Download Nutriceuticals: Over-the-Counter Products and Osteoporosis

serum calcium levels are too low, and adequate calcium
is not provided by the diet, calcium is taken from bone.
Osteoporosis: Clinical Updates
Osteoporosis Clinical Updates is a publication of the National
Osteoporosis Foundation (NOF). Use and reproduction of
this publication for educational purposes is permitted and
encouraged without permission, with proper citation. This
publication may not be used for commercial gain. NOF is a
non-profit, 501(c)(3) educational organization. Suggested
citation: National Osteoporosis Foundation. Osteoporosis
Clinical Updates. Issue Title. Washington, DC;Year.
Long-term dietary calcium deficiency is a known risk
factor for osteoporosis. The recommended daily calcium intake from diet and supplements combined is
1000 mg/day for people aged 19 to 50 and 1200 mg/
day for people older than 50. For all ages, the tolerable
upper limit is 2500 mg calcium per day.
Adequate calcium intake is necessary for attaining peak
bone mass in early life (until about age 30) and for
slowing the rate of bone loss in later life.3 Although
calcium alone (or with vitamin D) has not been shown
to prevent estrogen-related bone loss, multiple studies have found calcium consumption between 650 mg
and over 1400 mg/day reduces bone loss and increases
lumbar spine BMD.4-6
Please direct all inquiries to: National Osteoporosis
Foundation 1150 17th Street NW Washington, DC 20037,
USA Phone: 1 (202) 223-2226
Fax: 1 (202) 223-1726 www.nof.org
Statement of Educational Purpose
Osteoporosis Clinical Updates is published to improve
osteoporosis patient care by providing clinicians with
state-of-the-art information and pragmatic strategies on
prevention, diagnosis, and treatment that they may apply in
clinical practice.
How to take calcium supplements:
‡ Take calcium supplements with food.
‡ If unable to take calcium with food or if taking acid-blocking medication, calcium citrate is
recommended
‡ Spread calcium out
‡ 600 mg or less is absorbed best at one time
‡ Best to take supplement at a relatively low- calcium
meal
‡ Chew chewables, swallow tablets
‡ Take with full glass of water and food
Overall Objectives
Despite the availability of effective prevention, diagnostic,
and treatment protocols for osteoporosis, research indicates
that it is significantly underdiagnosed and undertreated
in the general population. Through this publication, NOF
encourages participants to incorporate current evidence
and expert recommendations into clinical practice to
improve the bone health of their patients.
Upon completion of each issue of Osteoporosis Clinical
Updates, participants should be able to:
‡ Recognize current concepts in osteoporosis research
and clinical practice
‡ Identify implications of these concepts for osteoporosis
patient care
‡ Adopt evidence-based strategies to study, prevent, and/
or treat osteoporosis
‡ Improve patient care practices by integrating new data
and/or techniques
Dietary sources of calcium include:
‡ Dairy products: milk (300 mg/cup), yogurt (300400 mg/cup) and cheeses (138 mg/cup skim cottage cheese)
‡ Fortified orange juices (300 mg/8 oz), breads (150200 mg/slice), and cereals (Total® brand Raisin Bran
1038 mg/cup);
‡ Nuts (almonds 75 mg/1 oz, about 25 nuts) and
seeds (sesame seed butter, tahini, 64 mg/tbsp)
‡ Fish eaten with bones (sardines 325 mg/3oz, canned
salmon 183 mg/3oz)
‡ Soy milk (61 mg/cup)
‡ Tofu processed with calcium salts (164 mg/quarter
cup)
‡ Green vegetables, such as collards (357 mg/cup)
‡ Beans, such as navy beans (126 mg/cup) and soy
beans (261 mg/cup)
Intended Audience
This continuing education activity is intended for
health professionals who care for patients at risk for or
suffering from osteoporosis practicing in primary care,
endocrinology, geriatrics, gynecology, internal medicine,
obstetrics, orthopedics, osteopathy, pediatrics, physiatry,
radiology, rheumatology, and/or physical therapy.
This includes physicians, nurse practitioners, registered
nurses, pharmacists, physician assistants, technologists,
researchers, public health professionals and health educators
with an interest in osteoporosis and bone health.
