Frequently Asked Questions

Like many vitamins and minerals, vitamin K appears to play a role in your bone health. The recommended daily intake is 90 -120 micrograms (μg).There are two types of vitamin K: vitamin K1 and vitamin K2.
• Vitamin K1 sources include kale, brussels sprouts, spinach, mustard greens, turnip greens and vegetable oils.
• Vitamin K2 sources include egg yolks, organ meats and natto (a type of fermented soybean).

At this time, research does not support the practice of taking vitamin K supplements to prevent osteoporosis and broken bones. Taking a supplement doesn’t always have the same effects as eating whole foods that contain that same nutrient. Also, because vitamin K plays a role in blood clotting, getting too much vitamin K could cause problems in individuals who take blood thinning medicines or are at risk of blood clots. More research will help us to determine the amount and type of vitamin K that is necessary for bone health. Until we know more, try to get enough vitamin K from food sources.

Talk to your healthcare provider about any nutrition deficiencies you may have and discuss which supplements you should take for your bone health.

Taking more calcium than what you need is not beneficial and may even be harmful. When you take too much calcium from supplements, the excess calcium is excreted through your kidneys into your urine. In some people, this increases the risk of kidney stones. Some studies have also suggested a link between calcium supplements and heart disease; however, these findings are not conclusive. To play it safe, BHOF recommends trying to meet your daily calcium needs by eating calcium-rich foods. Only supplement the estimated amount you do not get through your diet.

Products that come from soybeans like soymilk and tofu naturally contain calcium. The amount of calcium in these foods varies and can be much lower than the calcium that is found in regular milk and other dairy products. However, many brands of soymilk are fortified with calcium. In many cases you can get about the same amount of calcium from a glass of calcium-fortified soymilk that you would from a glass of regular milk. The amount of calcium in tofu varies depending on the way the tofu is prepared. For example, ¼ block of firm tofu prepared with calcium sulfate provides about 160 milligrams of calcium. Remember, food labels list calcium as a percentage of the daily value (DV). This amount is based on 1,000 mg of calcium per day. You might see that an eight ounce (8 oz.) glass of fortified soymilk has 30% of the DV for calcium. This amount equals 300 mg of calcium.

There are many factors that can contribute to osteoporosis, one of which is not getting enough calcium. However, people who get enough calcium from foods and/or supplements can still be at risk of bone loss due to other reasons, such as having a family history of osteoporosis, not exercising, smoking, drinking too much alcohol, not getting enough vitamin D and having certain medical conditions or taking certain medicines that can cause bone loss. While getting the recommended amounts of calcium, vitamin D and exercise each day does not always prevent osteoporosis, these healthy lifestyle behaviors can help everyone have healthier bones.

While there is no agreed upon answer to this question, some would suggest trying the lactose-free milk which is naturally rich in calcium. Calcium-fortified soymilk tends to have about the same amount of calcium as regular milk; however, this is because calcium has been added to the beverage. If you are lactose-intolerant, you may think you should avoid all dairy products that aren’t labeled lactose-free. However, you may be surprised to learn that many people who consider themselves lactose-intolerant are able to consume certain dairy products without side effects. Most aged cheese, including cheddar, Colby and parmesan are naturally lactose-free. Many people who are sensitive to lactose can also tolerate yogurt with live cultures. These tips may help you to add more foods that are naturally rich in calcium back into your diet.

Daily Values (DV) are standardized measures developed by the U.S. Food and Drug Administration (FDA) to help people learn the amount of specific nutrients contained in foods. The DV also allows you to compare the nutrients in one food product to another.

The percent DV helps you determine whether a food is high or low in a nutrient. In general, 5% DV or less is low in a nutrient, while 20% DV or more is high. Daily Values are printed on the “Nutrition Facts” panel on food labels. The percent DV is based on one serving of food. Be sure to read the label carefully to learn the serving size and the number of servings.

