Nutrition and lifestyle
Dietary factors: It is important to that there is enough calcium in the diet for proper bone health. Healthcare professionals recommend calcium intakes of at least 1,000mg daily for everyone over eight years of age. Higher calcium intakes of 1,200mg daily are recommended for adults over 50 years and 1,300mg daily for teens nine to 18 years. Adequate vitamin D intake is also important for calcium absorption and to maintain muscle strength. Healthcare professionals recommend 400 international units of vitamin D daily until age 60, then 600-800 international units per day after age 60. Doses can be adjusted by a doctor according to blood levels of vitamin D.
Milk and milk products are calcium-dense foods providing about 300 milligrams calcium per serving. These foods also contain other nutrients important to bone health such as vitamin D (if fortified), phosphorus, and magnesium. Approximately 73% of calcium in the food supply comes from dairy products, 9% from fruits and vegetables, 5% from grain products, and 12% from all other sources such as dietary supplements.
Weight-bearing exercises: Exercise is an important treatment for osteoporosis to maintain healthy bones. Weight-bearing aerobic activities, involving the bones supporting body weight, have been shown to have a positive effect in maintaining and increasing bone mass and preventing osteoporosis. These activities include weight-lifting, jogging, hiking, stair-climbing, step aerobics, dancing, racquet sports, and other activities that require muscles to work against gravity. Swimming and simply walking, although good for cardiovascular fitness, are not the best exercises for building bone. Individuals who live a sedentary lifestyle have weaker bones and are subjected to a higher risk of sustaining fractures.
Bisphosphonates: Alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®), and zoledronate (Zometa®) are approved by the U.S. Food and Drug Administration (FDA) for the prevention and treatment of osteoporosis in postmenopausal women. Alendronate is a drug currently approved for management of osteoporosis in men. Both alendronate and risedronate are approved for the prevention and treatment of steroid-induced osteoporosis in men and women. Bisphosphonates help slow down bone loss and have been shown to decrease the risk of fractures. All are taken on an empty stomach with water. Because bisphosphonates have the potential for irritating the esophagus, remaining upright for at least an hour after taking these medications is recommended by healthcare professionals. Alendronate and risedronate can be taken once a week, while ibandronate can be taken once a month. An IV form of ibandronate, given through the vein every three months, also has been FDA-approved for the management of osteoporosis. Another IV bisphosphonate being studied for osteoporosis is zoledronic acid or zoledronate (Zometa®). This form is injected once yearly.
Side effects, which can be severe, include nausea, abdominal pain, and the risk of an inflamed esophagus or esophageal ulcers, especially if the individual has had acid reflux or ulcers in the past. If individuals cannot tolerate oral bisphosphonates, the doctor may recommend the periodic intravenous infusions of a bisphosphonate.
Use of bisphosphonates in women who are pregnant or breastfeeding is not well studied. Blood calcium levels in women who take bisphosphonates during pregnancy are usually monitored. Individuals using Boniva® injection will have blood levels of creatinine measured prior to each dose to determine kidney function. Creatinine is measured using blood tests.
Calcitonin (Miacalcin®): Calcitonin is a naturally occurring hormone produced by the thyroid gland that can be given as an injection or taken as a nasal spray. Calcitonin also inhibits the function of the cells that breakdown bone, the osteoclasts. Calcitonin has long been known to be beneficial in individuals with osteoporosis, but the injections were difficult to administer and had unpleasant side-effects. The nasal spray has greatly improved the use of calcitonin, and it is much more commonly used today. Calcitonin has been reported to slow bone loss, and also decrease pain associated with osteoporosis fractures.
Hormone replacement therapy (HRT): Estrogen therapy alone or in combination with another hormone, progestin, has been reported to decrease the risk of osteoporosis and osteoporotic fractures in women. However, the combination of estrogen with a progestin has been shown to increase the risk for breast and ovarian cancer, strokes, heart attacks, and blood clots. Estrogens alone may increase the risk of strokes. Healthcare professionals recommend weighing all options before choosing HRT as part of osteoporosis prevention.