Calcium supplements are available in several forms:
calcium carbonate (most common), calcium citrate,
3
Calcium Safety
and calcium phosphate. Compounds contain different
amounts of elemental calcium. Calcium intake should
be estimated on the basis of elemental calcium in the
supplement taken (shown on the nutrition supplement
label).
Concern has been raised about a possible connection
between calcium supplementation and cardiovascular
risks. Associations have been observed between calcium
supplementation without vitamin D and increased risk
of myocardial infarction (MI). Using a more powerful
tool of combining effects seen in individual studies by
meta-analysis of randomized trials of calcium supplementation (minus vitamin D), the same association was
demonstrated: roughly a 30% increase in MI, but not
stroke or mortality.7,8 A similar, although smaller increase in MI was observed in meta-analysis of data from
the Women’s Health Initiative.9
Calcium in over-the-counter supplements is generally well absorbed in the various compounds available.
Individual users may find that one compound works
better for them because it causes fewer side effects,
such as gas or constipation. Because the body doesn’t
readily absorb more than about 600 mg of elemental
calcium at a time, it is best to take calcium supplements
with a low-calcium meal and to spread out supplements, perhaps taking one in the morning and one at
night. Calcium carbonate is absorbed best when taken
with food. Calcium citrate can be taken anytime.
Data on calcium taken in conjunction with vitamin D
and pharmacotherapy for osteoporosis, however, have
demonstrated no increase in overall mortality and
cardiovascular events.10-12 There is still much that is
unknown about the risk of high calcium intake on the
cardiovascular system.
Achieving bone-building and bone-preserving effects of
pharmacologic therapies for osteoporosis requires adequate calcium intake.
The current consensus is that calcium consumed
through food intake is the best means to meet daily
intake recommendations and is unlikely to have a negative impact. Therefore, individuals should consume
as much calcium as possible from foods. Supplements
should be used only to bring all-source intake to recommended levels of 1000-1200 mg/day. In general,
more calcium than the recommended amount will not
provide added benefit and may, indeed, pose a risk.
In years past, the main concern about calcium supplements was lead contamination in calcium-carbonate
based supplements derived from dolomite, bone meal,
or unrefined oyster shell. Like other nutritional supplements, calcium supplements are not FDA tested for
lead content. It is up to the manufacturer to ensure
that a supplement meets FDA standards. The FDA
Provisional Total Tolerable Intake level for lead is 75
mcg for adults. Several studies have found detectible
lead in commercial calcium supplements.13,14 In 2008,
the FDA tested lead content in 324 multivitamins
sold in the U.S. Small amounts of lead were found in
most of them (320 of 324), but none came close to
the harmful threshold (highest daily exposure was <5
mcg/day).15
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If the supplement has a USP label, the lead content
has been tested and determined to be within acceptable levels. Most major brands of calcium supplements
voluntarily meet the USP standards for purity and safe
lead levels.
CME Program Eligibility
Method of Participation in the Learning Process: Clinician
learners will read and analyze the subject matter, conduct
additional informal research through related internet
searches on the subject matter, and complete a post-test
assessment of knowledge and skills gained as a result of the
activity.
After participating in this activity, the reader has the
option of taking a post-test with a passing grade of 70% or
better to qualify for continuing education credit for this
activity. It is estimated it will take 1.0 hour(s) to complete
the reading and take the post-test. Continuing education
credit will be available for two years from the date of
publication.
Calcium is known to offset the effects of lead by blocking its absorption (both in the supplement and in other
dietary contributors of lead).16,17 Research has shown
that blood lead levels are lower in people who take
calcium supplements than in those who do not.18 Data
available to date support the view that patients are safe
taking calcium-plus-vitamin-D supplements from respected manufacturers. Patients should, however, avoid
supplements derived from dolomite, bone meal, or
unrefined oyster shell. Be advised that calcium carbonate preparations are currently the least expensive and
the most widely available. Alternatives to calcium carbonate include calcium citrate, calcium phosphate, and
(by prescription) calcium acetate.
Accreditation
The National Osteoporosis Foundation is accredited by the
Accreditation Council for Continuing Medical Education
to provide continuing medical education for physicians.
