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1. I do not have a regular weight-bearing exercise routine
Yes responses may indicate elevated risk for osteoporosis
Notes/Initials
Weight-bearing aerobic activities: These types of exercises work
directly on the bones in your legs, hips and lower spine to slow mineral
loss. They can also provide aerobic benefits, such as reducing your risk
of cardiovascular disease
Movements patient should avoid:
Mild bone deterioration without osteoporosis shouldn't interfere with recreation. In fact,
activities such as golf and bowling may be beneficial. However, patients who have osteoporosis,
should not do the following types of exercises:
High-impact exercises, such as jumping, running or jogging. These activities increase
compression in the spine and lower extremities and can lead to fractures in weakened bones.
Avoid jerky, rapid movements in general. Try to move in a slow and controlled manner.
Exercises that require bending forward and twisting the waist, such as touching toes, doing
sit-ups or using a rowing machine. These movements also compress the bones in the spine.
Other activities that may require bending or twisting forcefully at the waist are golf, tennis,
bowling and some yoga poses.
Sources: International Osteoporosis Foundation
http://www.iofbonehealth.org/patients-public/about-osteoporosis/prevention/exercise.html
2. I drink two or more glasses of alcohol a day on a regular basis
Yes responses may indicate an increased risk for osteoporosis
Notes/Initials
Most modifiable risk factors directly impact bone biology and result in
a decrease in bone mineral density (BMD), but some of them also
increase the risk of fracture independently of their effect on bone itself.
These include: Alcohol, Smoking, Low body mass index, Poor
nutrition, Vitamin D deficiency, Eating disorders, Insufficient exercise,
Low dietary calcium intake, Frequent falls
Alcohol: People with excessive alcohol consumption (>2 units daily) have a 40% increased risk
of sustaining any osteoporotic fracture, compared to people with moderate or no alcohol intake.
High intakes of alcohol cause secondary osteoporosis due to direct adverse effects on boneforming cells, on the hormone that regulates calcium metabolism and poor nutritional status
(calcium, protein and vitamin D deficiency).
If patient is willing to moderate drinking, the following steps are recommended:
Provider should use an empathetic counseling style. A warm, reflective, and understanding
style of delivering brief intervention is more effective than an aggressive, confrontational, or
coercive style.
Negotiating and Goal-setting: The treatment provider and patient agree on a mutually
acceptable goal for reducing alcohol use (e.g., the moderate drinking levels recommended by the
NIAA). No more than 2 drinks a day for men, and one drink per day for women.
Behavior Modification techniques: The healthcare provider helps the patient to identify highrisk situations in which drinking will likely occur, such as family celebrations or stressful
situations at work. The provider also familiarizes patient with coping techniques for managing
such high-risk situations and with ways for establishing a support network to help in this process.
Self-help-directed bibliotherapy: For reinforcement, the provider supplies the patient with
informational materials on alcohol use and its associated problems as well as on behavioral
modification exercises.
Follow-up and reinforcement: To ensure the long-term effectiveness of the brief intervention,
the healthcare provider establishes a system for conducting supportive telephone consultation
and follow-up visits with patient.
You may wish to screen patient for alcohol risk during her next visit using a standardized
assessment such as the CAGE or AUDIT.
Sources: World Health Organization, and The Department of Mental Health and Substance
Dependence
3. I am physically inactive for prolonged periods of time
Yes responses may indicate an increased risk for bone loss, or osteoporosis.
Insufficient exercise: Patients with a more sedentary lifestyle are
more likely to have a hip fracture than those who are more active. For
example, women who sit for more than nine hours a day are 50%
more likely to have a hip fracture than those who sit for less than six
hours a day.
Notes/Initials
Exercise is not just important to general health, it helps build bone
mass in youth and slows down bone loss in adults. Exercise is also a
factor in helping to reduce the risk of falls as it strengthens muscles,
increases flexibility, and improves coordination and balance. During
physical activity bones receive messages that they need to work and be strong.