Selective estrogen receptor modulators (SERMs): Selective estrogen receptor modulators (SERMS) mimic the positive effects of estrogen on bones without some of the serious side effects such as breast cancer and stroke. Raloxifene (Evista®) decreases spine fractures in women, and is approved for use only in women at this time. Hot flashes are a common side effect of raloxifene, and individuals with a history of blood clots should not use this drug.
): Teriparatide is a form of parathyroid hormone that helps stimulate bone formation. Teriparatide is approved for use in postmenopausal women and men at high risk for osteoporotic fracture. It is given as a daily injection under the skin and can be used for up to two years. If the individual has ever had radiation treatment or if parathyroid hormone levels are already too high, they may not be able to take this medication.
Tamoxifen (Nolvadex®): Tamoxifen (Nolvadex®) is a synthetic hormone is used to treat breast cancer and is given to certain high-risk women to help reduce their chances of developing breast cancer. Although tamoxifen blocks estrogen's effect on breast tissue, it has an estrogen-like effect on other cells in the body, including bone cells. As a result, tamoxifen appears to reduce the risk of fractures, especially in women over age 50. Possible side effects of tamoxifen include hot flashes, stomach upset, and vaginal dryness or discharge.
Vertebroplasty: Vertebroplasty is a minimally invasive procedure used to reinforce vertebrae with compression fractures. Compression fractures are common in individuals with osteoporosis. Vertebroplasty involves injecting an acrylic compound into the collapsed vertebra to stabilize the weakened bone. The procedure is performed in an operating room or radiology suite and treatment of each affected vertebra takes approximately one hour.
Local anesthesia, usually lidocaine (Xylocaine®), is injected into the vertebra. Then, a small incision is made, and a bone biopsy needle is inserted. Several small syringes of the acrylic cementing material are then injected through the needle into the vertebra. The cement hardens almost immediately.
Approximately 70-90% of individuals experience pain relief after vertebroplasty and most are released from the hospital the same day. Anti-inflammatory medications, such as ibuprofen (Motrin®, Advil®), may be used to relieve pain after the procedure.
Complications from a vertebroplasty are rare. Bone cement may enter the lung, spinal cord, or epidural space surrounding the vertebra. Other possible complications associated with vertebroplasty include nerve irritation, punctured lung (pneumothorax), and spinal cord injury.
Kyphoplasty: Multiple spinal compression fractures caused by osteoporosis may lead to height loss, kyphosis (extreme curvature of the spine), and pain. Kyphoplasty is a minimally invasive procedure that is used to restore the height of the vertebrae and stabilize weakened bone. Kyphoplasty cannot correct established spine deformities and is used in individuals who have experienced recent fractures, usually within two to four months. The procedure is usually performed in the hospital under local or general anesthesia and takes approximately one hour for each affected vertebra.
A small incision is made and a fluoroscope (device that consists of a screen and an x-ray tube) is used to guide the insertion of a balloon catheter into the vertebra. The balloon is inflated slowly to raise the compressed vertebra and is deflated. An acrylic compound (cementing material) is then injected into the vertebra through a bone biopsy needle. The material hardens almost immediately. Pain relief usually occurs within two days.
Most individuals are released from the hospital the day after kyphoplasty and can resume daily activities upon discharge. Strenuous activity, such as heavy lifting, should be avoided for at least six weeks.
Strong scientific evidence
Calcium: Calcium is the nutrient consistently found to be the most important nutrient for attaining peak bone mass and preventing osteoporosis. Adequate vitamin D intake is required for optimal calcium absorption. Adequate calcium and vitamin D are deemed essential for the prevention of osteoporosis in general, including postmenopausal osteoporosis.
Although calcium and vitamin D alone are not recommended as the sole treatment of osteoporosis, they are necessary additions to pharmaceutical treatments. The vast majority of clinical trials investigating the efficacy of pharmaceutical treatments for osteoporosis have investigated these agents in combination with calcium and vitamin D. So, although calcium alone is unlikely to have an effect on the rate of bone loss following menopause, osteoporosis cannot be treated in the absence of calcium. Treatment of postmenopausal osteoporosis should only be done under the supervision of a qualified healthcare professional.