The National Osteoporosis Foundation designates this
educational activity for a maximum of 1.0 AMA PRA
Category 1 Credit(s)TM. Physicians should only claim credit
commensurate with the extent of their participation in the
activity.
The National Osteoporosis Foundation is accredited
as a provider of continuing nursing education by the
American Nurses Credentialing Center’s Commission on
Accreditation.
The National Osteoporosis Foundation designates this
educational activity for a maximum of 1.0 continuing
nursing education credit(s).
Other healthcare providers will also be able to receive a
certificate of completion; nurse practitioners and physician
assistants may request an AMA PRA Category 1 Credit(s)™
certificate of participation.
Vitamin D and Bone
Vitamin D regulates intestinal calcium absorption
and helps mineralize bone. The most readily available
source of vitamin D is direct sunlight, which some
people avoid because of skin cancer risk and concern
about wrinkles and photo damage. Additionally, the
skin’s ability to metabolize vitamin D declines with
age. Other sources of vitamin D are needed such as fish
liver oils, fatty fish, eggs, liver, and fortified foods such
as milk and cereal.
Vitamin D deficiency can be a problem among
individuals who avoid sunlight, do not drink vitamin
D fortified milk, or do not take a multivitamin containing vitamin D. It is also common in people who
are homebound or institutionalized, are on dialysis or
anticonvulsive medication, or who suffer from diabetes, hypertension, chronic neurological disorders, or
gastrointestinal diseases. In addition, research on hospital inpatients found a significant degree of vitamin
D deficiency (42%) in patients with no known risk
factors.19
Disclosure of Commercial Support
It is the policy of the National Osteoporosis Foundation
(NOF) to ensure balance, independence, objectivity,
and scientific rigor in all its sponsored publications and
programs. NOF requires the disclosure of the existence of
any significant financial interest or any other relationship
the sponsor, editorial board, or guest contributors have
with the manufacturer(s) of any commercial product(s)
discussed in an educational presentation. All authors and
contributors to this continuing education activity have
disclosed any real or apparent interest that may have direct
bearing on the subject matter of this program.
NOF’s accreditation status with ACCME and ANCC does
not imply endorsement by NOF, ACCME or ANCC of any
commercial products displayed in conjunction with this
activity or endorsement of any point of view.
For a more in-depth coverage of the critical role of
vitamin D in calcium metabolism and maintenance of
bone health, please see the issue of Osteoporosis: Clinical
Updates entitled, “Vitamin D and Bone Health.”
US RDI for vitamin D is 600 IU for men and women
ages 50 to 70 and 800 IU for all people over age 70.
The safe upper limit is 4000 IU. Dietary sources of vitamin D include:
‡ Salmon 815 IU/half fillet
Statement Regarding Off-Label Use
Any publication of the Osteoporosis Clinical Updates that
discusses off-label use of any medications or devices will be
5
retinol, the carotenoids have shown promise in studies
to increase bone density and/or reduce fractures.26-30 In
the Framingham study, the highest intake levels of total
carotenoids were associated with reduced 15-year fracture incidence (46% in women and 34% in men).28
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The recommended intake of vitamin A is 900 mcg/
day (3000 IU) for men and 700 mcg/day (2300 IU) for
women with a limit of 3000 mcg/day (10,000 IU).29
Dietary sources of vitamin A or its precursor carotene
include:
‡ Skim or fat-free milk 500 IU/cup as retinol
‡ Beef liver 22175 IU/cup as retinol
‡ Carrot juice 45133 IU/cup as carotene
‡ Sweet potato 28058 IU/potato as carotene
‡ Spinach 22916 IU/cup as carotene
‡ Beet greens 11022 IU/cup as carotene
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Because of the possible detrimental effects of retinol
on bone, it is advisable to select supplements that contain no more than 2000–3000 IU retinol. Alternatively
you can choose supplements that provide vitamin A as
carotene.
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osteoporosis.
