Osteoporosis is a major public health threat for 44 million Americans and is known as the "silent disease". It is a silent disease in that it progresses insidiously and painlessly up until the first symptom, which is usually a broken bone.  Unfortunately by then, most of the damage has been done.  As with many illnesses, early detection and prevention of osteoporosis is vital. 

Bone is living tissue--your body is always breaking down old bone and replacing it with new bone tissue. As people enter their forties and fifties, more bone is broken down than is replaced. The inside of bone looks something like a honeycomb. When you have osteoporosis, the spaces in this honeycomb grow larger. And the bone that forms the structure of the honeycomb gets smaller. The outer shell of your bones also gets thinner. All of this bone loss makes your bones weaker.

Osteopenia is a term used to refer to this early stage of bone loss, where more bone is being broken down than is replaced. Bone density testing can determine if osteopenia is present.

Osteoporosis is a term used to describe a more advanced stage of bone loss where the bones are so thin, porous, and weak that they fracture easily.

Bone fractures occur typically in the hip, spine, and wrist but any bone can be affected. Hip fractures are common in people with osteoporosis and almost always require hospitalization and major surgery. Hip fractures often impair a person's ability to walk unassisted and may lead to prolonged disability or even death.

Loss of height and severe deformity, such as curvature of the spine occurs from vertebral fractures (bones in your spine fracture). They are extremely painful, can cause loss of height and can result in severe deformity such as severe curvature of the spine or stooped posture.

One-half of all women and one in four men over 50 will have an osteoporosis-related fracture in their lifetime. This occurs despite the fact that osteoporosis can be prevented and treated. (1,2) 

• A diet low in calcium and vitamin D.  The majority of bone mass is developed during the adolescent and young adulthood years, with nearly 90% of skeletal mass accumulated by age 18. Current research has demonstrated that many adults and children in the U.S. have calcium intake levels well below the recommended dietary value.
• Little or no weight-bearing exercise.  Inactive lifestyle or extended bed rest. 
• Use of certain medications long-term, may adversely influence calcium balance:  steroids,  anticonvulsants such as Dilantin or phenobarbitol,  certain antibiotics used long-term in the treatment of acne such as tetracycline, minocycline and possibly doxycycline, and antacids containing aluminum.  "Loop diuretics" such as Lasix, Bumex and Demadex increase the excretion of calcium; however, "thiazide diuretics" actually do the opposite and may actually help to protect against possible bone loss.  Thus, it is important for patients to tell their physician or nurse practitioner about all medications they are taking so that any possible interactions with calcium can be identified.(6)
• Cigarette smoking--Older smokers have 20 to 30 percent less bone mass than nonsmokers
• Excessive use of alcohol--Alcohol is a diuretic and calcium is lost in the urine. Also, moderate amounts of alcohol consumption interferes with calcium absorption and long-term consumption of alcohol in high amounts has been thought to adversely affect calcium-regulating hormones.(6)
• Excessive caffeine intake results in loss of calcium in the urine.
• Gender - Women are four times more likely than men to develop the disease, although men also suffer from osteoporosis. 
• Aging for a number of reasons, adversely contributes to osteoporosis.  
• Body size - Small (under 127 lbs), Women with less body fat tend to have lower estrogen levels and thus are at greater risk of osteoporosis.  Studies show that women athletes with little body fat and resultant amenorrhea have 20 to 30 percent less bone mineral content than have those with regular cycles. 
• Thin-boned women are at greater risk.
• Ethnicity - Caucasian and Asian women are at highest risk. African-American and Latino women have a lower but significant risk.
• Family history - Susceptibility to fracture may partly be hereditary.  
• Menopause  Women can lose up to 20 percent of their bone mass in the five to seven years following menopause, making them more susceptible to osteoporosis.(2)
• Low testosterone levels in men
• Women who have never been pregnant. They haven't experienced the same bursts of estrogen in their bodies as women who have been pregnant.
• Lighter complexions. Women with darker pigmentation have roughly 10 percent more bone mass than do women with fairer pigmentation because the former produce more calcitonin, the hormone that strengthens bones.
• High-protein diet. This contributes to a loss of calcium through the urine. The average American diet is high in protein and low in fruits and vegetables. Even those who consume the least protein eat approximately 25% more than the recommended dietary allowance (RDA), according to researchers at Tufts University, 2001.(6)   
• Various other disease states that influence calcium absorption or excretion can also play a role in the development of osteoporosis

• A balanced diet rich in calcium and vitamin D:
  
  Daily calcium intake should be at least
  • 1000 mg in premenopausal women and in men.
  • 1200 mg for postmenopausal women, including calcium supplements if necessary

Daily Vitamin D: vitamin D3, of 800 to 1,000 IU per day is recommended for individuals at risk of insufficiency(6). For most patients, the total daily calcium intake should not routinely exceed 2000 mg due to the possibility of adverse side effects.(3)

A simple blood test can determine if there is sufficient intake of vitamin D to prevent disease, whereas bone density testing is required to determine if the diet is adequate in calcium.

