Calcium supplements Calcium Citrate Take with or without food 21% Calcium More frequently causes gas, bloating, constipation Calcium Carbonate Requires stomach acid, take with food 40% Calcium Fewer side effects Inexpensive
Vitamin D Supplements Ergocalciferol (Vitamin D2) Fungal derivative Vegan supplement Cholecalciferol (Vitamin D3) Synthesized in the skin Wool oil Preferred supplement
New Guidelines AgeDosage Adults < 50*400 to 800 IU daily Adults > 50*800 to 1,000 IU daily Normal Vitamin D level, do not exceed 4,000IU daily. *Do not commit these to long term memory, follow-up research pending.
Joan Surber Age 68 Pelvic Fracture 1/28/2012 T-Score of -2.5 in her Lumbar Spine, - 1.8 in the Right hip and a -2.2 in the Left hip. Vitamin D=12ng/mL
Severe Osteoporosis T-score –2.5 or less & a fragility fracture has occurred.
Leg braces as a child Menopause at age 34 Calcaneus Fracture at age 42 20+ year history of GERD with medication use
Risks factors & Prevention Don’t have it in your genes Hormone replacement (at the guidance of your PCP) Not recommending to avoid this one. Avoid long-term use of bone depleting medications Heredity/Ethnicity Hormonal Changes (Estrogen & Testosterone) Aging Pharmaceuticals
(Cont.) Risk Factors & Prevention Low BMI History of Fracture EAT! -a diet rich in colors and eat real foods! Bubble wrap
(Cont.) Risk Factors & Prevention Malabsorption Poor Diet Smoking Alcohol in excess Lack of Exercise Avoid Gastric Bypass, Celiac Sprue, Anorexia… Eat FOODs rich in Vitamins and minerals Don’t do that! Limit alcohol to no more than 2 beverages daily Weight bearing exercises such as walking, tia chi, & weight lifting/resistance exercises
Types of Osteoporosis Primary Relatively unknown cause other than advancing age and postmenopausal Secondary Has a known cause or reason for having developed (i.e.=oral corticosteroid use, other medications, diseases or conditions)
True or False Kyphosis of the spine is “normal for aging.”
False Decreasing height and humped back are not normal. They are indications of compression fractures.
Own The Bone Nutrition Counseling Calcium Vitamin D Physical Activity Counseling Weight-bearing and muscle-strengthening exercise Fall prevention education Lifestyle Counseling Smoking Cessation Limiting excessive alcohol intake Pharmacology For the treatment of osteoporosis Testing Dual Energy X-Ray Absorptiometry (DXA) Communication Physician referral letter Follow-up note and educational material to patie
Step-wise Approach Remove Bisphosphonates Fracture immobilization/ fixation Draw Labs/BMD Vitamin D Correction Heal the Fracture Initially After a Fracture
Step-wise Approach Check Vitamin D Increase bone mass if warranted Fracture Risk Assessment Educate patients on calcium, Vitamin D, exercises Resume Bisphosphonates Through the OP Clinic
National Osteoporosis Foundation Recommends treatment: T-score is less than -2.0 Or Less than -1.5 with a risk factor (after the fracture has healed )
MedicationRoute and FrequencyUse AlendronateOral; Daily or WeeklyPrevent/Manage avoid in Hyperparathyroidism or Renal Dysfunction CalcitoninIntranasal; DailyManagement IbandronateOral or IV; Daily/Monthly/q 3 mo. Prevent/Manage avoid in Hyperparathyroidism or Renal Dysfunction RaloxifeneOral; DailyPrevent/Manage +Breast CA prevention RisedronateOral; Daily or WeeklyPrevent/Manage avoid in Hyperparathyroidism or Renal Dysfunction TeriparatideInjection; DailyManagement DenosumabSubQ; q 6 mo.Management +Breast CA prevention Zoledronic acidInjection; yearlyManagement
What are the top three definitions of clinical osteoporosis? #2
Clinical Definitions of OP #1) Vertebral height loss of > 25% of the vertebral body #2) 2 compression fractures #3) 2 or more fragility fractures
