3

serum calcium levels are too low, and adequate calcium is not provided by the diet, calcium is taken from bone.

Long- term dietary calcium deficiency is a known risk factor for osteo porosis. The recommended daily cal-cium 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 slow ing 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 stud-ies have found calcium consumption between 650 mg and over 1400 mg/day reduces bone loss and increases lumbar spine BMD.4-6

How to take calcium supplements:Take calcium supplements with food. If unable to take calcium with food or if tak-ing 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

Dietary sources of calcium include: Dairy products: milk (300 mg/cup), yogurt (300-400 mg/cup) and cheeses (138 mg/cup skim cot-tage cheese) Fortified orange juices (300 mg/8 oz), breads (150-200 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)

Calcium supplements are available in several forms: calcium carbonate (most common), calcium citrate,

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.

Please direct all inquiries to: National Osteoporosis Foundation 1150 17th Street NW Washington, DC 20037, USA Phone: 1 (202) 223-2226Fax: 1 (202) 223-1726 www.nof.org

Statement of Educational PurposeOsteoporosis 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.

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

Intended AudienceThis 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.

4

Calcium Safety

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 supple-mentation (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 in-crease in MI was observed in meta-analysis of data from the Women’s Health Initiative.9

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.

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 nega-tive impact. Therefore, individuals should consume as much calcium as possible from foods. Supplements should be used only to bring all-source intake to rec-ommended 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 supple-ments was lead contamination in calcium-carbonate based supplements derived from dolomite, bone meal, or unrefined oyster shell. Like other nutritional supple-ments, 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

If the supplement has a USP label, the lead content has been tested and determined to be within accept-able levels. Most major brands of calcium supplements voluntarily meet the USP standards for purity and safe

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).

Calcium in over-the-counter supplements is gener-ally 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 supple-ments, 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.

Achieving bone-building and bone-preserving effects of pharmacologic therapies for osteoporosis requires ade-quate calcium intake.

Figure 1.

5

lead levels.

Calcium is known to offset the effects of lead by block-ing its absorption (both in the sup plement and in other dietary contributors of lead).16,17 Research has shown that blood lead levels are lower in peo ple 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 re-spected manufacturers. Patients should, however, avoid supplements derived from dolomite, bone meal, or unre fined oyster shell. Be advised that calcium carbon-ate preparations are currently the least expensive and the most widely available. Alternatives to calcium car-bonate include calcium citrate, calcium phosphate, and (by pre scription) calcium acetate.

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 metabo lize vitamin D declines with age. Other sources of vita min 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 individu als who avoid sunlight, do not drink vitamin D fortified milk, or do not take a multivitamin con-taining vitamin D. It is also common in people who are homebound or institutionalized, are on dialysis or anticonvulsive medication, or who suffer from diabe-tes, hypertension, chronic neurological disorders, or gastroin testinal diseases. In addition, research on hos-pital inpa tients found a significant degree of vitamin D deficiency (42%) in patients with no known risk factors.19

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 vi-tamin D include:

Salmon 815 IU/half fillet

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.

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.

Disclosure of Commercial SupportIt 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.

Statement Regarding Off-Label Use Any publication of the Osteoporosis Clinical Updates that discusses off-label use of any medications or devices will be

7

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 frac-ture incidence (46% in women and 34% in men).28

The rec ommended 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 retinolBeef liver 22175 IU/cup as retinolCarrot juice 45133 IU/cup as caroteneSweet potato 28058 IU/potato as caroteneSpinach 22916 IU/cup as caroteneBeet greens 11022 IU/cup as carotene

Because of the possible detrimental effects of retinol on bone, it is advisable to select supplements that con-tain no more than 2000–3000 IU retinol. Alternatively you can choose supplements that provide vitamin A as carotene.