The key message is to mobilize in order to strengthen muscles, which brings considerable
benefit:
In the young, exercise helps to build strong bones
It helps adults maintain their bones
Exercise helps prevent bone loss and falls in the elderly
People who have suffered fractures can benefit from special exercises and training (under
medical supervision) to improve muscle strength and muscle function for greater mobility and
improved quality of life.
Weight-bearing exercise is good for bone health. This type of exercise includes walking, jogging,
stair climbing, tennis, volleyball and similar sports, aerobics, tai chi and dancing.
Resistance training, also known as weight or strength training, is also good for muscles and helps
maintain bone mass. Speak to your doctor to find out which sort of exercise is best for you
according to your age and health condition.
How much exercise is recommended?
The amount and type of exercise will vary depending on your age and bone health. An exercise
program should be individually tailored to your needs and capabilities. Overall, most people
should aim to exercise for 30-40 minutes three to four times each week, with some weightbearing and resistance exercises in the program.
Exercise to build healthy bones in the young
Through weight-bearing exercises (jumping, running, dancing, walking), young peoples' bones
acquire both density and mass. The bones become stronger and less vulnerable to osteoporosis
later in life. Building up bone density and bone mass is particularly important for young girls and
boys aged 8-16, and to a lesser extent, in younger adults.
Sources: International Osteoporosis Foundation
http://www.iofbonehealth.org/patients-public/about-osteoporosis/prevention/exercise.html
4. I smoke
Yes responses indicate increased risk for bone loss.
Patients with a past history of cigarette smoking and patients who
smoke are at increased risk of any fracture, compared to nonsmokers. If patient is a smoker and willing to quit, provide patient
with the following recommendations:
For the patient willing to make a quit attempt, offer medication and
provide or refer for counseling or additional treatment to help the
patient quit.
Provide patient with the following preparations for quitting:
Notes/Initials
Patient should set a quit date. Ideally, the quit date should be within 2 weeks.
Tell family, friends, and coworkers about quitting, and request understanding and support.
Anticipate challenges to the upcoming quit attempt, particularly during the critical first few
weeks. These include nicotine withdrawal symptoms.
Remove tobacco products from the environment. Prior to quitting, avoid smoking in places
where you spend a lot of time (e.g., work, home, car). Make the home smoke-free.
Recommend the use of medications. Explain how these medications increase quitting success
and reduce withdrawal symptoms. First line medications include: Bupropion SR, nicotine gum,
inhaler, lozenge, nasal spray, patch, and varenicline; second line medications include: clonodine,
nortriptyline. (There is insufficient evidence to recommend meds for certain populations, i.e.
pregnant women, smokeless tobacco users, light smokers, adolescents).
Provide practical counseling:
Abstinence. Striving for total abstinence is essential. Not even a single puff after the quit date.
Past quit experience. Identify what helped and what hurt in previous quit attempts. Build on past
success.
Anticipate triggers or challenges in the upcoming attempt. Discuss challenges/triggers and how
the patient will successfully overcome them (e.g., avoid triggers, alter routines).
Alcohol. Because alcohol is associated with relapse, the patient should consider
limiting/abstaining from alcohol while quitting. (Note that reducing alcohol intake could
precipitate withdrawal in alcohol-dependent persons.)
Other smokers in the household. Quitting is more difficult when there is another smoker in the
household. Patients should encourage housemates to quit with them or to not smoke in their
presence.
Provide a supportive clinical environment while encouraging the patient in his or her quit
attempt. “My office staff and I are available to assist you.” “I’m recommending treatment that
can provide ongoing support.”
Provide supplemental materials, info on quit lines: Federal agencies, nonprofit agencies, national
quitline network (1-800-QUIT-NOW), or local/state/tribal health departments/quitlines
For patients unwilling to quit at the time, provide interventions designed to increase future quit
attempts.