Multiple studies of calcium supplementation in the elderly and postmenopausal women have found that high calcium intakes can help reduce the loss of bone density. Studies indicated that bone loss could be prevented in many areas including ankles, hips, and spine.
Vitamin D: Vitamin D is found in numerous dietary sources such as fish, eggs, fortified milk, and cod liver oil. The sun is also a significant contributor to our daily production of vitamin D, and as little as 10 minutes of exposure is thought to be enough to prevent deficiencies.
In adults with severe vitamin D deficiency, bone mineral is lost ("hypomineralization") and results in bone pain and osteomalacia (soft bones). Osteomalacia may result from deficiency of vitamin D in elderly patients, decreased absorption of vitamin D, patients with chronic malabsorption syndrome secondary to jejunoileal bypass, patients with partial gastrectomy, aluminum-induced bone disease, chronic liver disease, or kidney disease with renal osteodystrophy. Treatment for osteomalacia depends on the underlying cause of the disease and often includes pain control and orthopedic surgical intervention, as well as vitamin D and phosphate binding agents.
Vitamin D: Without sufficient vitamin D, calcium absorption cannot be maximized and the resulting elevation in parathyroid (PTH) secretion by the parathyroid glands results in increased bone resorption, which may weaken bones and increase the risk of fracture. Vitamin D supplementation has been demonstrated to slow bone loss and reduce fracture, particularly when taken with calcium.
Oral calcifediol or ergocalciferol may help manage hypocalcemia and prevent renal osteodystrophy in people with chronic renal failure undergoing dialysis. Renal osteodystrophy is a term that refers to all of the bone problems that occur in patients with chronic kidney failure.
Black tea: Black tea (Camellia sinensis) is from the same shrub as green tea and oolong tea. Each is processed differently. Preliminary research suggests that chronic use of black tea may improve bone mineral density (BMD) in older women. Better research is needed in this area before a conclusion can be drawn.
Caffeine is a stimulant of the central nervous system and may cause insomnia in adults, children, and infants (including nursing infants of mothers taking caffeine). Caffeine acts on the kidneys as a diuretic (increasing urine and urine sodium/potassium levels, and potentially decreasing blood sodium/potassium levels), and may worsen incontinence. Caffeine-containing beverages may increase the production of stomach acid, and may worsen ulcer symptoms. Tannin in tea can cause constipation. Caffeine in certain doses can increase heart rate and blood pressure, although people who consume caffeine regularly do not seem to experience these effects in the long-term. There are many drug interactions possible when using caffeinated beverages.
Boron: Boron is a trace mineral found in the global environment. Animal and preliminary human studies report that boron may play a role in mineral metabolism, with effects on calcium, phosphorus, and vitamin D. However, research of bone mineral density in women taking boron supplements does not clearly demonstrate benefits in osteoporosis. Additional study is needed before a firm conclusion can be drawn.
Calcium: Calcium is the nutrient consistently found to be the most important for attaining peak bone mass and preventing osteoporosis. Adequate vitamin D intake is required for optimal calcium absorption. Adequate calcium and vitamin D are deemed essential for the prevention of osteoporosis in general, including postmenopausal osteoporosis.
Calcium supplementation in patients on long-term, high-dose inhaled steroids for asthma may reduce bone loss due to steroid intake. Treatment using the prescription drug pamidronate with calcium has been shown to be superior to calcium alone in the prevention of corticosteroid-induced osteoporosis. Inhaled steroids have been reported to disturb normal bone metabolism, and they are associated with a decrease in bone mineral density. Results suggest that long-term administration of high-dose inhaled steroid induces bone loss that is preventable with calcium supplementation with or without the prescription drug etidronate. Long-term studies involving more patients should follow to confirm these preliminary findings.
Rickets and osteomalacia (bone softening) are commonly thought of as diseases due to vitamin D deficiency; however, calcium deficiency may also be another risk factor in sunny areas of the world where vitamin D deficiency would not be expected. Calcium gluconate is used as an adjuvant in the treatment of rickets and osteomalacia, as well as a single therapeutic agent in non-vitamin D deficient rickets. Research continues into to the importance of calcium alone in the treatment and prevention of rickets and osteomalacia. Treatment of rickets and osteomalacia should only be done under supervision of a qualified healthcare professional.
