The Osteoporosis Book (3rd Edition)

Table of Contents:

Foreword by Jonathan D. Adachi MD, FRCPC Introduction Caring About Your Bone Health Part One: The Basics for Men and Women Chapter 1: What is Happening on the Inside?

Bone Growth and Development Inside the Bones Primary and Secondary Osteoporosis

Chapter 2: Menopause and Hormone Therapies

Menopause Hormone Therapies

Chapter 3: Testosterone, Andropause and Bone Loss

Calling All Men Testosterone Levels Testosterone Replacement Therapy Other Treatments for Osteoporosis in Men Monitor Your Therapy

Part Two: Osteoporosis Prevention

Chapter 4: Calcium

Diet and Bone Health Calcium Calcium Intake Calcium Supplements

Chapter 5: Vitamin D and Other Vitamins and Minerals

Vitamin D Vitamin D Sources How much Vitamin D do I need? Other Vitamins and Minerals Alkaline (Basic) or Acid-Producing Foods and Bone Health

Chapter 6: The Importance of Exercising and Safe Movement

Non Weight-bearing Activities Weight-bearing Activities Walk, Walk, Walk Joining a Fitness Program Exercise Considerations

Chapter 7: Exercises

Choosing the Appropriate Exercises Charting Your Course Set A: Stretching Exercises Set B: Balance Exercises

Part Three: Clinical Evaluations and Treatments Chapter 8: Clinical Evaluation to Assess Bone Health

Risk Factors for Osteoporosis Risk Factors for Fall and Fracture Ways to Assess Your Bone Health

Chapter 9: 10-Year Fracture Risk Assessment Tools

Assessing Your Fracture Risk FRAX CAROC Fracture Risk Assessment

Chapter 10: Fall and Fracture Prevention and Post-Fracture Care

Fall Prevention Fracture Prevention Post-Fracture Care

Chapter 11: Medical Treatments

Mechanism of Action Route of Administration Benefit, Risk and Cost Factors Side Effects and Rare Events Treatments for Osteoporosis Cancer Medications and Glucocorticoids: Treatments to Protect Bone Future Drug Therapies

Chapter 12: Understanding Health Headlines

Be Cautious When Reading Headlines Research Terminology

Part Four: Ta king Control of Your Bone Health Chapter 13: Bringing It All Together

Managing the Prevention of Bone Loss Managing Your Osteoporosis

Chapter 14: Living well with Osteoporosis

Daily Movement and Activities Daily Living Tasks Managing Pain

Chapter 15: Examples of Patients with Osteoporosis Chapter 16: Resources Chapter 17: Glossary Bone Health Care Plan Acronyms and Abbreviations Acknowledgements About the Authors

Book Excerpt–Chapter 5: Vitamin D and Other Vitamins and Minerals

Most experts recommend that adults under 50 need 400IU to 1,000IU of vitamin D supplementation per day and those over 50 need about 800IU to 2,000IU supplementation per day. As medical guidelines are updated, experts are suggesting up to 2,000IU of calcium intake per day is safe. Intakes of 4,000IU to 5,000IU per day may be safe, but can be associated with possible kidney stones, which are very painful. The benefits of vitamin D appear to reach beyond the skeleton. Research is being done on the impact of vitamin D on common cancers, autoimmune disorders, infections, cardiovascular disease and muscle strength. For our purposes, we will discuss the vitamin D group, the need for vitamin D, its sources and the optimal levels for bone health. We will also review other vitamins and minerals that contribute to healthy bones. Vitamin D Vitamin D is essential in calcium and phosphorus metabolism and required for normal development of bones and teeth. It is a fat-soluble vitamin that when ingested or produced by the skin is changed in the liver and kidney to its active form, known as calcitriol (1, 25, hydroxy-vitamin D). Other forms include vitamin D2 (ergocalciferol, a plant source) and vitamin D3 (cholecalciferol, an animal source). Known as the sunshine vitamin, vitamin D is an important part of bone health, both in the prevention and treatment of osteoporosis. For many years, we have known the value of vitamin D in the normal development and maintenance of strong bones and teeth. The role of vitamin D in nerve and muscle tissue is now showing its value in fall and fracture prevention. Studies have shown that, for people over 65, high vitamin D levels can improve walking compared to people with low vitamin D levels. Studies pooled together (called a meta-analysis) show that, among older individuals who take a vitamin D supplement at a dose of 700IU to 1,000IU per day, the risk of falling is reduced by nearly 20 percent. Research continues to point out that many people are still deficient in vitamin D. Between 40 and 100 percent of elderly men and women living in an institution, such as a care home or hospital, are deficient in vitamin D and more than 50 percent of women already taking medication to treat osteoporosis are also deficient in vitamin D. Vitamin D Sources Vitamin D comes from two main sources: dietary intake and the skin’s exposure to the sun. Dietary Sources Few foods naturally contain or are fortified with vitamin D. Natural food sources of vitamin D include fatty fish, fish liver oils and egg yolks. Foods fortified with vitamin D include margarine, milk, orange juice, cheese, butter and yogurt. Check the food label for actual vitamin D content.