Arrange follow-up. For the patient willing to make a quit attempt, arrange for follow-up contacts,
beginning within the first week after the quit date. A second follow-up contact is recommended
within the first month. Schedule further follow-up contacts as indicated.
Actions during follow-up contact: For all patients, identify problems already encountered and
anticipate challenges in the immediate future. Assess medication use and problems.
Remind patients of quitline support (1-800-QUIT-NOW). Address tobacco use at next clinical
visit (treat tobacco use as a chronic disease).
For patients who are abstinent, congratulate them on their success.
If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence.
For patients unwilling to make a quit attempt at the time, address tobacco dependence and
willingness to quit at next clinic visit.
Sources: Clinical Interventions for Tobacco Use and Dependence, 2008 Update, US Department
of Health and Human Services, 2008.
http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf
http://www.aafp.org/afp/20030615/us.html
5. I regularly drink more than three cups of caffeinated beverages (coffee, soda, tea) in a
day.
Patients with high caffeine intake may be at increased risk for bone loss
complications.
Notes/Initials
When cutting back on daily caffeine consumption by eliminating
certain beverages, it's important to replace the caffeinated drinks with
water or other non-caffeinated beverages, as drinking less fluid overall
can also lead to dehydration and bone loss.
The following steps can help decrease the impact of caffeine.
Limit caffeine intake to 300 milligrams or less per day.
Eat a diet rich in calcium - aim for 1,200 milligrams per day - from sources such as low fat dairy
foods, dark green leafy vegetables, dry beans, tofu made with calcium and canned fish with
edible bones. Adequate dietary calcium can counteract much of the negative effects of higher
caffeine consumption.
Add low-fat milk to regular coffee drinks or mix decaffeinated coffee with regular coffee.
Replace some caffeinated drinks with water throughout the day.
Sources: Pat Kendall, Ph.D., R.D., Food Science and Human Nutrition Specialist
6. I take steroids, anticonvulsants, or thyroid medication
Yes response indicates a high risk for bone loss; patients taking any of the following
medications are at elevated risk for osteoporosis and should be tested for bone loss; patient
meets Medicare’s minimum requirement for testing.
Corticosteroids have several adverse effects on bone metabolism.
Direct inhibition of osteoblast function
Direct enhancement of bone resorption
Inhibition of gastrointestinal calcium absorption
Increases in urine calcium loss
Inhibition of gonadal hormones
Notes/Initials
Corticosteroid medications. Long-term use of corticosteroid
medications, such as prednisone, cortisone, prednisolone and
dexamethasone, is damaging to bone. These medications are
common treatments for chronic conditions, such as asthma,
rheumatoid arthritis and psoriasis. If patient needs to take a
steroid medication for long periods, physician should monitor her
bone density and consider other drugs to help prevent bone loss.
Thyroid hormone. Too much thyroid hormone also can cause bone loss. This can occur either
because thyroid is overactive (hyperthyroidism) or because patient takes excess amounts of
thyroid hormone medication to treat an underactive thyroid (hypothyroidism).
For recommendations and testing options see “Labs/Tests for Bone Density”
IF test is positive for bone loss and patient must continue the medication for other health
reasons, biphonsphonates or SERMs may be helpful at slowing the rate or in some cases
reversing the rate of bone loss. See section “Diagnosis/Treatment Support” for more
information.
Source: National Osteoporosis Foundation
7. I do not consume the minimum recommended requirement for calcium on a daily basis
Yes response indicates an increased risk for bone loss. Suggest patient find alternative ways to
increase calcium. Other than exercise, increasing calcium is considered one of the most effective
measures at reducing bone loss.
Notes/Initials
Sources of Calcium:
Food remains the best source of calcium. Dairy products are high in
calcium, while certain green vegetables and other foods contain
calcium in smaller amounts. For people who have trouble digesting
dairy products because of lactose intolerance, lactose free dairy
products and lactase enzyme pills are also available. Calciumfortified foods and calcium supplements are helpful for people who
are unable to get enough calcium in their diets. Some juices, breakfast foods, soymilk, cereals,
snacks, breads and bottled water have calcium that has been added.