The DV for calcium is based on 1,000 mg. This means a serving of milk with a Daily Value of 30% calcium has 300 mg of calcium.

In the case of vitamin D, the DV is based on 400 IU for adults. This means a food serving with a Daily Value of 25% vitamin D has 100 IU of vitamin D. There are few food sources for vitamin D. So, unless an item has been fortified with vitamin D, most food labels do not list the percent of the DV of vitamin D.

BHOF recommends that adults aged 50 and older get 1,200 mg of calcium every day, and adults under age 50 get 1,000 mg of calcium every day. Often, a balanced diet can include up to 250 mg of calcium from trace sources that are difficult to count, such as broccoli and certain green vegetables.

Getting enough vitamin D every day is important to help your body absorb calcium. Adults aged 50 and older need 800-1,000 IU of vitamin D every day, and adults under age 50 need 400-800 IU of vitamin D every day. Older individuals and those with osteoporosis may need more.

Vitamin D plays an important role in building and protecting bones by helping the body absorb calcium. The VITALS study, the largest and most comprehensive vitamin D study of its kind on a community population, reported in 2022 that vitamin D supplementation does not prevent fractures in healthy adults. It did not address whether people with osteoporosis or low bone mass should take supplemental vitamin D along with calcium and a prescribed medication to prevent further bone loss and fractures. Healthy adults with no vitamin D deficiency should be able to get adequate amounts of vitamin D by consuming a well-balanced diet.

People with osteoporosis and low bone mass should discuss their vitamin D levels with their healthcare provider to ensure they are getting an optimal amount.

Caffeine appears to decrease calcium absorption by a small amount. Drinking more than 3 cups of coffee every day may be harmful to bone health. If you enjoy drinking coffee and tea, you can help to make up for any calcium loss by getting enough calcium to meet your body’s needs.

Many of us enjoy the taste of a soft drink or soda. Others like the caffeine boost they get from drinking a cup of coffee or a cola. Certain soft drinks and sodas, especially colas, contain phosphorous in the form of phosphoric acid. These drinks may also have caffeine. Some people are concerned that the phosphoric acid and caffeine in soft drinks can harm bone health. Colas may have other chemicals, besides phosphoric acid and caffeine, that can affect the bones. People with osteoporosis should not drink more than five cola drinks a week.

Phosphorus: Phosphorous exists in the human body as phosphate and, like calcium, is a major part of bone. The phosphorus found in food is needed to build healthy bones and other tissues. Because phosphorus is in many foods, it’s rare for healthy people not to get enough.

Phosphorous in the form of phosphate or phosphoric acid is often added to processed foods and soft drinks. As a result, concern has been expressed that Americans may be getting too much phosphorous. Some studies suggest that too much phosphorous can reduce the amount of calcium that the body absorbs. However, there is no scientific agreement about whether the current level of phosphorus in the American diet is harmful to the bones. For people with normal kidney function, getting more phosphorus is believed to be safe as long as they get enough calcium.

Caffeine: Caffeine is found naturally in coffee and tea, and it is often added to soft drinks. Caffeine in high amounts can cause bone loss. It interferes with calcium absorption and causes a slight increase in the amount of calcium in the urine. One study suggests that drinking 330 mg of caffeine, or about4 cups of coffee every day, increases the risk of broken bones. If you enjoy drinks that have caffeine, you can make up for any calcium loss by getting enough calcium to meet your body’s needs. You can get calcium by eating calcium-rich foods and taking calcium supplements if you need them.

Be careful not to substitute caffeinated drinks for milk and calcium-fortified juices. When drinks that have caffeine take the place of milk and other sources of calcium, bone health may be affected. For coffee drinkers, the addition of milk can help make up for the loss of calcium caused by caffeine.

Carbonation: There is no connection between the carbonation in soft drinks and bone loss. In fact, certain carbonated mineral waters have been shown to improve bone health.