B Vitamins
Inadequate intake and/or compromised metabolism of
folic acid/folate (B9), pyridoxine (B6), riboflavin (B2),
or cobalamin (B12) have been shown to lead to high
homocysteine levels.30 Emerging data point to a doseresponse association between elevated serum homocysteine and a modest increased risk of fracture.31-34
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Large studies in the Netherlands observed high homocysteine combined with low vitamin B12 was associated
with high markers of bone turnover, increased fracture
risk, and low ultrasound measurement of bone density.33,34 In the Rotterdam study, a dose response was seen
between low B6 intake, high homocysteine levels, and
increased risk of hip fracture independent of BMD.33
The same study also observed a positive independent
relation between dietary intake of riboflavin (B2) and
pyridoxine (B6) and BMD.33
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Studies of B vitamin effects on bone have shown divergent effects in men and women. In a large Norwegian
observational study, elevated homocysteine and low folate were associated with reduced BMD in women but
not in men.35,36 No specific action on bone has been
identified either for B vitamins or homocysteine.
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7
to characterize the role of B vitamins in bone metabolism and the potential for therapeutic supplementation
to prevent fracture. It is clear that a diet rich in foods
that are good sources of B vitamins, such as whole
grains, fruits, and vegetables, should be recommended
to all patients.
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US RDI for B2 (riboflavin) is 1.3 mg/day for adult men
and 1.1 mg/day for adult women. Dietary sources of
B2 include:
‡ Beef liver 2.9 mg/3 oz
‡ Turkey giblets 2.2 mg/cup
‡ Duck meat 1 mg/half duck
‡ Malted milk drink mix made with whole milk 1
mg/cup
US RDI for B6 (pyridoxine) is 1.3 mg/day for adults
under age 50, male and female. Over age 50, the RDI
for women is 1.5 mg/day and for men is 1.7 mg/day.
Dietary sources of vitamin B6 include:
‡ Cereal, raisin bran 2.1 mg/cup
‡ Fish, salmon 1.1 mg/half fillet
‡ Chickpeas 1.1 mg/cup
‡ Malted milk drink mix made with whole milk 1.015
mg/cup
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US RDI for folate (B9) is 4 mg/day for adults, male and
female. Foods are fortified with folic acid in order to
raise folate intake. Dietary sources of B9 include fortified sources such as bread, cereal, and rice and natural
sources such as beans:
‡ Rice, white long grain 797 mg/cup
‡ Cereal, malt-o-meal 756 mg/cup
‡ Wheat flour, white, bread 358 mg/cup
‡ Beans, pinto 294 mg/cup
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US RDI for B12 is 2.4 +g/day for adults, male and female. Dietary sources of vitamin B12 include:
‡ Beef 70.7 +g/3 ounces
‡ Mollusks, clam 15.8 +g/3 ounces
‡ Chicken 13.7 +g/cup
‡ Soup, New England clam chowder 12 +g/cup
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(Because 10% to 30% of older people may malabsorb
food-bound B12, the Institute of Medicine advises those
older than 50 years to meet their RDA mainly by consuming foods fortified with B12 or a supplement containing B12.)38
effect, vitamin B sufficiency reduces fracture risk by
improving bone quality and/or preventing falls through
collagen-mediated protection of neurologic function.37
Whatever the exact process, further research is needed
Boron
Currently no recommended daily intake or average
8
increases the need for calcium by interfering with calcium absorption through increased secretion of parathyroid hormone. Studies have also observed that phosphorous deficiency may reduce the absorption of calcium and thereby lead to bone loss.65 The key is to maintain a balance between intake of calcium and intake of
phosphorus (roughly 2:1). The common Western diet
is characterized by low calcium-to-phosphorus ratios
(less calcium than phosphorus). Research has demonstrated that habitually low calcium-to-phosphorus diets
negatively impact calcium metabolism.66 It seems clear
that adding dietary calcium and reducing non-nutritive
phosphorus intake (i.e. soda drinks and foods high in
phosphorus preservatives) can be beneficial to bone
health.
with chronic kidney disease should be warned not to
take magnesium supplements without first consulting
their physician.