What are the top objective (laboratory/radiological) definitions of good bone health? (I have 6 answers) #3
Good Bone Health BMD with T-score from 0- 0.9. Vitamin D > 30ng/mL Calcium (within local lab normal limits) Magnesium (within local lab normal limits) Alkaline Phosphatase (within local lab normal limits) Phosphorus (within local lab normal limits)
List the top sources of Vitamin D. (7 were listed) #4
Vitamin D sources 1. Sunlight 2. Cod liver oil 3. Swordfish 4. Salmon 5. Tuna 6. Fortified Milk 7. Fortified Orange Juice (Eggs also pictured)
What are some great exercises for preventing bone loss? (I have listed 6) #5
Exercises to prevent bone loss Walking Yoga Tai Chi Weight or Strength/Resistance training Balance training Good Posture
What are the top risk factors for developing OP? ( I discussed 11) #6
References Adi Cohen, MD, MHS Columbia University, May 18-21,2011 Osteoporosis in Premenopausal Women: diagnosis and Treatment Issues, ISO9 course, Las Vegas Nevada. Bone Health. "Make Every Bite Bone-Friendly." Health monitor 2012: 26-27. Web. 07 May 2012. "Clinical Practice Comparison of Clinical Efficacy and Safety between Denosumab and Alendronate in Postmenopausal Women with Osteoporosis: a Metaanalysis." Docguide.com. Docguide.com, n.d. Web. 20 Mar. 2012. Conde Nast Digital. "Foods Highest in Vitamin D." Nutritiondata.self.com. Conde Nast Digital, 01 Aug. 2011. Web. 03 Aug. 2011. Dr. Norman. "High Blood Calcium (too Much Calcium in the Blood)." Parathyroid.com/high-calcium.htm. Norman Parathyroid Center, 23 Feb. 2012. Web. 20 Mar. 2012. Ehrlich, Steven D. "University of Maryland Medical Center | Home." University of Maryland Medical Center. VeriMed Healthcare Network, 17 June 2011. Web. 08 May 2012.. Epocrates. "Epocrates Home | Epocrates." Epocrates Home | Epocrates. Epocrates, 2012. Web. 03 Feb. 2012.. Google. "Google Images." Google Images. N.p., n.d. Web. 20 Apr. 2012.. Gronholz, DO, M. J. "JAOA: Journal of the American Osteopathic Association." JAOA: Journal of the American Osteopathic Association. JAOA, 1 Oct. 2008. Web. 03 Mar. 2012.. "Higher Magnesium Intake Linked to Higher Bone Density Effect Seen in Older White, But Not Black, Adults." Health in Aging. The AGS Foundation for Health in Aging, n.d. Web. 03 Feb. 2012..
References (Continued) "International Osteoporosis Foundation | Bone Health." International Osteoporosis Foundation | Bone Health. International Osteoporosis Foundation, Jan. 2011. Web. 03 Mar. 2012.. Calcium rich foods Livestrong. "What Foods Raise Alkaline Phosphatase Levels." Livestrong.com. N.p., n.d. Web. 20 Mar. 2012. Mason, Moya K. "Calcium." Moyak.com. N.p., 2012. Web. 20 Mar. 2012. Mosner, RD,CDN, Michelle. "NYSOPEP." Community Education. Proc. of International Symposium of Osteoporosis, Las Vegas. N.p.: n.p., n.d. N. pag. Print. NIH Consensus Development Panel. "Osteoporosis Prevention, Diagnosis, and Therapy." NIH Consensus Development Program. U.S. Department of Health and Human Services, 27 Mar. 2000. Web. 22 Mar. 2012.. NIH. "Dietary Supplement Fact Sheet: Magnesium." Ods.od.nih.gov/factsheets/magnesium. National Institute of Health, n.d. Web. 20 Mar. 2012. NIH. "Vitamin D Factsheet." Nih.gov. N.p., n.d. Web. 22 Mar. 2012. NOF. "About Osteoporosis | National Osteoporosis Foundation." About Osteoporosis | National Osteoporosis Foundation. N.p., n.d. Web. 30 Apr. 2012.. NOF. "Why Bone Health Is Important | National Osteoporosis Foundation." Why Bone Health Is Important | National Osteoporosis Foundation. N.p., n.d. Web. 30 Apr. 2012.. Watts, Dr. Nelson,MD Bone Health and OP Center University of Cincinnati, May 18-21, 2011 International Symposium of Osteoporosis, Las Vegas, Nevada (IOF course)