B Vitamins

Inadequate intake and/or compromised metabolism of folic acid/folate (B

9), pyridoxine (B

6), riboflavin (B

2),

or cobalamin (B12

) have been shown to lead to high homocysteine levels.30 Emerging data point to a dose-response association between elevated serum homocys-teine and a modest increased risk of fracture.31-34

Large studies in the Netherlands observed high homo-cysteine combined with low vitamin B

12 was associated

with high markers of bone turnover, increased fracture risk, and low ultrasound measurement of bone densi-ty.33,34 In the Rotterdam study, a dose response was seen between low B

6 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 (B

2) and

pyridoxine (B6) and BMD.33

Studies of B vitamin effects on bone have shown diver-gent effects in men and women. In a large Norwegian observational study, elevated homocysteine and low fo-late 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.

It has been speculated that, rather than a direct bone

Support NOF . . . . . . . . . . . . .

osteoporosis.

8

to characterize the role of B vitamins in bone metabo-lism 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.

US RDI for B2 (riboflavin) is 1.3 mg/day for adult men

and 1.1 mg/day for adult women. Dietary sources of B

2 include:Beef liver 2.9 mg/3 ozTurkey giblets 2.2 mg/cupDuck 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 B

6 include:

Cereal, raisin bran 2.1 mg/cupFish, salmon 1.1 mg/half filletChickpeas 1.1 mg/cup Malted milk drink mix made with whole milk 1.015 mg/cup

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 B

9 include forti-

fied sources such as bread, cereal, and rice and natural sources such as beans:

Rice, white long grain 797 mg/cupCereal, malt-o-meal 756 mg/cupWheat flour, white, bread 358 mg/cupBeans, pinto 294 mg/cup

US RDI for B12

is 2.4 g/day for adults, male and fe-male. Dietary sources of vitamin B

12 include:

Beef 70.7 g/3 ouncesMollusks, clam 15.8 g/3 ouncesChicken 13.7 g/cupSoup, New England clam chowder 12 g/cup

(Because 10% to 30% of older people may malabsorb food-bound B

12, the Institute of Medicine advises those

older than 50 years to meet their RDA mainly by con-suming foods fortified with B

12 or a supplement con-

taining B12

.)38

Boron

Currently no recommended daily intake or average

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

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increases the need for calcium by interfer ing with cal-cium absorption through increased secretion of para-thyroid hormone. Studies have also observed that phos-phorous deficiency may reduce the absorption of calci-um and thereby lead to bone loss.65 The key is to main-tain 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 demon-strated 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.

The RDI for phosphorus is 700 mg/day for men and women. Dietary sources of phosphorus include:

Cornmeal, self-rising enriched 860 mg/cupMilk, canned sweetened, condensed 774 mg/cup Fast foods biscuit with egg and sausage 562 mg/biscuitFish, salmon, cooked, dry heat 491 mg/half fillet

Strontium

Strontium is a trace element found in seawater. Its primary source in the diet is seafood. Other strontium-containing foods include whole milk, wheat bran, meat, poultry, and root vegetables. There are no rec-ommended daily or adequate intakes established for strontium. However, aver age daily intakes have been estimated to be about 1–3 mg.

Research on humans and animals over the past thirty-odd years has shown pharmacologic doses of strontium to be associated with increased bone strength and re-duced 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 stron-tium 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

Strontium Ranelate: 50% Vertebral Fractures

15-20% Nonvertebral Fractures

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/cupSemisweet chocolate 193 mg/cupSpinach, canned, drained 163 mg/cupBeans, black, cooked, boiled, no salt,120 mg/cup

Manganese, Copper, Zinc

The dietary minerals man ganese, copper, and zinc are cofactors for enzymes required for healthy bone metabolism.62

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 ani-mal models has suggested a potential role for manga-nese supplementation in maintenance of bone health; however, more research is needed.63,64

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, sea-food, nuts, seeds, cereals, whole grains, and cocoa.

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 nor-mal 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.

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 in-clude dairy products, meat, peas, eggs, and some cere-als. Phosphorous is also widely used as a preservative (phosphoric acid) in carbonated beverages and pro-cessed foods. As is the case with many nutrients, too much or too little phosphorus leads to problems.