Summary: For bone health, it is best not to drink too many soft drinks or cups of coffee every day. To maintain bone health, BHOF recommends that adults under age 50 get 1,000 mg of calcium every day, and adults aged 50 and older get 1,200 mg of calcium every day.

Strontium is a mineral that is present in some foods. It is also available in certain dietary or nutritional supplements. Some supplement companies promote the benefits of this mineral but there isn’t enough research at this time to show that taking strontium is safe and beneficial to bone health.

The mineral forms of strontium are not the same as strontium ranelate, which is a drug sold in Europe and other countries to treat osteoporosis. Chemically, strontium ranelate consists of a combination of strontium and ranelic acid. Strontium ranelate is not available in the U.S. since it has not been approved by the U.S. Food and Drug Administration (FDA).

In summary, strontium is not a new drug or a new treatment for osteoporosis. It is a mineral that is available in dietary supplements. Strontium ranelate is a drug that is not FDA-approved for use in the U.S. It is important to note that a dietary supplement does not substitute for a medicine that has been approved by the FDA for the treatment of osteoporosis. Additionally, dietary supplements are not FDA regulated or tested like drugs, nor are their health claims approved by the FDA.

Many people prefer not to take drugs or medications because they want to treat their osteoporosis “naturally,” but at this time, there are no herbal supplements or “natural” treatments that are proven to be both safe and effective to treat osteoporosis and prevent broken bones. BHOF reviews the results of many research studies that look at the possible bone health benefits of certain vitamins, minerals, herbs and foods. Before supporting a claim about an alternative or natural treatment, BHOF must see scientific evidence and consistent study results proving the benefits.

It is also important to note that the U.S. Food and Drug Administration (FDA) is not able to approve health claims for dietary supplements. Manufacturers and distributors of dietary supplements and nutrients do not need approval by the FDA to sell their products. The FDA does not regulate or evaluate dietary supplements in the same rigorous way as prescription medicines.

The U.S. Pharmacopeia (USP) is an independent, scientific nonprofit organization focused on setting quality standards for the world’s medicines, dietary supplements and foods. Visit the USP Quality Supplements website to learn more about verified supplements and where to find them: https://www.quality-supplements.org/

The resources below offer additional information about alternative medicine and natural treatments:

National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health (NIH)
Phone: (888) 644-6226
Web site: https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-center-complementary-integrative-health-nccih

Academy of Nutrition and Dietetics
Offers information about diet, nutrition and a database of nutrition and dietetics practitioners
Phone: (800) 877-1600
Web site: www.eatright.org

Dietary Supplements Labels Database
Offers information about the ingredients in more than2,000 selected brands of dietary supplements
Web site: dsld.nlm.nih.gov/

National Institutes of Health (NIH)
Offers information on complementary and alternative therapies
Web site: www.nlm.nih.gov/medlineplus/complementaryandalternativetherapies.html

Office of Dietary Supplements (NIH)
Phone: (301) 435-2920
Web site: www.ods.od.nih.gov

Both weight-bearing and resistance exercises are important to bone health. Resistance exercises use muscular strength to improve muscle mass and strengthen bone. They are also called muscle-strengthening exercises. Depending on the muscle groups used, this type of exercise usually benefits the bones of the arms, legs and back. Increasing muscle strength can improve the quality of life of frail or elderly persons with osteoporosis by enabling them to perform daily activities more easily and can help them be more independent.

Muscle-strengthening / Resistance exercises include activities such as lifting your own body weight such as rising from a chair, performing certain yoga poses, tai chi or balance exercises. It also includes the use of free weights, wrist weights, weighted vests, exercise bands and weight machines found at gyms and health clubs. You can also do this type of exercise in your home without any special equipment, using your body as the resistance. For example, grasping the arms of a chair and using your arms and shoulders to gradually lift yourself up and lower yourself down is a resistance exercise. Wall and doorway pushes are other examples.