The RDI for magnesium is 420 mg for men and 320
mg for women. Dietary sources of magnesium include:
‡ Trail mix with chocolate chips, salted nuts, seeds
235 mg/cup
‡ Semisweet chocolate 193 mg/cup
‡ Spinach, canned, drained 163 mg/cup
‡ Beans, black, cooked, boiled, no salt,120 mg/cup
Manganese, Copper, Zinc
The dietary minerals manganese, copper, and zinc
are cofactors for enzymes required for healthy bone
metabolism.62
The RDI for phosphorus is 700 mg/day for men and
women. Dietary sources of phosphorus include:
‡ Cornmeal, self-rising enriched 860 mg/cup
‡ Milk, canned sweetened, condensed 774 mg/cup
‡ Fast foods biscuit with egg and sausage 562 mg/
biscuit
‡ Fish, salmon, cooked, dry heat 491 mg/half fillet
There is currently no recommended daily intake for
manganese. Adequate intake for men is 2.3 mg/day and
for women is 1.8 mg/day, with a tolerable upper limit
of 11 mg/day. Dietary sources of manganese include
nuts, legumes, tea, and whole grains. Research in animal models has suggested a potential role for manganese supplementation in maintenance of bone health;
however, more research is needed.63,64
Strontium
The recommended intake of copper for adults is 900
mcg/day with an upper limit of 10000 mcg/day.
Dietary sources of copper include organ meats, seafood, nuts, seeds, cereals, whole grains, and cocoa.
Strontium is a trace element found in seawater. Its
primary source in the diet is seafood. Other strontiumcontaining foods include whole milk, wheat bran,
meat, poultry, and root vegetables. There are no recommended daily or adequate intakes established for
strontium. However, average daily intakes have been
estimated to be about 1–3 mg.
The recommended intake of zinc for adults is 11 mg/
day for men and 8 mg/day for women with an upper
limit of 40 mg/day, assuming that the person has normal kidney function. Dietary sources of zinc include
fortified cereals, eggs, dairy products, nuts, red meat,
peas, and certain seafoods. Patients with chronic kidney
disease should not take zinc supplements.
Research on humans and animals over the past thirtyodd years has shown pharmacologic doses of strontium
to be associated with increased bone strength and reduced fracture rates.67-71
Several large, randomized placebo-controlled studies of
postmenopausal women with osteoporosis taking 1 to 2
grams/day of strontium in the form of the drug strontium ranelate observed reductions in rates of fractures
over 4 to 5 years: roughly 30% to 50% for vertebral
fractures,15% to 20% for nonvertebral fractures, 20%
to 30% for major fragility fractures, and 20% for hip
fractures.72-74
Phosphorus
The recommended intake for phosphorus is 700 mg/
day for men and women, with an upper limit of 4000
mg/day until age 70, after which the safe limit drops
to 3000 mg/day. Dietary sources of phosphorus include dairy products, meat, peas, eggs, and some cereals. Phosphorous is also widely used as a preservative
(phosphoric acid) in carbonated beverages and processed foods. As is the case with many nutrients, too
much or too little phosphorus leads to problems.
Strontium Ranelate:
? 50% Vertebral Fractures
? 15-20% Nonvertebral Fractures
It has long been known that excess phosphorus intake
11
to be consumed or administered enterally under the
supervision of a physician and which is intended for the
specific dietary management of a disease or condition
for which distinctive nutritional requirements, based
on recognized scientific principles, are established by
medical evaluation.” 89
discussion on vitamin A.) Supplements are widely
available.
Protein
There have been a large number of observational studies and clinical trials looking at the impact of protein
on bone.98–100 Although outcomes have varied, research
data support the view that adequate protein intake is
needed to achieve peak bone mass in childhood and
maintain healthy bone in adulthood. In the elderly, nutrition is often inadequate, and protein intake may be
suboptimal for skeletal health.
In clinical trials, a medical food containing 27 mg genistein aglycone, 20 mg citrated zinc bisglycinate, and
200 IU cholecalciferol (trade name FOSTEUM®) was
demonstrated to decrease markers of bone turnover
and increase markers of bone formation. While this
trial did not report fracture outcomes and the magnitude of change observed is very small in real terms, the
preliminary data are suggestive of bone density maintenance.90 Additional information is needed on fracture
outcomes and long-term impacts in order to establish
if this intervention is a practicable adjunct and/or addition to curent osteoporosis therapies.
A recent meta-analysis of hundreds of double-blind
placebo-controlled clinical studies conducted over the
past 30 years found no association, negative or positive,
between fracture rates and dietary protein (animal or
vegetable) in healthy adults. The meta-analysis found
a small but significant positive correlation between
dietary protein intake and BMD, BMC (bone mineral
content), and markers of bone turnover at all skeletal
sites. However, no reduction in fracture risk was observed.101 Because the studies under review did not
include long-term interventional trials, the possibility
of positive effects on fracture rates over time could not
be assessed.
