
Calcium and vitamin D are essential to maintain bone health. Calcium is an essential building block of bone. Vitamin D is required for adequate absorption of calcium from the gastrointestinal tract.
Calcium—Dietary calcium may help combat low bone mass and reduce the risk of osteoporosis. Recommended food sources of calcium include low-fat dairy products (such as milk, cheese, and yogurt); dark, leafy green vegetables (such as broccoli and spinach); sardines and salmon with the bone; foods fortified with calcium (such as orange juice and cereals). Calcium needs change throughout life, with a greater demand occurring during childhood and adolescence, during pregnancy and breastfeeding, and in postmenopausal women and older men. For example, 1,300 mg/day of calcium is recommended for children and adolescents age 9 to 18 years, and 1,200 mg/day is recommended for adults age 51 and older. Debate has surfaced regarding the appropriate daily intake of calcium. Current recommendations suggest 600 mg of calcium with any remainder from dietary sources including dairy products, like milk or yogurt, and vegetables, like broccoli. A variety of calcium supplements are available. Calcium citrate is more easily absorbed. Calcium carbonate is another form of calcium supplement.4
Vinegar test A vinegar test is a good means to determine if you calcium supplement is absorbable in the gastrointestinal tract. Place your calcium pill in about a quarter cup of vinegar and swirl it around. If in 30 minutes the pill has not dissolved, throw the supplement out and obtain a brand-name product. If it does not dissolve in the vinegar, it will not dissolve in your stomach and will go all the way through without any absorption.
Vitamin D Vitamin D contributes to calcium absorption as well as bone health. The body makes vitamin D through exposure to sunlight (15 minutes per day is recommended), and it can also be found in food sources including egg yolks, saltwater fish, and liver. Vitamin D supplements may be suggested for people who cannot get adequate sun exposure.The dose of vitamin D varies depending on the level in the bloodstream. Vitamin D is made in our skin when exposed to the sun. The difficulty is that northern latitudes do not have strong enough sun exposure to produce vitamin D year round. Most medical experts recommend a daily intake of between 400 and 800 international units (IU) of vitamin D.4
Recently updated recommendations for daily vitamin D consumption by adults 50 and over is between 800 and 1,000 IU.5 Vitamin D can be quantified with blood tests. Calcium and vitamin D are prerequisite therapies for the other therapies administered for osteoporosis. The risk of side effects with other agents is increased in the absence of these supplements.Individuals should also avoid smoking and excessive alcohol use, as these behaviors are associated with weaker bones and increased risk for fracture.
Hormone Replacement Therapy
Estrogen deficiency after menopause leads to bone loss. The greatest rate of bone loss occurs in the first years after ovarian failure. Estrogen replacement therapy or ERT has been successfully used in postmenopausal women. Replacement estrogen can maintain bone mineral density but cannot increase density in women who are already osteoporotic. The Women’s Health Initiative, a large study of estrogen and progesterone replacement therapy reported an increase in cardiovascular disease and breast cancer in women on ERT. Some women have severe estrogen deficiency symptoms including hot flashes continue to take small amounts of estrogen which may have some effect on BMD.Hormone replacement therapy is no longer routinely recommended to treat bone loss because two large studies have shown that it increases the risk of heart attack, stroke, and breast cancer.6,7 “But if a woman is on HRT for other reasons—such as to treat menopausal hot flashes—it will prevent the rapid bone loss than can occur around menopause.” All postmenopausal women should discuss the benefits and the risks of HRT with their doctor.The role of ERT remains an individual choice between a patient and their physician.
Evista (Raloxifene) is a selective estrogen receptor modulator with estrogen-like effects on bone resorption but without stimulating the lining of the uterus or breast tissue. The drug is administered as orally once a day. Clinical studies have demonstrated increased BMD in the spine but less in the hips. Side effects from the medicine include blood clots, leg cramps, and hot flashes.