Lifting weights is probably the most familiar type of resistance exercise. With proper supervision and instruction, older adults can also lift weights and increase muscle strength while gaining bone benefits. Initially, the weights should be light, and you should pay close attention to using proper technique and posture to avoid placing too much stress on the spine. You can exercise each muscle group by doing the recommended exercises in repetitions with a brief rest of one to five minutes between each set of repetitions.

Weight-bearing exercises, include activities such as walking, dancing, jogging, and climbing stairs.

Weight-bearing exercises should be done almost every day for at least 30 minutes. Resistance or muscle-strengthening exercises, on the other hand, should only be done 2-3 times a week, with at least a day of rest in between to let the muscles recover and grow.

Staying as active as possible provides a benefit to your bones. Daily activities and most sports involve a combination of both resistance and weight-bearing exercises.

Note: Before beginning an exercise program, we recommend discussing guidelines for safety with your healthcare provider.

If you have osteoporosis, you should avoid any movements that require you to bend forward from the waist, such as doing a toe touch. When you bend forward from the waist, your shoulders and back become rounded. This is also known as spine flexion and can increase the risk of a spine fracture. Many movements that involve spine flexion can be modified by bending the knees and hinging at the hips. Gentle twisting motions should be safe for most people. If you have osteoporosis or are otherwise at risk of breaking bones in your spine, you should avoid twisting to a point of strain. Examples include a full golf swing or swinging a tennis racket. Ask your healthcare provider, who knows you best, what types of exercises and movements are safe for you.

Many people can improve their balance and reduce their risk of falling by repeating a few simple exercises every day. Here are two exercises that may help you:

Exercise 1. While standing and facing a countertop or the back of a sturdy chair, hold on and stand on one leg at a time for one minute. Switch sides and repeat.

Exercise 2. While standing and facing a countertop or the back of a sturdy chair, hold on and rock up onto your toes for a count of ten. Then roll back onto your heels for a count of ten. Repeat ten times.

Start each exercise at Level 1 below. When you can do it comfortably, move on to the next level.

• Level 1: Hold on with both hands during exercise
• Level 2: Hold on with one hand only
• Level 3: Hold on with one fingertip only
• Level 4: Keep both hands two inches above a countertop or back of a study chair
• Level 5: Close your eyes and keep both hands two inches above a countertop or back of a study chair

Always consult with your healthcare provider before starting an exercise program.

It has long been known that high-intensity resistance exercise and impact increases osteogenic loading and facilitates bone mineral density acquisition. Several of the manuscripts and abstracts shared by OsteoStrong® describe the effects of high-intensity resistance exercise using the bioDensity® equipment on force production, leg muscle strength, HbA1c diabetes marker and bone mineral density (BMD) outcomes in small uncontrolled studies of adults (sample sizes ranged from n=9 to n=21). The larger published studies they shared examined levels of impact loading on BMD outcomes in adolescents, assessed sex differences and learning effects in maximal force production and reported in an abstract that the underweight adults only were able to produce adequate force production for osteogenic loading. None of the studies were adequately powered randomized controlled trials investigating the effects of the OsteoStrong® exercise program on BMD outcome, and none compared the effectiveness of the bioDensity® program to a more generic, high-intensity resistance exercise program. The studies to date do provide preliminary data for this type of large effectiveness trials which are needed in order to change guidelines or make recommendations.

In summary, the scientific community has long known the benefits of high-intensity resistance and impact exercise on BMD. While the high-intensity bioDensity® exercise program may be beneficial for increasing BMD in adults, the evidence presented does not demonstrate efficacy of the OsteoStrong® program on BMD outcomes. Furthermore, we do not know how it compares to the benefits of the current BHOF recommendations for weight bearing and resistance exercise. Further research is warranted before the benefits of the OsteoStrong® program can be determined.

The evidence for using a weighted vest exercise program to improve bone mineral density or prevent skeletal fractures in women and men is uncertain. Larger studies of older adults with low bone density or osteoporosis over a longer follow up time are needed to determine whether weighted vest exercise will lead to beneficial outcomes.