Copper: Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains, and fruits, as well as shellfish, avocado, and beef (organs such as liver). Osteopenia and other abnormalities of bone development related to copper deficiency may occur in copper-deficient low-birth weight infants and young children. Supplementation with copper may be helpful in the treatment and/or prevention of osteoporosis, although early human evidence is conflicting. The effects of copper deficiency or copper supplementation on bone metabolism and age-related osteoporosis require further research before clear conclusions can be drawn.
DHEA: Laboratory studies have found that dehydroepiandosterone (DHEA) may improve bone mineral density. The ability of DHEA to increase bone density in humans is under investigation. Effects are not clear at this time.
Gamma linolenic acid (GLA): Some evidence from a clinical trial along with observations of clinicians and dieticians have suggested that gamma linolenic acid (GLA) and eicosapentaenoic acid (EPA) enhance the effects of calcium supplementation in elderly patients with osteoporosis. More clinical studies are required to produce results to determine effectiveness in diverse elderly and middle-age populations.
Horsetail: Silicon may be beneficial for bone strengthening. Because horsetail (Equisetum arvense) contains silicon, it has been suggested as a possible natural treatment for osteoporosis. Preliminary human study reports benefits, but more detailed research is needed before a firm recommendation can be made. People with osteoporosis should speak with a qualified healthcare provider about possible treatment with more proven therapies.
Physical therapy: Supervised or home-based physical therapy has been used in combination with resistance and endurance training in physically frail elderly women taking hormone replacement therapy to improve bone density. Long-term high-intensity weight-bearing exercise programs have also been used in rheumatoid arthritis patients with some success. Although early study is promising, more studies are needed in this area.
Red clover: It is not clear if red clover (Trifolium praetense) isoflavones have beneficial effects on bone density. Most studies of isoflavones in this area have looked at soy, which contains different amounts of isoflavones, as well as other non-isoflavone ingredients. More research is needed. Red clover extract may increase bleeding in sensitive individuals, including those taking blood-thinning medications such as warfarin (Coumadin®).
Soy: It has been theorized that soy (Glycine max) "phytoestrogens" (plant-based compounds with weak estrogen-like properties) such as isoflavones may increase bone mineral density in post-menopausal women and reduce the risk of fractures. However, most studies have not been well designed or reported. Until better research is available, a firm conclusion cannot be drawn. Individuals at risk for osteoporosis should speak with a qualified healthcare provider about the therapeutic options for increasing bone mineral density.
Tai chi: Preliminary research suggests that tai chi may be beneficial in delaying early bone loss in postmenopausal women. Additional evidence and long-term follow-up is needed to confirm these results.
Tamarind: Preliminary study has examined the use of tamarind (Tamarindus indica)for fluorosis prevention. Although beneficial outcomes have been reported, these results are not conclusive. Additional study is needed in this area.
Vitamin D: Some evidence implies that steroids may impair vitamin D metabolism, further contributing to the loss of bone and development of osteoporosis associated with steroid medications. There is limited evidence that vitamin D may be beneficial to bone strength in individuals taking long-term steroids.
Osteoporosis is common in patients with cystic fibrosis due to fat malabsorption, which leads to a deficiency of fat-soluble vitamins such as vitamin D. Oral calcitriol administration appears to increase absorption of calcium and lower parathyroid concentrations.
Vitamin K: Vitamin K appears to prevent bone resorption, and adequate dietary intake is likely necessary to prevent excess bone loss. Elderly or institutionalized patients may be at particular risk, and adequate intake of vitamin K-rich foods should be maintained. Unless patients have demonstrated vitamin K deficiency, there is no evidence that additional vitamin K supplementation is helpful. However, vitamin K may play a role in the prevention and treatment of glucocorticoid-induced bone loss. Further research is needed to confirm these results. Over-the-counter vitamin K1-containing multivitamin supplements may disrupt warfarin anticoagulation in vitamin K1-depleted patients. Vitamin K-depleted patients are sensitive to even small changes in vitamin K1 intake.