Sunshine When the sun’s rays hit the skin, vitamin D is produced. Sunshine is considered the best, most efficient source for your daily requirement of vitamin D. Research shows that when using simulated sunlight, a single minimal erythemal (red) skin dose will raise circulating levels of vitamin D [1, 25(OH)D] comparable to ingestion of 10,000IU to 25,000IU of vitamin D3. Exposure to between five and 10 minutes of sunlight can provide the equivalent of about 3,000IU of vitamin D. Getting adequate amounts of vitamin D may be difficult for people living near or north of the forty-second parallel. In North America, the forty-second parallel runs roughly from New York State on the east coast to Washington State on the west coast. Therefore, people living in the northern United States and Canada need to supplement their vitamin D intake from October through March to compensate for the lack of sun exposure on the skin, specifically the ultraviolet B (UVB) rays. The amount of vitamin D you receive from your skin’s exposure to UVB rays decreases due to any of the following:

• Age. The skin of older adults often cannot synthesize vitamin
• D as efficiently and their kidneys are less able to convert vitamin
• D to its active hormone form.
• Dark skin. The amount of melanin or pigment in your skin can decrease absorption.
• Amount of smog in the air or use of sunscreen can filter the UVB rays.
• Cloud cover or time spent in the shade can reduce UVB ray exposure by half.
• Living north of forty-second parallel. UVB from the sun in northern regions, especially in fall and winter, is less useful.
• Time of day. UVB rays tend to be weakest outside the peak hours of 10 a.m. and 3 p.m.
• Wearing long robes or head coverings or staying indoors.

Daily sunshine exposure of 15 to 30 minutes with maximum skin exposure and no sunscreen should provide your daily recommended dose of vitamin D.