Daily Calcium Recommendations:
Adults under age 50 need 1,000 mg of calcium and 400-800 IU of vitamin D3 daily.
Adults 50 and over need 1,200 mg of calcium and 800-1,000 IU of vitamin D3 daily.
When available, choose a supplement of vitamin D3 (cholecalciferol) over vitamin D2
(ergocalciferol) to protect bone health. People who get the recommended amount of calcium
from foods do not need to take a calcium supplement. These individuals, however, still may need
to take a vitamin D supplement. Getting too much calcium may increase the chance of
developing kidney stones in some people. According to most experts, the safe upper limit for
total daily calcium intake from all sources is 2,000 - 2,500 mg.
Source: National Osteoporosis Foundation
8. I am female and have abnormal absence of menstrual periods.
Yes response may indicate an increased risk for bone loss and/or
osteoporosis. (IF yes response is due to early menopause, then
patient meets the minimum requirement for a BMD testing and
should be tested.)
Notes/Initials
Estrogen and other ovarian hormones help maintain bone density.
Whether menopause is natural or results from surgical removal of
reproductive organs, it can seriously affect bone health. Early onset of
menopause due to abnormal absence of menstrual periods, can also lead
to decreases in Estrogen. Estrogen plays an important role in protecting
bones, and as estrogen production declines during perimenopause and menopause, bone loss
occurs. In some women the impact on bone health can be severe. The amount of bone density a
woman has during perimenopause and menopause and the rate of bone loss afterwards are
important factors in predicting whether she will develop osteoporosis. Patients with early
menopause should test their rate of bone loss frequently.
For recommendations and testing options see “Labs/Tests for Bone Density”
IF test results determine the curvature is due to osteoporosis, see “Diagnosis/Treatment
Support” for evaluation and management guidelines.
9. I am Caucasian or Asian
Yes response indicates an increased risk for bone loss complications.
Caucasian and Asian women are at greater risk for developing
Osteoporosis. These patients should be informed of their increased
risk. Counsel on the following preventive measures that can help
postpone or prevent onset.
Adequate calcium and vitamin D is an important factor in reducing
risk of osteoporosis. If patient already has osteoporosis, getting
Notes/Initials
adequate calcium and vitamin D, as well as taking other measures, can help prevent bones from
becoming weaker.
The amount of calcium needed to stay healthy changes over one’s lifetime. The body’s demand
for calcium is greatest during childhood and adolescence, when one’s skeleton is growing
rapidly, and during pregnancy and breast-feeding. Postmenopausal women and older men also
need to consume more calcium. Over time, the body becomes less efficient at absorbing calcium.
Also, older patients are more likely to take medications that interfere with calcium absorption.
Premenopausal women and postmenopausal women who use HT should consume at least 1,000
milligrams (mg) of elemental calcium and a minimum of 800 international units (IU) of vitamin
D every day. Postmenopausal women not using HT, anyone at risk of steroid-induced
osteoporosis, and all men and women older than 65 should aim for 1,500 mg of elemental
calcium and at least 800 IU of vitamin D daily.
Calcium and vitamin D supplements are most effective taken together in divided doses with
food.
Other tips for prevention (These measures can also help prevent bone loss)
Exercise (particularly weight-bearing exercises — such as walking, jogging, running, stair
climbing, skipping rope, skiing and impact-producing sports)
Add soy to your diet
Don't smoke
Hormone therapy. Hormone therapy can reduce a woman's risk of osteoporosis during and after
menopause. But because of the risk of side effects, discuss the options with your doctor and
decide what's best for you. Testosterone replacement therapy works only for men with
osteoporosis caused by low testosterone levels. Taking it when you have normal testosterone
levels won't increase bone mass.