Prolia (Denosumab) Rank ligand (RANKL) is a protein signal to osteoclasts to become active. The result is a loss of bone mineral density. Antibodies that block RANKL prevent the activation of osteoclasts thereby increasing bone mineral density. Prolia is a RANKL fully human antibody that binds to the protein. Prolia is administered as a subcutaneous injection once every 6 months. The beneficial effects can be detected within hours of the injection. Injections need to be repeated to have a sustained benefit. The full duration of Prolia therapy remains to be determined. Potential toxicities are similar to those of bisphosphonates including bone pain, osteonecrosis of the jaw and atypical fractures of the femur. An additional risk is that of cellulitis or other infections in individuals who are taking immunosuppressive agents like anti TNF antibody therapy.
Evenity (romosozumb) works to increase the formation of new bone and slow the breakdown of old bone. Sclerostin is a protein that is a negative regulator of bone formation that is secreted by osteocytes, that decreases the stimulus for bone-forming cells, osteoblasts. Evenity is an antibody directed against sclerostin, promoting the formation of bone. Evenity was approved for the treatment of osteoporosis based on a study of 7180 postmenopausal women with osteoporosis as measured in their hip bones. Women were randomized to a monthly injection of 210 mg of Evenity or placebo for 12 months. At 12 months, new vertebral fractures occurred .5% of women receiving Evenity compared to 2% of those receiving a placebo. Nonvertebral fractures were also less common int Evenity treated patients.16,17
Mild side effects of Evenity can include joint pain, headache, muscle spasm, weakness, insomnia and injection site reactions. More serious side effects from Evenity aren’t common but can occur. Evenity has a “black box warning.” This is the most serious warning from the Food and Drug Administration (FDA). Serious side effects and their symptoms can include heart attack or stroke, bone fractures, low blood calcium resulting in cramps, spasms or tingling in toes or fingers and Osteonecrosis of the jaw (death of bone tissue). Symptoms can include loosening of a tooth, pain in your jaw, teeth, or mouth, gum pain, swelling, or discharge, sores on your gums that don’t heal, numbness or a feeling of heaviness in your jaw.
Bisphosphonates are the most commonly prescribed therapy for osteoporosis. The concept behind these medicines was the interaction between detergents and hard water. Bisphosphonates are similar in structure to a component of bone. Osteoclasts are the cells that break down bone during the remodeling process. Bisphosphonates attach to the active sites on osteoclasts and prevents their activation. By decreasing bone reabsorption bone mineral density is increased by allowing a preference to the osteoblast bone forming cells. The effect on density is rapid within months.The toxicities of oral bisphosphonates are greatest on the gastrointestinal tract with esophageal irritation. They also have poor intestinal absorption. The drug is taken in the morning after an overnight fast, with a large glass of water. Remaining upright for 30 minutes is necessary to decrease the risk of to the esophagus. With movement of calcium into bones, muscles may become calcium deficient resulting in persistent cramping. Bone and joint pain may also occur.
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Fosamax (Alendronate) is a bisphosphonate, taken orally on a weekly basis. Fosamax has beneficial effects on bone mineral density in the spine and hip. The effect on bone is prolonged. Bone mineral density may increase by 5% to 10% over 2 to 4 years and reduce fracture risk by 30% to 50%. The optimal duration of therapy has not been determined.
Actonel is a bisphosphonate taken weekly at 35 mg or 150 mg once a month. The drug increases bone mineral density in hips and spine.
Boniva (Ibandronate) can be administered orally or intravenously. The oral form is given monthly in a 150 mg dose given the same day of the month. The intravenous form is given by vein, 3 mg/3ml every 3 months. The benefits on spine and hip are similar to other bisphosphonates as are the side effects.
Reclast (Zolendronic Acid) is an intravenous form of bisphosphonate administered once a year. Reclast reduces hip and spinal fractures and increases bone mineral density. Infusions may be given for 3 years. Infusions, given over 15 minutes or longer, are usually well tolerated with about 20% having 3 days of muscle or bone pain. A much smaller group of patients may develop a severe bone pain syndrome that can last for months.
Osteonecrosis of the Jaw Another potential side effect associated with all bisphosphonates is osteonecrosis of the jaw. Osteonecrosis is an area of bone where cells have died. The result is an area of bone that will disintegrate. The risk for jaw osteonecrosis increases if dental repairs are conducted after bisphosphonate therapy is established. Risk is increased the longer an individual takes bisphosphonates. A recommendation is given to have dental work completed before initiating bisphosphonate therapy. The risk of jaw necrosis is small in most individuals taking bisphosphonates. Intravenous forms of bisphosphonates are more closely associated with this toxicity.