Selenium: Selenium is a trace mineral found in soil, water, and some foods. It is an essential element in several metabolic pathways. Kashin-Beck disease is an osteoarthropathy endemic in selenium- and iodine-deficient areas. Preliminary evidence suggests that selenium supplementation does not significantly improve this disease.
Integrative therapies used in pain, or related complications of osteoporosis causing pain, that have historical or theoretical uses but lack sufficient clinical evidence include: the Alexander technique, anise (Pimpinella anisum), applied kinesiology, arginine (L-arginine), black cohosh (Actaea racemosa), bovine colostrum, chelation (EDTA) therapy, dong quai (Angelica sinensis), folate (folic acid), glucosamine, green tea (Camellia sinensis), hops (Humulus lupulus), kudzu (Pueraria lobata), kundalini yoga, maca (Lepidium meyenii), magnet therapy, melatonin, mistletoe (Viscum album), octacosanol, omega-3 fatty acids (fish oil, alpha-linolenic acid), probiotics, resveratrol, rosemary (Rosmarinus officinalis), shiitake (Lentinula edodes), vitamin B12 (cyanocobalamin), vitamin C (ascorbic acid), and yoga.
Smoking cessation: Smokers lose bone more rapidly than nonsmokers. Among 80 year olds, smokers have up to 10% lower bone mineral density, which translates into twice the risk of spinal fractures and a 50% increase in risk of hip fracture. Fractures heal slower in smokers, and are more apt to heal improperly.
Alcohol in moderation: Excessive alcohol has been associated with osteoporosis due to the degenerative metabolic effects of alcohol. Alcohol excess may inhibit calcium absorption and bone formation.
Healthy body weight: Being underweight is a risk factor for osteoporosis. Staying within a healthy weight for an individual is important. Extreme thinness is a risk factor for osteoporosis. The onset of anorexia nervosa frequently occurs during puberty, the time of life when maximal bone mass accrual occurs, thereby putting adolescent girls with anorexia nervosa at high risk for reduced peak bone mass.
Sunlight: Healthcare professionals recommend sun exposure of 15 minutes a day to hands and face to help the body make vitamin D. Vitamin D helps calcium be absorbed and used by the body. Avoid overexposure to the sun.
Diet: A high protein diet or high coffee consumption increases calcium loss and may increase the calcium needs for the body. Fiber, oxalates (in rhubarb, spinach, beets, celery, greens, berries, nuts, tea, cocoa), and high zinc foods (such as oysters and red meats) decrease absorption, requiring taking more calcium in dietary supplement form. The plant estrogens found in soy help maintain bone density and may reduce the risk of fractures, particularly in the first 10 years after menopause.
Exercise: The amount and type of exercise will vary depending on age and bone health. An exercise program should be individually tailored to the individual's needs and capabilities. Overall, most individuals should aim to exercise for 30-40 minutes three to four times each week, with some weight-bearing and resistance exercises in the program.
Although exercise is important in the prevention of osteoporosis, women and teenage girls who exercise to an extreme degree can develop amenorrhea (cessation of menstruation) due to estrogen deficiency. Estrogen deficiency in younger women contributes to bone loss, in much the same way that estrogen deficiency after menopause does. Both male and female athletes who practice excessive exercise without adequate caloric intake are at heightened risk of osteoporosis. Athletes who train hard while trying to keep their weight below a certain level for competitive reasons are at particularly high risk.
Eliminating fall hazards: If an individual has osteoporosis, it is important not only to help prevent further bone loss, but also to prevent a fracture. Eliminating hazards in the house that can increase the risk of falling is important. Removing loose wires or throw rugs, installing grab bars in the bathroom and non-skid mats near sinks and in the tub, and not walking in slick shoes or socks is recommended by healthcare professionals. Healthcare professionals also recommend caution when carrying or lifting items, as this could cause a spinal fracture. Wearing sturdy shoes is important. Using a cane or walker is recommended by healthcare professionals if the individual has balance problems or other difficulties walking.