Given concerns about skin cancer caused by to too much exposure to the sun, some dermatologists suggest limiting sun exposure or using a sunscreen lotion with a high sun protection factor (SPF). It is important to assess and consider your personal sun exposure, cancer risk and vitamin D intake. The amount of sun exposure you need in any one day to get your recommended dose of vitamin D depends on various factors as outlined above. Experts agree, however, that sun exposure of about ten to thirty minutes a day will probably provide the required daily dose of vitamin D. Adjust the time to consider the different factors mentioned above, and remember, excessive exposure to the sun may increase the risk of skin cancer and wrinkling or drying of the skin. How much vitamin D do I need? The recommended dosage of vitamin D for people over 50 is 800IU to 2,000IU per day. Research is underway to assess daily requirements that may well exceed these amounts. Many experts feel the current tolerable upper limit of daily vitamin D intake for adults over age 50 is 2,000IU, while some experts say 2,500IU per day is the upper limit. Some individuals take as much as 5,000IU per day, but these levels might result in high levels of calcium in the blood and urine and may result in kidney stones. Talk with your doctor about the latest research and your needs. Vitamin D levels can be easily checked by your doctor if there is a concern about malabsorption of this vitamin. Most specialists do not check vitamin D levels routinely prior to starting vitamin D supplements. Some experts suggest that if you are going to measure the levels, the best time is three months after you start on a vitamin D supplement. Other experts feel you should only Daily sunshine exposure of 15 to 30 minutes with maximum skin exposure and no sunscreen should provide your daily recommended dose of vitamin D. Chapter 5: Vitamin D and Other Vitamins and Minerals 77 measure vitamin D levels if you are on treatment and still losing bone or experiencing fractures. Discuss with your doctor whether you should have your level checked or just go on a good amount of vitamin D. If you miss a dose and later remember, it is safe to double the dose to make up for it. If diagnosed with vitamin D deficiency, some doctors may suggest a large loading dose of 50,000IU per day or weekly of vitamin D2 (Ostoforte) for a short period of time. Vitamin D supplements may be either vitamin D2 or D3, which are similar. Vitamin D3 is the naturally-occurring form of vitamin D and thought to be more than three times as effective as the same amount of vitamin D2 in affecting blood levels and maintaining those levels longer. When taking a non-prescription supplement, the vitamin D3 form, rather than the vitamin D2 form, is generally used. Vitamin D2 is sometimes used in multivitamin preparations. Vitamin D2 may also be written as a prescription for 50,000IU of vitamin D2 ergocalciferol. While this may seem like a strong dose, remember, vitamin D2 is less potent than vitamin D3. Most supplements now consist of vitamin D3 rather than vitamin D2. Vitamin D2 may be appropriate for vegans or anyone who avoids animal products. It is derived from a plant source, whereas D3 is manufactured from an animal source. Check with your pharmacist to ensure it is the right supplement for you. Calcitriol is the active form of vitamin D, which is infrequently used and more expensive than vitamins D2 or D3. Some studies with calcitriol have demonstrated significant decrease in fractures of the spine among individuals with severe osteoporosis. However, calcitriol can do its job too well and help absorb too much calcium. With too much vitamin D, calcium levels can build up in the blood and settle in parts of the body where it should not, and thus cause damage. This could cause calcium kidney stones, which can be painful and may damage the kidney. Calcitriol treatment should only be prescribed by doctors with expertise in treating patients with osteoporosis.

Book Excerpt–Chapter 13: Bringing It All Together

Healthcare is constantly changing. The roles of doctors and other healthcare providers are shifting. Seldom does a doctor make a house call or take sole responsibility for the treatment recommended. Managing a chronic disease, such as osteoporosis, is now a collaborative effort that requires doctors, pharmacists, dietitians, physical therapists, nurses, the patient and sometimes the patient’s friends or family working together. As the patient, you are a participant and the person who brings a unique knowledge to the team. You are the expert in how you behave, what you desire and what you will and will not do to reach your desired outcome. Research shows that people do better if they participate in their own care. Those who seek information and ask questions tend to be able to maintain a better quality of life. For example, if the doctor says the medication you need requires a needle every day, and you dislike needles and will not follow through, then discuss that with your team. You are not the first person to dislike needles. The team may have several other options or ideas on how to manage this issue. If necessary, discuss a compromise in order to meet or to come as close as possible to the desired goal. Remember, they see hundreds of people in a year where you may only have the valuable, but limited experience of one. Managing the Prevention of Bone Loss Become your own best advocate. Take an active role in your bone health and you will have better outcomes, be more satisfied and treatment will be more successful. A passive patient is less credible information about the disease. Talk with friends, colleagues, local and national organizations, and your doctor to find experts in bone health. Put together a patient-centered care team list of healthcare providers that you trust. Have a discussion about patient involvement with your doctor and healthcare providers. Be sure your healthcare team understands and agrees that you are responsible for and have the right to be engaged as a decision maker in your bone healthcare. Learn to be comfortable in discussing your concerns, preferences and desires with your team. Speak up for yourself. View yourself as an expert on you – how you cope and what you value. Understand what the disease means to your independence and quality of life so you are motivated to learn all you can and implement the decisions you have made. Healthcare professionals bring expertise and clinical practice experience about bone health and diseases. They offer education, support and assistance with problem solving. They provide options for discussion, including risks and benefits of those options. Follow through on the decisions that you and your team have agreed upon. Your objective as a team member is to work with the team to minimize bone loss as you age, to maintain and build bone (if possible), to prevent fractures and improve your quality of life. To succeed in this approach, you, as your own advocate, will want to adapt your positive, assertive, attitudes and behaviors to reflect your desire to be informed, involved and responsible for the decisions about your bone health and treatment. As a team member, you bring expertise from your life experiences that will affect the treatments that are suggested for you. Develop a Management Plan With a little guidance, education and possibly a few lifestyle changes, your bones may remain healthy for years. As your own advocate, be prepared when you meet with anyone on the team. You can facilitate this by developing a bone health care plan and file.