A weighted vest may not be safe for those who have had spine fracture, spine surgery or have a high risk of breaking a bone. To prevent injury, before using a weighted vest consult with a healthcare professional or exercise specialist with expertise in osteoporosis to better understand if this may be a good option for you.

In addition to your family history, there are many factors that can increase your likelihood of developing osteoporosis. That’s why estimates suggest that about 1 in 2 women and up to 1 in 4 men will break a bone in their lifetime due to osteoporosis. You are at increased risk of developing osteoporosis if you are a postmenopausal woman with a small and thin build. As you age, your risk of osteoporosis and broken bones increases. Also, certain medical conditions or taking certain medicines may increase your chance of developing osteoporosis. To learn more about these medical conditions and medications visit What is Osteoporosis.

Having an underactive thyroid, a condition called hypothyroidism, does not increase your risk for bone loss and osteoporosis. Taking the amount of thyroid hormone medicine needed to replace what your body’s thyroid is not making does not hurt your bones. However, taking more thyroid hormone medicine than you need can cause bone loss. An excess of thyroid hormone is harmful to your bones. This can be caused by an overactive thyroid, a condition called hyperthyroidism. It can also be caused by taking too much thyroid hormone medicine as a replacement for an underactive thyroid.

When you take thyroid hormone medicine, your doctor or other healthcare provider will check your thyroid function with a blood test called a thyroid-stimulating hormone (TSH). If the results of the blood test show that you are taking too much or too little thyroid hormone, your doctor will adjust your dosage. Most doctors do a TSH lab test at least once a year for patients taking thyroid hormones.

During pregnancy, it is important that a woman get enough calcium for both herself and growing baby. Because of this important need for calcium, studies have been done to learn if pregnancy causes a woman to have a greater chance of having low bone density or osteoporosis. Most studies show that while some bone loss may occur during pregnancy, a woman usually regains it after giving birth.

According to research studies, women who have been pregnant more than one time have no lasting harm to their bones. These studies include women in the U.S. and other countries. One reason is that women absorb more calcium during pregnancy, especially in the second and third trimesters. This additional absorption of calcium helps to meet much of the developing baby’s calcium needs. Another change during pregnancy that may protect bones is an estrogen surge during the third trimester

In fact, studies show that having children, even as many as 10, does not increase a woman’s chance of getting osteoporosis later in life. Research even suggests that each additional pregnancy provides some protection from osteoporosis and broken bones. Women who have never been pregnant might actually be at higher risk for bone loss and osteoporosis compared to women who have given birth according to some findings.

For women who had pregnancies in their teens, the effects on bone health later in life are still not certain. Teens have not yet reached peak bone mass. This is the point at which they have the greatest amount of bone they will ever have. Additional studies are needed to find out if teen pregnancies can affect future bone health.

Breastfeeding for the recommended 6-12 months has great health benefits for both mother and baby. Breastfeeding even longer does not appear to have lasting influence on bone health.

All women who are pregnant or nursing need to get enough calcium, vitamin D and appropriate exercise to keep their bones healthy. Pregnant or breastfeeding women aged 19 years and older need 1,000 mg of calcium and 400-800 IU of vitamin D every day. Pregnant or breastfeeding teens age 18 years and younger need 1,300 mg of calcium and 400-800 IU of vitamin D every day.

Several studies have shown a connection between certain acid suppression medicines and an increased chance of breaking a hip. The medicines in this study are in a class of drugs called proton pump inhibitors (PPI). They include Nexium®, Prevacid® and Prilosec®. PPI medicines are used very commonly to treat conditions such as heartburn and acid reflux disease.

The link between the PPI medicines and the risk of a broken hip appears to be a problem only for people on fairly high doses, equal to 40 mg or more a day, for a long period of time. People who use over the counter or even prescription doses once in a while should not be concerned.

