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Recs are only available for screens that have raised risk on at least one question.
I do not have a regular weight-bearing exercise routine
Yes responses may indicate elevated risk for osteoporosis
Weight-bearing aerobic activities: These types of exercise 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.
I drink two or more glasses of alcohol a day on a regular basis
Yes responses may indicate an increased risk for osteoporosis
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.
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.
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.
Resources: International Osteoporosis Foundation
http://www.iofbonehealth.org/patients-public/about-osteoporosis/prevention/exercise.html
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 non-smokers. 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:
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
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.
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
Investigators from Creighton University in Omaha, Nebraska; the National Institute of
Environmental Health Sciences in Research Park Triangle, North Carolina and Ryschon Health
and Technology Services in Valentine, Nebraska observed overall that "caffeine intake of more
than 300 mg/d increased the rate of bone loss significantly at the spine in subjects studied
longitudinally.
I take steroids, anticonvulsants, or thyroid medication
Yes response indicates an increased risk for bone loss complications.
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
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
you need to take a steroid medication for long periods, your doctor should monitor your bone
density and recommend other drugs to help prevent bone loss.
Thyroid hormone. Too much thyroid hormone also can cause bone loss. This can occur either
because your thyroid is overactive (hyperthyroidism) or because you take excess amounts of
thyroid hormone medication to treat an underactive thyroid (hypothyroidism).
Treatment:
Bisphosphonates: Much like estrogen, this group of drugs can inhibit bone breakdown, preserve
bone mass, and even increase bone density in spine and hip, reducing the risk of fractures.
Bisphosphonates may be especially beneficial for men, young adults and people with steroidinduced osteoporosis. They're also used to prevent osteoporosis in people who require long-term
steroid treatment for a disease such as asthma or arthritis.
Source: National Osteoporosis Foundation
I do not consume the minimum recommended requirement for calcium on a daily basis
Yes response indicates an increased risk for bone loss complications.
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. Calcium-fortified 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
I am female and have abnormal absence of menstrual periods.
Yes response may indicate an increased risk for bone loss complications.
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.
Hormone Replacement Therapy, or HRT, can slow down bone loss and osteoporosis, but some
women have side effects or medical conditions that may be aggravated by HRT. If a woman
cannot take HRT, other options are available, including raloxifene (EVISTA), calcitonin nasal
spray (Miacalcin), risendronate (Actonel) and alendronate (Fosamax).
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 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
I am female and am postmenopausal, including early menopause and or surgically induced
menopause.
Yes response may indicate an increased risk for bone loss complications.
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.
Hormone Replacement Therapy, or HRT, can slow down bone loss and osteoporosis, but some
women have side effects or medical conditions that may be aggravated by HRT. If a woman
cannot take HRT, other options are available, including raloxifene (EVISTA), calcitonin nasal
spray (Miacalcin), risendronate (Actonel) and alendronate (Fosamax).
Source: National Osteoporosis Foundation
I have a family history of osteoporosis
Yes responses indicate increased risk for osteoporosis
While family history is a risk factor that cannot be controlled by patient, there are 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 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
My upper back curves forward.
Yes responses may indicate advanced osteoporosis.
Tests and diagnosis
Dual energy X-ray absorptiometry: The best screening test is dual energy X-ray
absorptiometry (DEXA). This procedure is quick, simple and gives accurate results. It measures
the density of bones in the spine, hip and wrist — the areas most likely to be affected by
osteoporosis — and it's used to accurately follow changes in these bones over time.
Other tests that can accurately measure bone density include:
Ultrasound
Quantitative computerized tomography (CT) scanning
Who should be tested? The National Osteoporosis Foundation recommends that all women over
the age of 65 have a bone density test. Younger women with one of the following conditions
should also be tested:
Postmenopausal and have at least one risk factor for osteoporosis, including having fractured a
bone
A vertebral abnormality
Take medications, such as prednisone, that can cause osteoporosis
Type 1 diabetes, liver disease, kidney disease, thyroid disease or a family history of osteoporosis
Experienced early menopause
Treatment options include:
Hormone therapy: Hormone therapy (HT) was once the mainstay of treatment for osteoporosis.
But because of concerns about its safety and because other treatments are available, the role of
hormone therapy in managing osteoporosis is changing. Most problems have been linked to
certain oral types of HT, either taken in combination with progestin or alone. Alternative forms
of hormone therapy are available, including patches, creams and the vaginal ring.
Discuss the various options with patient to determine the best option.