Another isoflavone under study is the coumestan-rich
red clover. Clover has been researched in recent years
in both animal and human studies.91,92 Typical of these
studies is the one-year double-blind trial reported by
Atkinson, et. al., that randomized postmenopausal
women to placebo or a red-clover-derived isoflavone
supplement. Results showed significantly less spine
bone loss in the red-clover group along with higher
markers of bone formation. No change was seen in
bone loss at the hip or markers of bone resorption.93
Further investigation is needed to determine if changes
to current protein intake recommendations are warranted for any specific age group. At present, daily
intake at recommended levels from animal and/or vegetable sources is sound policy for patients of all ages.
Dietary sources of isoflavones include soybeans, chickpeas, red clover, and legumes. Long-term clinical trials
are needed to assess the effectiveness of isoflavones on
fracture rates and BMD at various skeletal sites.
Recommended intake of protein is 56 grams/day for
adult men and 46 grams/day for adult women (roughly
1 gto 1.5 g/day per kg). Dietary sources of protein
include:
‡ Duck 51.89 g/half-duck
‡ Chicken meat 42.59 g/cup
‡ Fish salmon, cooked dry heat 39.37 g/half-fillet
‡ Fast food hamburger, double large patty 34.28 g/
burger
Omega-3, or n-3, polyunsaturated fatty acids come
from plant sources (lignans) or animal sources (fish
oil). Omega-3 fatty acids have been shown in animal
and cell research to have a beneficial effect on bone
mass.94 However, these results have not been replicated
to date in human studies. The effects of omega-3 fatty
acids on BMD have been variable, with either positive
or no effect on BMD.95,96
Tea
Plant sources of omega-3 fatty acids (lignans) include
soybeans, flaxseed, and walnuts. Animal sources of
omega-3 fatty acids include fatty fish (e.g., salmon,
mackerel, and sardines).97 Vegetable sources may be
preferable to avoid any detrimental effects of retinol,
found in high concentrations in fish oil. (See above
Multiple population and retrospective studies have
investigated tea drinking and any effect it may have
on bone and fracture risk. Observations have trended
in a slightly positive direction concerning BMD and
fracture reduction.102–104 However, there have been no
13
multivitamin contains vitamin D (600 IU), she participates regularly in outdoor activities, and is not elderly,
she is at low risk for low vitamin D. However, vitamin
D deficiency is very common in American adults, especially African Americans. The only way to rule it out is
to perform serum measurment.
vitamin A in multivitamins to the beta-carotene form.
Animal and epidemiological studies have indicated that
omega-3 fatty acids from nonretinol sources such as
flax seed oil may have a positive impact on bone and
cardiovascular health, so the physician recommends this
as an alternative source of omega-3 fatty acid.
What should be done to assess the patient’s bone
health?
Because she is postmenopausal with a family history of
fragility fracture, a baseline bone density scan is appropriate. The clinician prescribes a bone density test by
DXA and schedules a follow-up appointment to discuss
results, future fracture risk (using the FRAX® tool)
and, if warranted, possible pharmacologic options and
tracking of biochemical markers of bone turnover.
Should the physician discourage continued use of
supplemental magnesium, zinc, and soy?
Not if they are kept within safe limits (350 mg/day for
magnesium and 40 mg/day for zinc). Because zinc and
magnesium are involved in healthy bone metabolism,
it is possible that intake of these minerals may be beneficial to bone. However, research is lacking to support
this hypothesis.
The clinician recommends a varied diet that includes
leafy greens, fruits, and vegetables. In addition, the clinician recommends that the patient engage in weightbearing exercise and a bone density test at age 60.
Case 2: 45-Year-Old Perimenopausal Woman
The second patient we will discuss is a 45-year-old
woman with no family history of osteoporosis. She is
perimenopausal and concerned about maintaining her
bone health. The clinician finds no indicators of elevated osteoporosis risk in her history. Neither she nor her
parents has experienced bone fractures.