Human Parathyroid Hormone
Parathyroid hormone is a naturally occurring protein associated with maintaining blood levels of calcium. The source of calcium is bone. When present in persistent levels, bone loss occurs. When bone is exposed to small amounts, a contrary effect occurs on osteoblasts, causing a building of bone.Teriparatide (Forteo) is an injectable form of parathyroid hormone. A daily injection into the abdomen or thigh of 20 mcg for 2 years is associated with significant improved bone density in the spine and the hip. The drug is limited to a 2 year administration because longer duration of therapy is associated with the development of cancer in rats. This form of therapy is indicated for those individuals with previous fractures or inability to tolerate bisphosphonates. Toxicities associated with this injectable therapy include dizziness and nausea.
Calcitonin is a natural hormone that reduces bone breakdown in the human body. The hormone is produced by the C cells in the thyroid gland. The hormone is effective in decreasing the risk of fracture in the spine, but not as much in the hip. Women five years post-menopausal who are unable to take bisphosphonates are candidates for this drug. Men with normal testosterone levels are also responsive to this agent. Calcitonin harvested from salmon is used as a nasal spray as a therapeutic agent for mild osteoporosis. The recommended dose of calcitonin salmon nasal spray is 1 spray (200 units) per day alternating nostrils daily. Side effects include nasal irritation and a small, increased risk of malignancy 4% versus 2% in normal populations.
Side Effects of Treatment: Likely More Benefit Than Risk
Treatment of osteoporosis is a long-term, or lifelong, prospect. As a result, many patients are rightly concerned about possible side effects. According to Dr. Streeten, however, the reduction in fracture risk for patients at high risk “tremendously” outweighs the risk of side effects.
Each type of osteoporosis drug carries its own risk. With bisphosphonates, for example, a portion of patients (5 percent) may experience bone pain. Though uncomfortable, this pain is not associated with any bone damage. Individuals taking Reclast sometimes experience flulike symptoms for a day or two after early infusions. These symptoms tend to lessen with subsequent infusions.
Another rare risk of bisphosphonate treatment that Dr. Streeten mentions is what’s known as atypical femur fracture, which occurs when the femur breaks without trauma. Incidence of atypical femur fracture is going down, however, as we’ve learned more about risk factors for this type of fracture and alter treatment to reduce the risk. For example, the risk of this complication increases with the number of years of treatment, so continuous treatment over 10 years is generally not given. In addition, vitamin D deficiency increases the risk of atypical femur fracture and can be prevented by monitoring vitamin D blood level and adjusting vitamin D supplement dose to keep the level normal.
In addition, Dr. Streeten says that the US Food and Drug Administration (FDA) indications for using bisphosphonates have changed in such a way that fewer patients at risk of atypical femur fracture are receiving the drugs. “Prior to 2003,” she explains, “we were treating basically every postmenopausal woman with low bone mass,” as Fosamax was initially FDA approved for prevention of osteoporosis. “In other words,” she adds, “you didn’t have to have osteoporosis or fracture risk to be treated.” Today only those at high risk of fracture receive bisphosphonates. In addition, patients can get their vitamin D blood levels tested regularly during treatment to make sure they’re staying within the normal range.
Living with Osteoporosis
For Beth, Samantha, and all patients diagnosed with osteoporosis, treatment and management of the condition is ongoing. In addition to treatment with Prolia, Beth exercises three times a week. As a result, she is able to work full-time and is confident in the steps she’s taking to stay strong and reduce her risk of fracture. “I am very optimistic about my bone health and future,” she says.
Samantha also keeps up a regular fitness routine of walking, stretching, and light strength training. In addition, her diet is heavy on plant-based foods and includes two servings of dairy per day, as well as calcium and vitamin D supplements. She still considers her bone health “somewhat precarious” and says, “I am doing everything I can to maintain or improve it.”
Together both Beth’s and Samantha’s stories speak to the potential effectiveness of treatment for osteoporosis, the benefits of seeing a specialist, and the importance of healthy lifestyle practices in maintaining strong bones. On the whole the message is promising for those affected by low bone density and osteoporosis.