Avoid excessive alcohol
Limit caffeine
Sources: http://www.mayoclinic.com/health/osteoporosis/DS00128/DSECTION=prevention
10. I am female and am postmenopausal, including early menopause and or surgically
induced menopause.
Notes/Initials
Yes response may indicate an increased risk for bone loss. (IF yes
response is due to early menopause (before age 40) then patient
meets the minimum requirement for a BMD testing and should
be tested.)
Estrogen and other ovarian hormones help maintain bone density. Whether menopause is natural
or results from surgical removal of reproductive organs, it can seriously affect bone health.
Estrogen plays an important role in protecting bones, and as estrogen production declines during
menopause, bone loss occurs. In some women the impact on bone health can be severe. The
amount of bone density a woman has at menopause and the rate of bone loss afterwards are
important factors in predicting whether she will develop osteoporosis.
For recommendations and testing options see “Labs/Tests for Bone Density”
IF test results determine the curvature is due to osteoporosis, see “Diagnosis/Treatment
Support” for evaluation and management guidelines.
Source: National Osteoporosis Foundation
11. I have a family history of osteoporosis
Yes responses indicate increased risk for osteoporosis. All patients
will family history meet the minimum requirement for BMD
testing.
Notes/Initials
For recommendations and testing options see “Labs/Tests for Bone
Density”
IF test results determine the curvature is due to osteoporosis, see
“Diagnosis/Treatment Support” for evaluation and management
guidelines.
While family history is a risk factor that cannot be controlled by patient, there are preventive
measures that can help postpone or prevent early onset of osteoporosis.
Adequate calcium and vitamin D is an important factor in reducing risk of osteoporosis. If
patient already has osteoporosis, getting adequate calcium and vitamin D, as well as taking other
measures, can help prevent bones from becoming weaker.
The amount of calcium needed to stay healthy changes over one’s lifetime. The body’s demand
for calcium is greatest during childhood and adolescence, when one’s skeleton is growing
rapidly, and during pregnancy and breast-feeding. Postmenopausal women and older men also
need to consume more calcium. Over time, the body becomes less efficient at absorbing calcium.
Also, older patients are more likely to take medications that interfere with calcium absorption.
Premenopausal women and postmenopausal women who use HT should consume at least 1,000
milligrams (mg) of elemental calcium and a minimum of 800 international units (IU) of vitamin
D every day. Postmenopausal women not using HT, anyone at risk of steroid-induced
osteoporosis, and all men and women older than 65 should aim for 1,500 mg of elemental
calcium and at least 800 IU of vitamin D daily.
Calcium and vitamin D supplements are most effective taken together in divided doses with
food.
Other tips for prevention (These measures can also help prevent bone loss)
Exercise (particularly weight-bearing exercises — such as walking, jogging, running, stair
climbing, skipping rope, skiing and impact-producing sports)
Add soy to your diet
Don't smoke
Hormone therapy. Hormone therapy can reduce a woman's risk of osteoporosis during and after
menopause. But because of the risk of side effects, discuss the options with your doctor and
decide what's best for you. Testosterone replacement therapy works only for men with
osteoporosis caused by low testosterone levels. Taking it when you have normal testosterone
levels won't increase bone mass.
Avoid excessive alcohol
Limit caffeine
Sources: http://www.mayoclinic.com/health/osteoporosis/DS00128/DSECTION=prevention
12. My upper back curves forward.
Yes responses may indicate advanced osteoporosis. Patients with a
curved upper back meet the minimum requirement for BMD testing, and
their bone density should be tested regardless of age or whether other risk
factors are present.
For recommendations and testing options see “Labs/Tests for Bone
Density”
IF test results determine the curvature is due to osteoporosis, see
“Diagnosis/Treatment Support” for evaluation and management
guidelines.
Sources: American Academy of Family Physicians
http://www.nlm.nih.gov/medlineplus/osteoporosis.html
Notes/Initials