It has long been known that excess phos phorus intake

13

discussion on vitamin A.) Supplements are widely available.

Protein

There have been a large number of observational stud-ies 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, nu-trition is often inadequate, and protein intake may be suboptimal for skeletal health.

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 ob-served.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.

Further investigation is needed to determine if changes to current protein intake recommendations are war-ranted for any specific age group. At present, daily intake at recommended levels from animal and/or veg-etable sources is sound policy for patients of all ages.

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-duckChicken meat 42.59 g/cupFish salmon, cooked dry heat 39.37 g/half-fillet Fast food hamburger, double large patty 34.28 g/burger

Tea

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

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

In clinical trials, a medical food containing 27 mg ge-nistein 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 magni-tude of change observed is very small in real terms, the preliminary data are suggestive of bone density main-tenance.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 addi-tion to curent osteoporosis therapies.

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

Dietary sources of isoflavones include soybeans, chick-peas, 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.

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

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

16

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.

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 metabo lism, it is possible that intake of these minerals may be ben-eficial to bone. However, research is lacking to sup port this hypothesis.

The clinician recommends a varied diet that includes leafy greens, fruits, and vegetables. In addition, the cli-nician recommends that the patient engage in weight-bearing exercise and a bone density test at age 60.

Case 3: 75-Year-Old Woman with Low Bone Mass

The third patient we will discuss is a housebound el-derly 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).

What dietary supplements or nutriceutical

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.

Because of her age and lack of sun exposure, it is prob-ably safe to assume that this patient is vitamin D de-ficient. Vitamin D deficiency contributes significantly to bone loss. To estab lish serum calcium and 25-hy-droxyvitamin D levels, the physician orders appropriate blood panels.

The patient is asked about her diet. She reports that she eats mostly canned soup, tea, and toast: foods she can easily prepare.

bone status?

multivitamin con tains vitamin D (600 IU), she partici-pates 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, espe-cially African Americans. The only way to rule it out is to perform serum measurment.

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 appro-priate. 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.

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 elevat-ed osteoporosis risk in her history. Neither she nor her parents has experienced bone fractures.

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 mul tiple nutritional supplements, includ-ing multivitamins, flax seed oil, magnesium, zinc, and six fish oil capsules twice a day for their cardiovascular benefits.

Does anything in the patient’s reported history raise concern about her bone health?

Perhaps. Observational studies suggest that ingestion of high doses of sup plemental 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.

Should the patient be advised to curtail her use of

It may be a good idea. The potential cardiovascular benefit of fish oil supple ments (for their omega-3 fatty acid content) may be offset by skeletal harm. The clini-cian recommends that the patient discontinue intake of fish oil supplements and that she limit her intake of

17

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. Osteopo-ros 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 con-tent 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 Per-spect. 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/Food-Safety/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 so-ciodemographic 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. Reti-nol 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 partici-pants 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-caro-tene 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 ca-rotenoid 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. Pro-tective effect of total carotenoid and lycopene intake on the risk of hip

Her diet is high in sodium and low in calcium and pro-tein. It is advisable for her to take a daily supplement that con tains adequate vitamin D (800 IU) and calcium (1000 mg). The clinician explains the importance of ad-equate protein, calcium, and vitamins and recommends adding nuts, dairy foods, fresh fruits, and vegetables to her diet. To help the patient make these dietary chang-es, the clinician makes an appointment with a dietician who can help her develop a healthy eating plan she can manage on her own.

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 thera-pist to develop a safe movement/exercise plan to ease the patient into bone-preserving weight-bearing exer-cises 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 thera-peutics for preventing and treating osteoporosis. Unfortunately, there are also hundreds of non-FDA-ap-proved nutriceutical products on the market that claim to do the same things. Healthcare providers can edu-cate patients about which products’ claims can be sup-ported 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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