This name is an alias, as the patient asked that her real name not be used.*
Promise in the Pipeline: Osteoporosis Drugs Used to Treat Other Conditions
The promise of some of our current osteoporosis drugs even extends beyond treatment of osteoporosis, as researchers are finding uses in patients with both rheumatoid arthritis (RA) and breast cancer. In people with RA, for example, studies suggest that bisphosphonates may reduce the risk of heart attack and that Prolia might prevent joint erosion among patients taking the drug methotrexate. Breast cancer studies show that bisphosphonates may reduce the risk of developing the disease and may improve survival and reduce bone recurrence in postmenopausal women with early-stage disease.3-6
With Osteoporosis, Prevention Means Strong Bones and Avoiding Falls
As options for drug treatment for osteoporosis continue to evolve, the fundamentals of bone-loss prevention have remained fairly consistent in recent decades—namely the combination of the right amount of calcium and vitamin D and bone-building exercise. An additional aspect of the prevention conversation is the importance of preventing falls among people affected by low bone density, as these events are a major cause of fracture.
According to Heather Hofflich, DO, FACE, an associate clinical professor in the Department of Medicine at the University of California San Diego Health System, women over 50 (as well as men over 70) should aim for 1,200 mg per day of calcium. “Try to meet this amount with food sources first and then with a supplement,” Dr. Hofflich recommends. In other words, if you’re not getting 1,200 mg per day through diet (such as dairy products, leafy greens, and certain seafood), add a supplement to make up the difference.
The general recommendation for vitamin D is between 800 and 1,000 international units (IU) per day. Our bodies produce vitamin D with sunlight, but too much sun exposure is a risk for skin cancer and other skin damage, so it’s good not to rely on the sun for your vitamin D and instead take a supplement. You can have your vitamin D levels checked to determine if you need a supplement and how much to take.
Along with calcium and vitamin D, exercise is a major component of bone health. This is especially true of weight-bearing activities, such as walking, running, jogging, and using an elliptical machine. “These exercises help stimulate new bone and should be done for at least 30 minutes, five to seven days per week,” Dr. Hofflich says.
If you have low bone density, preventing falls is essential because osteoporosis increases your risk.
“Have your eyes checked routinely and have medications checked to make sure you’re not taking anything that causes problems like dizziness,” Dr. Hofflich advises. She also recommends using a walker or cane and seeing a physical therapist to help improve balance and stamina. At home, handrails on stairs and in bathrooms can help you stay on your feet, as can keeping floors clean (but not slippery) and free of clutter and using rubber mats in the bathtub and shower. Good lighting, Dr. Hofflich says, can also help reduce the risk of tripping and falling at home.
5 Steps to Better Bone Health
The National Osteoporosis Foundation offers 5 helpful tips to prevent osteoporosis:
- Get the calcium and vitamin D you need every day.
- Do regular weight-bearing and muscle-strengthening exercises.
- Don’t smoke and don’t drink too much alcohol.
- Talk to your healthcare provider about your chance of getting osteoporosis and ask when you should have a bone density test.
- Take an osteoporosis medication when it’s right for you
The "ABC's" for improving bone health: Activity, Balance, Calcium and Vitamin D
As we age, bone loss is inevitable—but we cannot feel it or see it.
A for Activity
You want to engage in weight-bearing activities, which load the bone with weight. These include walking, jogging, lifting weights, dancing, and even cleaning your house. In general, I recommend spending more time on your feet. You might consider a simple pedometer or other gadget to count your steps each day. The goal is at least 10,000 steps per day.If you already have low bone density in your spine, you should have a few sessions with a physical therapist to learn to exercise safely and properly. Be aware: if you do have low bone density in your spine, everyday lifting can pose risks during common activities. For instance, you should not lean over to pick up a toddler from the ground; instead, sit down and have the child climb onto your lap.
B for Balance
Building balance is key to avoiding falls. If you do not fall, it is unlikely that you will break your arm or your hip, as 90 percent of hip fractures are the result of falls. Tai chi and yoga are good, but anything to work on core strength is helpful. You can try simple methods throughout the day, like balancing on one leg while holding on to a kitchen or bathroom counter. If you are more advanced, you could work on stability by standing on a BOSU ball or similar device used for balance training.
