Sources of Calcium                                    Osteoporosis Screening Test

Medications for Osteoporosis                      Preventing Falls

What is Osteoporosis?

Osteoporosis (literally meaning "porous bones") is a disease in which your bones become thin, fragile, and more likely to break. If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks, usually the hip, wrist or spine.

Who is at risk for Osteoporosis?

Anyone can get osteoporosis. We are all potentially at risk for osteoporosis because of bone loss that occurs as we get older, but there are also many other factors that can increase our risk of osteoporosis, such as:

• Older age

• Female sex

• Thin, small body frame

• Caucasian race or Asian ethnicity

• Family history of osteoporosis

• Low vitamin D intake (or lack of sun exposure)

• Smoking

• Excess alcohol intake

• Long-term immobility

• Early menopause

• Low calcium intake

• Certain diseases (cancer, lung disease, absorption problems and others)

• Certain medications (cortisone-like drugs such as prednisone, some anti-seizure drugs)

• Eating disorders

How can I prevent osteoporosis?

Your genes determine the potential height and strength of your skeleton but lifestyle factors can control how strong your bones are. To help prevent developing osteoporosis be sure you:

• Get enough Calcium in your diet or from vitamins.

-1000 mg per day if you are a woman pre-menopause, a woman post-menopause who is taking estrogen, or a man under 65 years old.

-1500 mg per day, if you are a woman post-menopause or anyone over 65.

• Do regular weight-bearing exercises like walking, biking or running to keep your bones strong.

• Get enough Vitamin D. You can get this from safe exposure to the sunlight and from vitamin-enriched foods or by taking Vitamin D as a supplement (400-1000 units/day).

  Sources of Calcium

  Excellent sources include:

  (>200 mg per serving) 1 cup lowfat or nonfat milk

  1 cup lowfat or nonfat yogurt

  1 cup calcium-fortified orange juice

  2 ounces tofu

  1 ounce cheese

  Additional Sources:

  (100 mg or less per serving) ½ cup cooked collard greens

  ½ cup low fat cottage cheese

  ½ cup cooked broccoli

  ¼ cup almonds

Calcium Counts: Do You Get Enough?

The key to building strong bones and keeping them healthy is getting enough calcium. Many people do not get enough calcium from the foods they eat. Do you get enough calcium each day? Keep track of your intake for 4 days to see how it compares with the recommended levels.

How much calcium do you need each day?

Age	Milligrams (mg)
9-18 years	1300
19-50 years	1000
51+ years	1500

Food	mg calcium	Day 1	Day 2	Day 3	Day 4
Dairy Foods:
Skim milk, 1 cup	300
1% milk, 1 cup	300
2% milk, 1 cup	295
Whole milk, 1 cup	290
Chocolate milk, 1% or 2%	290
Nonfat dry milk, ¼ cup	377
Buttermilk, 1 cup	285
Plain yogurt, low fat or fat free, 1 cup	415
Flavored yogurt, low fat or fat free, 1 cup	345
Cottage cheese, 2%, ½ cup	78
Ricotta cheese, part-skim, ¼ cup	168
Parmesan cheese, 1 Tbsp	69
Mozzarella, part-skim, 1 oz	207
Cheddar cheese, 1 oz	204
Swiss cheese, 1 oz	272
Muenster cheese, 1 oz	203
Vanilla ice cream, 11% fat, 1 cup	176
Vanilla frozen yogurt, 1 cup	200
Fish:
Oysters, 1 cup	226
Sardines, with bones, 3 oz	372
Salmon, canned, w/bones, 3 oz	167
Shrimp, canned 3 oz	98
Clams, ½ cup	74
Haddock 3 ½ oz	42

Food	mg calcium	Day 1	Day 2	Day 3	Day 4
Vegetables:
Kale, frozen, cooked, ½ cup	90
Greens (beet, dandelion, turnip) cooked, ½ cup	87
Broccoli, frozen, chopped, cooked, ½ cup	47
Fruit:
Orange, 1 medium	52
Orange juice, calcium fortified, 1 cup	300
Rhubarb, cooked, ½ cup	174
Legumes:
Navy beans, cooked ½ cup	64
Tofu, raw, regular, 2 oz	63
Tofu, raw, firm, with calcium sulfate, 2 oz	387
Tofu, raw, regular, with calcium sulfate, 2 oz	199
Grain Products:
Instant oatmeal, 1 packet	160
Total cereal, with calcium, 1 cup	281
Pancake, made with milk, 4" diameter	83
Corn tortilla, 6" diameter	46
Other:
Almonds, whole, ? cup	125
Café latte, 12 fluid oz	412
Cappuccino, 12 fluid oz	262
Cheese pizza, 12" diameter, 1 slice	116
TOTALS:

ADD: 4 day total (Day 1 + Day 2 + Day 3 + Day 4) = ____________

DIVIDE: 4 day total ÷ 4 = _______________ = Average Daily Calcium Intake

• If it is higher, congratulations and keep up the good work!