Case 3: 75-Year-Old Woman with Low Bone
Mass
The third patient we will discuss is a housebound elderly woman, 75 years old, who lives alone. She is in
good general health. Her recent DXA scan is diagnostic
of osteopenia (hip BMD –2.0).
She has always been in good health, has never smoked
or consumed alcohol, and has never taken medications
that cause bone loss. The clinician asks if the patient
takes any supplements or herbal products, she reports
that she takes multiple nutritional supplements, including multivitamins, flax seed oil, magnesium, zinc, and
six fish oil capsules twice a day for their cardiovascular
benefits.
What dietary supplements or nutriceutical
SURGXFWVLIDQ\FRXOGEHRIEHQHÀWWRWKLVSDWLHQW·V
bone health?
Adequate calcium, vitamin D, and protein intake have
all been shown to significantly benefit bone health in
elderly women. Although these alone will not prevent
osteoporosis, they are necessary components of an
overall prevention or treatment plan.
Does anything in the patient’s reported history
raise concern about her bone health?
Perhaps. Observational studies suggest that ingestion
of high doses of supplemental retinol, found in high
concentrations in fish oil, may increase a woman’s risk
of hip fracture. This patient’s daily fish oil intake may
reach the level of concern.
Because of her age and lack of sun exposure, it is probably safe to assume that this patient is vitamin D deficient. Vitamin D deficiency contributes significantly
to bone loss. To establish serum calcium and 25-hydroxyvitamin D levels, the physician orders appropriate
blood panels.
Should the patient be advised to curtail her use of
ÀVKRLOVXSSOHPHQWV"
It may be a good idea. The potential cardiovascular
benefit of fish oil supplements (for their omega-3 fatty
acid content) may be offset by skeletal harm. The clinician recommends that the patient discontinue intake
of fish oil supplements and that she limit her intake of
The patient is asked about her diet. She reports that she
eats mostly canned soup, tea, and toast: foods she can
easily prepare.
&DQWKHSDWLHQW·VGLHWEHPRGLÀHGWRLPSURYHKHU
bone status?
16
Her diet is high in sodium and low in calcium and protein. It is advisable for her to take a daily supplement
that contains adequate vitamin D (800 IU) and calcium
(1000 mg). The clinician explains the importance of adequate protein, calcium, and vitamins and recommends
adding nuts, dairy foods, fresh fruits, and vegetables to
her diet. To help the patient make these dietary changes, the clinician makes an appointment with a dietician
who can help her develop a healthy eating plan she can
manage on her own.
Res. 1998;13(2):168–74.
6 Reid IR, Ames RW, Evans MC, Gamble GD, Sharpe SJ. Effect of calcium
supplementation on bone loss in postmenopausal women. N Engl J Med.
1993;328(7):460–4.
7 Bolland MJ, Barber PA, Doughty RN, et al. Vascular events in healthy older
women receiving calcium supplementation: randomised controlled trial.
BMJ. 2008;336:262
8 Bolland MJ, Avenell A, Baron JA, et. Al. Effect of calcium supplements on
risk of myocardial infarction and cardiovascular events: meta-analysis. BMJ.
2010 Jul 29;341:c3691.
9 Bolland MJ, Grey A, Avenell A, Gamble GD, IR. Calcium supplements
with or without vitamin D and risk of cardiovascular events: reanalysis
of the Women’s Health Initiative limited access dataset and meta-analysis.
BMJ. 2011; 342:d2040.
10 Camm JA. Review of the cardiovascular safety of zoledronic acid and other
bisphosphonates for the treatment of osteoporosis. Clin Ther. 2010;32:426–
36.
11 Christensen S, Mehnert F, Chapurlat RD, Baron JA, Sørensen HT. Oral
bisphosphonates and risk of ischemic stroke: a case-control study. Oral
bisphosphonates and risk of ischemic stroke: a case-control study. Osteoporos Int. 2011 Jun;22(6):1773–9.
12 LaCroix AZ, Kotchen J, Anderson G, et. al. Calcium plus vitamin D
supplementation and mortality in postmenopausal women: the Women’s
Health Initiative calcium-vitamin D randomized controlled trial. J Gerontol
A Biol Sci Med Sci. 2009 May;64(5):559–67.
