_______________________________________________________ Osteoporosis: Diagnosis and Management
According to BHOF guidelines, postmenopausal women and men 50 years of age and older who present with any of the following should be considered for treatment [20]: • Hip or vertebral (clinical or morphometric) fracture • T-score at the femoral neck or spine of <-2.5 (after evaluation has excluded secondary causes) • Low bone mass (T-score between -1.0 and -2.5 at femoral neck or spine) and 10-year probability of hip fracture >3% or 10-year probability of major osteoporosis-related fracture >20% These recommendations also are supported by the AACE/ ACE [49]. Although the guidelines are helpful, it is important to remember that treatment should be considered on an individual basis because T- and Z-scores are only part of a patient’s workup [20; 58]. Numerous treatment options exist, including [20]: • Diet/supplementation • Exercise • Medications Some patients may have a limited English proficiency, requiring the need of translators or foreign language brochures to properly convey the necessary information.
products), because supplements are not always absorbed well. To increase absorption, supplements should be taken with meals [23]. For patients on acid-reducing medications, calcium citrate should be used because calcium carbonate requires an acidic environment. Vitamin D Normally, vitamin D is mainly stimulated by ultraviolet radiation, or sunlight, on the skin and then by hydroxylation in the liver and kidney. Vitamin D then acts to increase intestinal absorption of calcium and promote bone formation. Deficiency of vitamin D in children causes rickets, and adult deficiency results in osteomalacia. Because it is not practical for many individuals to get adequate levels of vitamin D from exposure to sunlight, increasing vitamin D levels through diet and supplementation should be encouraged [23]. Vitamin D supplementation in conjunction with calcium has been shown to reduce fractures [21]. According to BHOF recommendations, adults 50 years of age and older should obtain 800–1,000 IU of vitamin D per day; AACE/ACE guidelines recommend 1,000–2,000 IU to maintain optimal serum 25 hydroxyvitamin D levels [20; 49]. High-risk patients (e.g., the elderly) may need more. The safe upper limit of daily vitamin D intake for the general adult population was increased to 4,000 IU/day in 2010 [60]. Evidence has shown that higher daily intakes are safe and that some elderly patients may need this amount to maintain optimal serum 25 hydroxyvitamin D levels [20; 49]. Keep in mind that both vitamin D and calcium supplements should be combined with other treatments. Phytoestrogens Plant-derived phytoestrogens may be found in such foods as beans, cabbage, rice, berries, sesame seeds, and grains. They are structurally similar to estrogen, but with weaker effects. They also are not stored in the body and may be easily broken down and eliminated. The three main dietary types of phytoestrogens are isoflavones, coumestans, and lignans. Most foods that contain these compounds include more than one type [61]. Most evidence about the potential role of phytoestrogens has been based on animal studies, and many of these studies have shown that treatment with phytoestrogens has serious adverse effects [62; 63; 64]. Phytoestrogens also have been associated with some serious drawbacks, including inability to accurately measure their levels in food; limited scientific evidence regarding active ingredients, dosage, and potential presence of unexpected agents; and a short-lived benefit cycle [65; 66]. Additionally, the evidence in humans remains conflicting [61; 67]. Few studies on the effect of phytoestrogens on BMD have shown a positive effect; supplementation is not recommended [68; 69; 70; 71].
DIET/SUPPLEMENTATION Calcium
The skeletal structures contain 99% of the body’s calcium stores. When the extraskeletal calcium level is inadequate, bone tissues are resorbed in an attempt to maintain equilibrium. To prevent excessive skeletal calcium loss, an adequate amount of calcium, as well as vitamin D, must be ingested. Clinical trials have shown that following a regimen of adequate consumption of calcium and vitamin D may significantly reduce fracture risk [20]. According to BHOF recommendations, men 50 to 70 years of age should obtain at least 1,000 mg/day of elemental calcium; women 51 years of age and older and men 71 years of age and older require 1,200 mg/day of elemental calcium [20]. National nutrition surveys have revealed that many individuals in the United States consume less than half of the recommended daily amount of calcium in their diet [20]. Dietary supplements may be necessary. Intakes in excess of 1,200–1,500 mg per day provide limited benefit and may increase the risk of developing kidney stones or cardiovascular disease [20]. The upper safe limit for total calcium intake is 2,500 mg/day [23; 59]. Calcium supplements are especially necessary in more fragile, older osteoporosis patients; however, the problem of reduced calcium absorption is more acute in older persons. This may be overcome by increasing overall calcium intake and maintaining adequate levels of vitamin D [23]. The best way to increase calcium intake is through diet (e.g., consumption of dairy
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