C for Calcium
The recommendations for daily calcium include all sources: food, drink, and supplements. For adult women up to age 50, 1,000 milligrams (mg) per day is recommended; for women over 50, 1,200 mg. Count your food and drink first before taking a calcium supplement, and take supplements only if you are not getting enough calcium in your diet. Dairy products are especially rich in calcium, but it is found in smaller amounts in vegetables and legumes. Kale, for instance, is a popular vegetable now and a very good source of calcium, as are turnip greens, collards, and black and white beans. Don’t forget to count the calcium that might be included in other supplements, such as multivitamins, that you may already be taking.
D for Vitamin D
Vitamin D is essential for bone health. Calcium absorption in the gut depends on adequate vitamin D. Sunlight absorbed through the skin is the main source of vitamin D, and recommended levels can be delivered through about 15 to 20 minutes of daily unprotected skin exposure to midday sunlight. In most parts of the country, however, there is sufficient radiation from the sun only May through October, so I recommend taking a vitamin D supplement, particularly during the winter, to ensure that you are getting sufficient amounts. The daily recommended amount for adults is 600 international units (IU) per day, but you may require more based on your body size and age.Talk with your healthcare provider about your risk for osteoporosis and fractures and what you should be doing. A bone density assessment of your hip and spine will measure your bone mass and estimate your fracture risk. According to current US guidelines, all women should have a bone density scan at age 65, or at younger ages as early as the peri menopausal period if they have additional risk factors. It is never too early or too late to take charge of your bone health.
- Osteoporosis. Centers for Disease Control and Prevention website. Available at: http://www. cdc.gov/nchs/fastats/osteoporosis.htm. Accessed April 18, 2016.
- Learn about Osteoporosis. National Osteoporosis Foundation website. Available at http:// nof.org/learn. Accessed April 18, 2016.
- Wolfe F, Bolster MB, O’Connor CM, Michaud K, Lyles KW, Colón-Emeric CS. Bisphosphonate use is associated with reduced risk of myocardial infarction in patients with rheumatoid arthritis. Journal of Bone and Mineral Research. 2013;28(5):984-91. doi: 10.1002/jbmr.1792.
- Takeuchi T, Tanaka Y, Ishiguro N, et al. Effect of denosumab on Japanese patients with rheumatoid arthritis: A dose-response study of AMG 162 (Denosumab) in patients with Rheumatoid arthritis on methotrexate to Validate inhibitory effect on bone Erosion (DRIVE)—a 12-month, multicentre, randomised, double-blind, placebo-controlled, phase II clinical trial. Annals of the Rheumatic Diseases. 2015 2015;0:1-8. doi:10.1136/annrheumdis-2015-208052.
- Newcomb PA, Trentham-Dietz A, Hamptom JM. Bisphosphonates for osteoporosis treatment are associated with reduced breast cancer risk. British Journal of Cancer. 2010;102:799-802. doi:10.1038/sj.bjc.6605555.
- Coleman R, Gnant M, Paterson A, et al. Effects of bisphosphonate treatment on recurrence and cause-specific mortality in women with early breast cancer: A meta-analysis of individual patient data from randomised trials. Presented at: 2013 San Antonio
- The National Institutes of Health Osteoporosis and Related Bone Diseases ~ National Resource Center
- National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse National Institutes of Health
- National Osteoporosis Foundation
- Prevention: Calcium Supplements. National Osteoporosis Foundation Web site. Available at .
- Prevention: Calcium and Vitamin D. National Osteoporosis Foundation Web site. Available at .
- Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. Journal of the American Medical Association. 2002;288(3):321-333.
- Anderson GL, Limacher M, Assaf AR, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: The Women’s Health Initiative randomized controlled trial. Journal of the American Medical Association. 2004;291(14):1701-12.
Kanayama Y. Short-term of clinical efficacy of Evenity in patients with rheumatoid arthritis and primary osteoporosis. Presented at: ASBMR 2020 Virtual Annual Meeting; September 11-15, 2020; Abstract #P-6800
Cosman F, et al: Romosozumba Treatment in Postmenopausal Women with Osteoporosis. N Engl J Med 2016:375:1532-1544