13 Bourgoin BP, Evans DR, Cornett JR, Lingard SM, Quattrone AJ. Lead content in 70 brands of dietary calcium supplements. Am J Public Health. 1993
Aug;83(8):1155–1160.
14 Scelfo GM, Flegal AR. Lead in calcium supplements. Environ Health Perspect. 2000 Apr;108(4):309–313.
15 United States Department of Health & Human Services. U.S. Food and
Drug Administration. Survey Data on Lead in Women’s and Children’s
Vitamins. August 2008. Available at: http://www.fda.gov/Food/FoodSafety/FoodContaminantsAdulteration/Metals/Lead/ucm115941.htm.
Accessed January 23, 2012.
16 Heaney RP. Lead in calcium supplements: cause for alarm or celebration?
JAMA. 2000;284:1432–3.
17 Gulson BL, Mizon KJ, Palmer JM, Korsch MJ, Taylor AJ. Contribution of
lead from calcium supplements to blood lead. Environ Health Perspect. 2001
Mar;109(3):283–8.
18 Muldoon SB, Cauley JA, Kuller LH, Scott J, Rohay J. Lifestyle and sociodemographic factors as determinants of blood lead levels in elderly
women. Am J Epidemiol. 1994;139:599–608.
19 Thomas MK, Lloyd-Jones DM, Thadhani RI, et. al. Hypovitaminosis D in
medical inpatients. N Engl J Med. 1998;338(12):777–83.
20 Promislow JH, Goodman-Gruen D, Slymen DJ, Barrett-Connor E. Retinol intake and bone mineral density in the.elderly: the Rancho Bernardo
Study. J Bone Miner Res. 2002 Aug;17(8):1349–58.
21 Binkley N, Krueger D. Hypervitaminosis A and bone. Nutr Rev.
2000;58:138–144.
22 Feskanich D, Singh V, Willett WC, Colditz GA. Vitamin A intake and hip
fractures among postmenopausal women. JAMA. 2002;287:47–54.
23 Melhus H, Michaelsson K, Kindmark A, et. al. Excessive dietary intake of
vitamin A is associated with reduced bone mineral density and increased
risk for hip fracture. Ann Intern Med. 1998 Nov 15;129(10):770–8.
24 Caire-Juvera G, Ritenbaugh C, Wactawski-Wende J, Snetselaar LG, Chen
Z. Vitamin A and retinol intakes and the risk of fractures among participants of the Women’s Health Initiative Observational Study. Am J Clin Nutr.
2009 Jan;89(1):323–30.
25 Lim LS, Harnack LJ, Lazovich D, Folsom AR. Vitamin A intake and the
risk of hip fracture in postmenopausal women: the Iowa Women’s Health
Study. Osteoporos Int. 2004 Jul;15(7):552–9.
26 Barker ME, McCloskey E, Saha S, et. al. Serum retinoids and beta-carotene as predictors of hip and other fractures in elderly women. J Bone Miner
Res. 2005 Jun;20(6):913–20.
27 Wattanapenpaiboon N, Lukito W, Wahlqvist ML, Strauss BJ. Dietary carotenoid intake as a predictor of bone mineral density. Asia Pac J Clin Nutr.
2003;12(4):467–73.
28 Sahni S, Hannan MT, Blumberg J, Cupples LA, Kiel DP, Tucker KL. Protective effect of total carotenoid and lycopene intake on the risk of hip
Are there any other measures that can be taken to
help this patient preserve her bone mass?
Inactivity is an established risk factor for bone loss and
osteoporosis. The patient is referred to a physical therapist to develop a safe movement/exercise plan to ease
the patient into bone-preserving weight-bearing exercises that she may perform at home.
The clinician discusses drugs approved for osteoporosis
prevention and recommends that the patient consider
beginning drug therapy to prevent further bone loss.
SUMMARY
There are multiple effective FDA-approved therapeutics for preventing and treating osteoporosis.
Unfortunately, there are also hundreds of non-FDA-approved nutriceutical products on the market that claim
to do the same things. Healthcare providers can educate patients about which products’ claims can be supported by data, which products may potentially benefit
bones, and which provide no benefit and may indeed
cause harm. Through this process, patients become
better able to make more-informed choices regarding
their healthcare options.
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