• If it is lower, try eating more of the foods on the list above and/or talk with your health professional about other sources of calcium.

Osteoporosis Screening Test

How is osteoporosis tested?

A bone mineral density test is often used to screen for and detect the early stages of osteoporosis. Your bone density is measured by a machine that uses small amounts of x-ray to see how much can pass through your bone, and your bone mineral density is calculated. The amount of bone mineral relates directly to bone strength. The scan usually focuses on the hip or spine, however for those unable to have such a study, portable devices are available that measure at the heel, finger, or wrist.

On the day of the test, you can eat and drink as usual, but do not take your calcium supplement. You should wear loose, comfortable clothing like sweatpants and a T-shirt, but nothing with metal, such as zippers, snaps, buttons, or buckles, and no jewelry. You will relax on a cushioned bed for about 3 minutes while a scanner arm passes over your body. The total time you will be at the Osteoporosis Center is about 20 minutes.

By knowing your bone mineral density test result (which is called a T-score), your doctor can tell if you have osteoporosis or are at risk of getting osteoporosis. Be sure to talk to your doctor about monitoring the health of your bones with follow-up bone mineral density tests.

 Osteoporosis: Can It Happen to You?

Complete the following questionnaire to determine your risk for developing osteoporosis. The more times you answer yes, the greater your risk for developing osteoporosis.

QUESTION	YES	NO
Are you past menopause?
Did or does your mother or sister have osteoporosis?
Have you broken a bone in your hip, wrist, or spine since the age of 50?
Do you smoke cigarettes, or have you been a regular cigarette smoker in the past 5 years?
Do you have a small, thin frame?
Do you currently take oral steroids, such as prednisone?
Does your daily diet include less than 1200mg of calcium, which is the equivalent of 1 quart of milk?
Do you do weight-bearing exercise, such as walking, fewer than 3-4 times a week?

• The causes of osteoporosis are unknown. However, when certain risk factors are present, your likelihood of developing osteoporosis is increased. Therefore, it is important for you to determine your risk of developing osteoporosis, and take preventive steps.

• Osteoporosis is preventable if bone loss is detected early. If the questions in the chart above suggest that you are at risk for developing osteoporosis, see your physician. Your physician may recommend that you have a bone density test, which safely and accurately measures the amount of bone mass in your hip, spine or wrist.
• If you already have osteoporosis, you can live actively and comfortably by seeking proper medical care and making some adjustments to your lifestyle. Your physician may prescribe a diet rich in calcium, a regular program of weight-bearing exercise, and medical treatment.

There are several medications available today for the prevention and treatment of osteoporosis. Listed below are medications typically used to treat osteoporosis along with instructions on how they are taken and side effects which may occur. These medications are listed by generic name first, followed by the brand name. For all of these medications, it is assumed that you will also be taking in adequate calcium and vitamin D, either from your diet or from supplements.

All of the bisphosphonates work by decreasing the activity of the osteoclasts, the cells that remove old bone. Alendronate, risedronate, and etidronate are each taken by mouth. Zoledronic acid and pamidronate are given intravenously and ibandronate can be given either by mouth or by intravenous infusion. The medications in the non-FDA approved group have been shown to increase bone density but have not been studied extensively enough to see if they reduce fractures sufficiently to meet FDA requirements. Alendronate has been shown to reduce the occurrence of vertebral or back fractures and hip fractures. Risedronate is approved for vertebral and non-vertebral fractures, and ibandronate for vertebral fractures. The zoledronic acid brand Reclast has been shown to reduce the occurrence of vertebral, non-vertebral and hip fractures.

The bisphosphonates can be taken less than daily since they have a long activity time. Alendronate and risedronate are usually taken once weekly, but can be taken daily at a smaller dose. Risedronate and ibandronate are approved for once monthly dosing. Etidronate has a unique dosage of being taken daily for 14 days with repeated dosing every 3 months.

