Get in the Bone Zone: Put Bone Health on Your Prevention Radar
November 2022 Issue — Paisley Prescriptions
Get in the Bone Zone: Put Bone Health on Your Prevention Radar
Jay W. Floyd, MD
Southeast Georgia Physician Associates-Primary Care
Maintaining good health for your bones is recommended at every age. Moderate exercise and vitamin-rich nutrition can help keep your skeleton in tip-top condition. However, aging bones can weaken and, in severe cases, become brittle. Bone health is usually not thought about until there’s a problem. That’s why it’s time to put your bones on your prevention radar to help reduce your risk of breaking a bone, maintaining good posture and reducing aches and pains. We asked Dr. Jay W. Floyd to get us started on taking care of our bones and share his knowledge about bone health with us. Read on to learn more.
Are there ways to keep osteoporosis from worsening?
Yes, there are a variety of ways to prevent osteoporosis from worsening, including lifestyle measures, such as adequate calcium and vitamin D intake, smoking cessation, moderation of alcohol intake and regular weight-bearing exercise. Also, taking prescription medication to treat diagnosed osteoporosis will prevent worsening and may improve overall bone health. Some prescription medication also may prevent progression of osteopenia (early bone loss) to osteoporosis.
How can I prevent fractures?
Preventing fractures is very similar to the osteoporosis prevention methods listed above. In addition, preventing falls is very beneficial. Fall prevention may require a multi-disciplinary approach that may include the primary care doctor and specialists, physical therapist, and home health nursing to assess for fall risk factors in the home.
Can medications taken for other illnesses cause bone loss?
Yes, perhaps the most common medicines associated with bone loss include oral or parenteral corticosteroids (i.e., prednisone) and injected depo-medroxyprogesterone acetate (i.e.,DMPA, depo-Provera) contraception. Other medications include anticonvulsants, chemotherapy agents, lithium, heparin, and possibly proton pump inhibitors (such as omeprazole, Prilosec), SSRI antidepressants (such as Prozac or Paxil), and thiazolidenediones (such as pioglitazone, Actos) used to treat diabetes.
How frequently should I have a bone density test? What does my T-score mean?
The T-score is derived from the diagnostic test used to identify osteoporosis, the Dual Energy X-ray Absorptiometry, or DEXA. (This test is commonly referred to by laypersons as a "bone scan," but that is not a correct name for this test. A better common name would be "bone density test.") The T-score is a measurement of bone mass, reported as related to a standardized 25-year-old female. The more negative the score, the lower the bone density or bone mass. Osteoporosis is diagnosed at a T-score of -2.5 or lower. Osteopenia is diagnosed at a T-score between -1.0 and -2.4. These criteria derive from the World Health Organization (WHO), are widely accepted and used in most DEXA reporting, and apply only to women and men aged 50 and older.
There is little agreement among recommending agencies on frequency of DEXA testing. Commonly used recommendations are from the National Osteoporosis Foundation (NOF), which recommends testing all women at age 65 and all men at age 70. Testing at an earlier age may be indicated based upon individual risk. The decision on repeat testing would be between the patient and his or her provider.
Prevention: How much calcium and vitamin D do I need every day, and how can I get enough of these nutrients?
Adequate calcium intake over a person’s lifespan is necessary, both to acquire normal bone mass and to maintain bone density. It is preferred to obtain calcium from food sources, such as dairy products, fortified foods and oily fish (for vegans—dark green leafy vegetables, tofu and soy products). However, a supplement may be necessary if the diet is deficient in these foods. The National Academy of Medicine (NAM) recommendation for men 50-70 years is 1,000 mg/day, while women older than 50 and men older than 70 is 1,200 mg/day.
Vitamin D is required, among other things, to allow proper and efficient calcium absorption in the intestine. Most recommending agencies agree that a Vitamin D supplement is required in persons with osteoporosis. A lacking dietary intake and deficiency states are common in many adults of all races and ethnicities. The diagnosis of osteoporosis clearly indicates a need for boosting Vitamin D levels. Talk with your health care provider to determine what treatment option works best for you.
Prevention: How much exercise do I need to boost bone strength, and which exercises do you recommend?
In general, strive for 150 minutes per week of moderate intensity aerobic exercise (such as brisk walking) and two to three days per week of weight or resistance training. The combination of both aerobic and weight training provides the best outcomes, both for bone health and fall prevention, and for many other diseases. People with diagnosed osteoporosis may wish to work with a physical therapist or a certified personal trainer with experience dealing with osteoporosis to customize an appropriate individualized exercise plan.
Prevention: What osteoporosis medications are available that prevent bone loss?
The purpose of using prescription medication to treat osteoporosis is not only to improve bone density and perhaps improve subsequent DEXA scores, but more importantly, to prevent bone fracture. Perhaps the most commonly used class of medication is the bis-phoshponates, including alendronate (Fosamax) and risedronate (Actonel) among others. Injected therapies include the parathyroid hormone analogues, teriperatide (Forteo) and abaloperatide (Tymlos), and the RANK-ligand inhibitor denosumab (Prolia) and sclerotin inhibitor romosozumab (Evenity). The oral selective estrogen receptor modulator (SERM) raloxifene (Evista) and calcitonin agonist calcitonin-salmon (Miacalcin) nose spray also may be indicated in select patients. With such a variety of effective prescription options for treatment, the decision must be weighed carefully between the patient and his or her provider.
Prevention: Is hormone replacement therapy (HRT) safe for preventing osteoporosis?
It has long been recognized that post-menopausal estrogen therapy can both prevent and possibly treat osteoporosis. After the publication of a large, randomized controlled trial on post-menopausal HRT, the Women's Health Initiative (WHI), revealed an increased risk of breast cancer and adverse cardiovascular events, such as heart attack and stroke, in certain (but not all) HRT recipients and the use of HRT for management of osteoporosis fell out of favor. However, it probably still has a role to play in select patients. Current guidelines by the North American Menopause Society support (but the American College of Physicians recommends against) the use of HRT solely for the purpose of osteoporosis management; however, if a woman is starting HRT for the treatment of symptomatic menopausal syndrome, she may rest assured that her bone health is being improved during the time she is taking HRT. The pros and cons of post-menopausal HRT should be carefully considered between the patient and her provider when initiating treatment.
Prevention: What are some other lifestyle changes I should make now to keep my bones strong?
• Quit smoking.
• Reduce alcohol intake to no more than one drink per day for women and two per day for men. Avoid binge drinking (greater than five drinks in one sitting). Total abstinence from alcohol use will provide other health benefits, such as reduction in various cancers and liver disease.
• Reduce caffeine intake to less than two and a half cups of coffee or five cups of tea per day.
Dr. Jay W. Floyd, MD practices
Family Medicine and Primary Care
for Adults at Southeast Georgia
Physician Associates-Primary Care,
3222 Shrine Road, Brunswick.