• Start by writing down your assessment results from the osteoporosis and fracture risk assessments addressed in Chapter 8. This will give you a general assessment of your bone health status.
• Second, write down your calcium and vitamin D intake as outlined in Chapter 5. If you need assistance, contact a registered dietitian. Adjust your dietary intake as necessary.
• Assess how active you are. Write down your daily exercise routine and if it includes weight-bearing, muscle strengthening and balance exercises as well as other activities. Review Chapter 7. If you need help, contact a physical therapist or trainer specializing in bone health programs. Develop and commit to an exercise routine that will improve your bone health.
• Review Chapter 8: Clinical Evaluation to Assess Bone Health and Fracture Risk. Write down any questions that come to mind. Be informed about assessment options when you next talk with your doctor. If you have any major risk factors or a few minor risk factors, consider having a bone mineral density test. Studies show that people tend to take better care of their bones if a review of their bone density shows they are at risk.
• Finally, use one of the fracture risk assessment tools in Chapter 9 to establish your own 10-year fracture risk. If you show low or high bone density, follow up with your doctor for a thorough clinical assessment of your bone health. If your bone density is normal, then follow up with your doctor in a year provided nothing else changes. See the Bone Health Care Plan on page 251 for an overview of assessment.

If you are diagnosed with low bone density, discuss your assessment and ask your doctor for his or her opinion on the value of a more detailed bone and fracture risk assessment. Your doctor can put things into perspective based on your medical history. By being informed about bone loss prevention and treatments, you will be able to communicate your concerns clearly. Be aware that low bone density alone becomes important as you age. If you are under 60, you are not facing an emergency, but you should start thinking ahead. As you gather information and meet with healthcare professionals, share your values and beliefs about medical treatments and taking medications. Be open to listening to their expertise. Be sure you understand the risks and benefits should you choose not to exercise, not to change your diet or not to take the medication at this time. If you are concerned and motivated, work with your team and management plan to change some of your behaviors to begin to improve your bone health through adequate calcium and vitamin D intake, appropriate exercises and a healthier lifestyle. If you are diagnosed with osteoporosis, you will become more involved with your healthcare team as you learn to manage living with this chronic disease. Communication and education are integral to preventing future fractures. Follow the patient-centered care approach discussed earlier. Use the education, support and encouragement provided by your healthcare team to deal with challenging situations that arise as you manage your disease.

Manage your osteoporosis through a multidiscipline integrated healthcare team approach. You are a part of that team. Do not hesitate to ask questions.

Managing Your Osteoporosis Knowledge and understanding are essential to so many things in our lives, especially our health and wellness. The more we know about a subject, the more confident we are and likely to be involved, participate and prevent further disease. We enjoy a sense of pride, accomplishment, achievement and self-respect as we learn new things. We feel our accomplishment as we step into a partnership with others in the management of our care. We are able to make informed choices about our care, treatments and quality of life. Once we accept that osteoporosis is a part of our lives, we can begin finding better ways to live well with the disease using our bone health care plan and file. Here are some ways you can participate in managing your disease.