• Regular, weight-bearing exercise
  
  
• Limit alcohol, caffeine, and soft drinks
  
  
• Quit smoking, if you smoke
  
  
• Bone density testing is the only sure way to determine bone density and fracture risk for osteoporosis. It is used to detect osteoporosis before a fractures occurs, predict your chances of fracturing in the future, and determine your rate of bone loss and/or monitor the effects of treatment. Bone density tests use either ultrasound or DEXA (dual energy X-ray absorptiometry). Either method is painless, noninvasive and safe. These tests can measure bone density in various sites of the body. Your doctor can help you determine whether you should have a BMD test. National Osteoporosis Foundation Guidelines indicate, bone density testing should be performed on:
  
  
  • All women aged 65 and older regardless of risk factors.
  • Younger postmenopausal women with one or more risk factors (other than being white, postmenopausal and female).
  • Postmenopausal women who present with fractures (to confirm the diagnosis and determine disease severity).
    
    
    • Bone density testing is repeated in approximately 2 years, depending on the person's risk factors, results of baseline study, and whether or not medication was started.  It's important to get more than one test to determine whether there is improvement or decline in bone density.  This follow-up study helps guide therapy.
      
      
• Medication when appropriate. There is no cure for osteoporosis, but if your bone density test is abnormal, your doctor or nurse practitioner may recommend one of several medications approved by the FDA to either prevent and/or treat osteoporosis:
  • Selective Estrogen Receptor Modulators (SERMs)
    • Evista (raloxifene)--a pill to be taken once daily
  • Bisphosphonates
    • Fosamax (alendronate)--a pill to be taken once weekly
    • Fosamax plus D--a pill taken once weekly
    • Boniva (ibandronate)--a pill to be taken once monthly
    • Actonel (risedronate)--a pill to be taken once weekly
    • Actonel with calcium--a pill to be taken once weekly on day 1, then 500 mg calcium needs to be taken on days 2-7 of the wk.
    • Reclast (zoledronic)--intravenous infusion once yearly
  • Calcitonin (Miacalcin, Fortical)--a nasal spray to be used once daily, or injectable every other day
  • Parathyroid Hormone Teriparatide (PTH (1-34) (Fortéo)--injectable, given once daily for 2 years
  • Note: It is no longer recommended to take estrogen as a first-line drug for osteoporosis.
    
  
  

1) Calcium citrate or citrate malate is generally thought to be better absorbed and more effective than calcium carbonate. Although calcium carbonate is one of the least expensive forms of calcium and is the most common commercial calcium supplement, it can cause constipation and bloating, and it may not be well absorbed by people with reduced levels of stomach acid, such as many people over age 50(3). CitracalPlus with Magnesium and Vitamin D is recommended by many health care providers. The magnesium minimizes any constipation that may occur, although risk of magnesium toxicity increases in patients with kidney failure.

2) Tums (chewable calcium carbonate) is also recommended in those who are younger(3).

• Food intake affects absorption of each form of calcium differently:
  • Tums are best absorbed with food;
  • Citracal is best absorbed without food. Bedtime is frequently an ideal time to take Citracal as people most often have an empty stomach and bedtime dosing of calcium is also thought to help with sleep.
    
    
• Do not take more than 500 mg of calcium at a time. If more needs to be taken, spread out the doses during the day in divided doses.    Doses any larger than 500 mg will not be absorbed.  Additionally, foods labeled as containing 100% of the recommended dietary value of calcium should not be considered as the single source of a full day's supply of calcium.
   
• Take calcium supplements with Vitamin D Calcium works in concert with Vitamin D to form and maintain strong bones. Vitamin D also has other important functions such as helping maintain a healthy immune system and helping regulate cell growth and differentiation. Vitamin D is thought to be important in cancer prevention, yet a widespread vitamin D deficiency still exists in the United States.
  
  
• Calcium supplements can block the absorption of certain medications. If you are also taking tetracycline, fluoroquinolones (such as Cipro, etc) iron, levothyroxine (thyroid medicine), or any medication to be taken on an empty stomach, take the oral calcium supplement at a different time of the day. For instance, take the thyroid medicine at 6am, and then take the calcium tablet later in the day. (2)(5)   It is important to talk with your health care provider about possible interactions between prescription or over-the-counter medications and calcium supplements.
  
  
• Certain foods and medications can decrease the absorption of calcium: Corticosteroids and foods such as rhubarb, spinach, and bran can interfere with the absorption of calcium. Take the calcium at a different time of the day.
  
  
• Side effects of calcium: While some people tolerate supplements well, others have difficulty with side effects, such as gas or constipation. If this occurs, consult with your health care provider who may recommend you try one or more of the following:
  • Maintain a regular exercise regimen
  • Increase fruits, vegetables, and high fiber foods in your diet;
  • Drink two to four extra glasses of water a day;
  • Eat 1-3 prunes and/or bran cereal every morning followed by a warm drink;
  • Ask your health care provider about taking calcium supplements with magnesium added (i.e. Citracal Plus w/Magnesium) to minimize the constipation. Dietary magnesium does not pose a health risk in most people, although risk of magnesium toxicity increases in patients with kidney failure. Also, very large doses of magnesium-containing laxatives and antacids also have been associated with magnesium toxicity.
  • Take a regular preparation of a water-soluble fiber (methylcellulose) such as Citrucel.
  • If all else fails, take a mild over-the-counter stool softener (Colace) every day.