Those bisphosphonates taken by mouth – alendronate, risedronate, ibandronate, and etidronate – are very poorly absorbed into the stomach and food can interfere with their absorption. The most common side effects are abdominal pain, bloating, nausea, and heartburn. Etidronate may also cause diarrhea. They can irritate the esophagus or food tube if they should get stuck there or if they float back into the food tube. For these reasons, the following steps must be taken:

1. Take the pill first thing in the morning.

2. Take with at least 8 ounces of water and only with water, not coffee, juice, tea, etc.

3. Stay standing or sitting after taking the pill until you have breakfast.

4. Wait 30 minutes before eating breakfast. In the case of monthly Ibandronate, you need to wait one hour for breakfast.

On rare occasion, these medications may cause bone pain after taking.

The intravenous medications zoledronic acid, pamidronate, and ibandronate are given into the vein once a year in the case of zoledronic acid, and once every three months for pamidronate and ibandronate. They are generally well tolerated, but at times a flu-like reaction lasting 24-48 hours can occur.

RALOXIFENE – EVISTA

Raloxifene, although chemically unrelated has some of the features of estrogen, the female hormone. It is only used for women and has been shown to increase bone density and reduce the risk of fractures in the spine. It is taken by pill daily and is usually well tolerated. The most common side effects are the re-emergence or worsening of hot flashes, leg cramps, and blood clots which can lead to the serious complication – a blood clot to the lung which can affect breathing or cause death. This is a rare complication. You should watch for persistent leg pain or swelling, sudden chest pain or shortness of breath. Raloxifene can be taken any time of the day and with any liquid, with or without a meal.

CALCITONIN – MIACALCIN

Calcitonin is a naturally occurring chemical which helps regulate calcium levels in our body. The type used for treatment can be given either by injection or nose spray daily. These are synthetic copies of calcitonin obtained from salmon which is more potent than synthetic human type calcitonin. The injectable variety is rarely used today. The nasal spray is quite safe and its side effects are generally mild and localized to the nose area, such as nose irritation, runny nose, bleeding from the nose, headaches, or sinus pain. Calcitonin appears to be weaker than some of the other medications but does reduce fractures of the back. It is approved for women who are at least five years past menopause.

TERIPARATIDE – FORTEO

Teriparatide is a very potent builder of bone which acts by stimulating the osteoblast or bone building cells. It is identical to a portion of a naturally occurring hormone called parathyroid hormone or PTH which is very important for regulation of the levels of calcium in our blood. It must be given by daily injection and is quite expensive compared to other treatments. It has very few side effects, but on occasion nausea may occur, as can a slight redness at the site of the injection. The medication comes in a preloaded syringe and is easy to administer. Because studies in growing rats showed the development of a type of bone tumor during treatment with teriparatide, the FDA has limited its use to 2 years, after which time another medication must be used.

People with weak bone mass are particularly susceptible to breaking or fracturing bones, through falling. Here are some suggestions on how to prevent falls.

Try to sit on furniture with good back support that you can get into and out of easily. Firm chairs with arm rests are easier to get out of. Add pillows to the back of the chair so your feet can touch the floor.

Increase lower body strength and improve balance through regular physical activity (Tai Chi is one type of exercise program that has been shown to be very effective).

Ask your doctor or pharmacist to review all medicines (both prescription and over-the-counter) to reduce side effects and interactions. It may be possible to reduce the number of medications used, particularly tranquilizers, sleeping pills, and anti-anxiety drugs.

Do you mop up spills immediately?

Is there good ventilation to reduce the risk of eyeglasses fogging?

Make sure all outside steps are highly visible by painting the front edge of the step a contrasting color.

Make sure paths are even and unbroken.

Keep paths free of moss and leaves, and take extra care in wet conditions.

Walk carefully near pets or small animals; their movement is unpredictable.

Use a hose reel to store your garden hose.

Store garden tools safely.

Contact your local government to advise them of problem areas near your home.

Many falls result from the use of ladders. Be extremely careful. If you cannot get someone else to assist you, ensure you comply with all safety instructions.

Wear sunglasses and/or a hat to reduce sun glare.

Have your vision checked regularly.

A product such as this lightweight traction device for the shoes is easy to use and will give greater stability on ice and snow.