Prescription medications: If HT is unsuccessful or patient requests an alternative approach,
and lifestyle changes don't help control osteoporosis, prescription drugs can help slow bone loss
and may even increase bone density over time. They include:
Bisphosphonates: Much like estrogen, this group of drugs can inhibit bone breakdown, preserve
bone mass, and even increase bone density in spine and hip, reducing the risk of fractures.
Bisphosphonates may be especially beneficial for men, young adults and people with steroidinduced osteoporosis. They're also used to prevent osteoporosis in people who require long-term
steroid treatment for a disease such as asthma or arthritis.
Side effects, which can be severe, include nausea, abdominal pain, and the risk of an inflamed
esophagus or esophageal ulcers, especially if patient had acid reflux or ulcers in the past.
Bisphosphonates that can be taken once a week or once a month may cause fewer stomach
problems. If patient can't tolerate oral bisphosphonates, periodic intravenous infusions of
bisphosphonate preparations may be recommended.
In 2007, the Food and Drug Association (FDA) approved the first once-yearly drug for
postmenopausal women with osteoporosis. The medication, zoledronic acid (Reclast), is given
intravenously at doctor's office. It takes about 15 minutes to get annual dose. One published
study found that zoledronic acid reduces the risk of spine fracture by 70 percent and of hip
fracture by 41 percent.
A small number of cases of osteonecrosis of the jaw have been reported in people taking
bisphosphonates for osteoporosis. These cases have primarily occurred after trauma to the jaw,
such as a tooth extraction, or cancer treatment. Risk appears to be higher in people who have
received bisphosphonates intravenously. While there is currently no clear evidence that patient
should stop taking bisphosphonates before dental surgery, patient should inform dentist of
medications and discuss any concerns.
Raloxifene (Evista). This medication belongs to a class of drugs called selective estrogen
receptor modulators (SERMs). Raloxifene mimics estrogen's beneficial effects on bone density
in postmenopausal women, without some of the risks associated with estrogen, such as increased
risk of uterine cancer and, possibly, breast cancer. Hot flashes are a common side effect of
raloxifene, and patients shouldn't use this drug if there is a history of blood clots. This drug is
approved only for women with osteoporosis and is not currently approved for use in men.
Calcitonin. A hormone produced by the thyroid gland, calcitonin reduces bone resorption and
may slow bone loss. It may also prevent spine fractures, and may even provide some pain relief
from compression fractures. It's usually administered as a nasal spray and causes nasal irritation
in some people who use it, but it's also available as an injection. Because calcitonin isn't as
potent as bisphosphonates, it's normally reserved for people who can't take other drugs.
Teriparatide (Forteo). This powerful drug, an analog of parathyroid hormone, treats
osteoporosis in postmenopausal women and men who are at high risk of fractures. Unlike other
available therapies for osteoporosis, it works by stimulating new bone growth, as opposed to
preventing further bone loss. Teriparatide is given once a day by injection under the skin on the
thigh or abdomen. Long-term effects are still being studied, so the FDA recommends restricting
therapy to two years or less.
Tamoxifen. This synthetic hormone is used to treat breast cancer and is given to certain highrisk women to help reduce their chances of developing breast cancer. Although tamoxifen blocks
estrogen's effect on breast tissue, it has an estrogen-like effect on other cells, including bone
cells. As a result, tamoxifen appears to reduce the risk of fractures, especially in women older
than 50. Possible side effects of tamoxifen include hot flashes, stomach upset, and vaginal
dryness or discharge.
Emerging therapies: A new physical therapy program has been shown to significantly reduce
back pain, improve posture and reduce the risk of falls in women with osteoporosis who also
have curvature of the spine. The program combines the use of a device called a spinal weighted
kypho-orthosis (WKO) — a harness with a light weight attached — and specific back extension
exercises. The WKO is worn daily for 30 minutes in the morning and 30 minutes in the afternoon
and while performing 10 repetitions of back extension exercises.
American Academy of Family Physicians
http://www.nlm.nih.gov/medlineplus/osteoporosis.html
This should appear on all printed recommendations:
Screening Methods for bone loss and Osteoporosis:
Urine tests: fasting calcium/creatinine, fasting
hydroxyproline/creatine
Blood tests
Calcium/phosphorous: 1,25(OH)2Vitamin D3
Progesterone; Estrogens (estradiol, estrone)
Serum Gla-protein
Photon Absorptiometry: single, dual
Computed tomography
(Useful information about research and effective treatments for osteoporosis)
http://w3.ouhsc.edu/phar5442/Lectures/Osteoporosis.html
http://www.umm.edu/patiented/articles/who_gets_osteoporosis_000018_5.htm