Talk to your doctor first before stopping your medicine. Many people take these medicines for serious medical conditions. These medicines are important for people with major health problems, but they are not for everyone. Patients should be prescribed the lowest effective dose available to treat their condition(s). People concerned about taking these medicines should speak with their doctor or other healthcare provider about whether they need to continue using the medicines.

Ask your healthcare provider if you need a bone mineral density test, also known as a DXA scan. Long-term use of PPI medicines may increase your chance of getting osteoporosis and having broken bones. If you are on high doses of these medicines for a long time, speak with your healthcare provider about whether you should have a bone density test.

Your calcium needs and PPIs. To keep their bones healthy, adults need to have a balanced diet. This includes eating a variety of fruits, vegetables and calcium-rich foods. It is especially important for people taking PPI medicines to get at least 1,200 mg of calcium every day. While some people on these medicines may need a bit more calcium, they should not get more than 1,500 mg a day.

Calcium Supplements. If you don’t get enough calcium from food, you need to take calcium supplements to get the rest of the calcium that you need. If you are taking PPI medicines, you may want to take calcium citrate supplements rather than other calcium supplements. Because these medicines block stomach acid, your body may absorb calcium citrate better than other types of calcium supplements. Unlike other calcium supplements, calcium citrate does not need stomach acid to be absorbed.

If you take another type of calcium supplement, like calcium carbonate, be sure to take it with a meal or snack. Your body makes stomach acid when you eat. Most calcium supplements need stomach acid to dissolve and for calcium to be absorbed.

Vitamin D. Like calcium, vitamin D is also important for your bone health. It helps your body absorb calcium. People under age 50 need between 400 and 800 international units (IU) of vitamin D every day. People aged 50 and older need between 800 and 1,000 IU of vitamin D every day. Some people may need even more. Getting regular weight-bearing and muscle-strengthening exercise helps keep your bones strong and healthy. Drinking too much alcohol and smoking is harmful to your bones.

Abstract of the PPI Study reported in JAMA.

View the abstract of the study reported in JAMA.

Depo-Provera® has been available for many years as a contraceptive injection given every three months. It provides a convenient birth control choice for many women. In 2004, the U.S. Food and Drug Administration (FDA) issued a warning that the use of Depo-Provera® may cause a loss of bone density. Bone loss is greater the longer a woman has used Depo-Provera®, and it may not be completely reversible.

In the case of teen girls and young women, it is not known if Depo-Provera® will reduce peak bone mass or increase the risk of osteoporosis and broken bones later in life. Peak bone mass is the point when a person has the greatest amount of bone she or he will ever have. A study funded by the National Institutes of Health (NIH) found that bone density appears to recover in teen girls after they stop using Depo-Provera®. The results of this study were published in 2005. Other studies have had similar findings, but the effects on bones might be different in women who use Depo-Provera® for a long time, especially five or more years.

Because of concerns about its effect on bones, the FDA has advised that Depo-Provera® should not be used longer than 2 years if other forms of birth control are available and appropriate.

You may wonder when you should have a bone density test, also known as a DXA scan. That depends on your risk factors for osteoporosis. There are no guidelines suggesting routine bone density testing of premenopausal women. Bone density tests are usually only recommended for premenopausal women if they break several bones easily or break bones that are unusual for this age group. For example, breaking a hip or breaking a bone in the spine is unusual. Health care providers may also recommend a bone density test for young premenopausal women who need to take a glucocorticoid (steroid) medicine.

Young women with a major family history of osteoporosis or with other risk factors for osteoporosis may want to choose a different form of contraception.

Because of your past use of Depo-Provera®, bone healthy behaviors are especially important. Be sure to get your calcium and vitamin D every day and exercise regularly. If you smoke, give it up, and don’t drink too much alcohol.

This is an important question because the National Cancer Institute estimates that 1 in 8 women in our country will develop breast cancer during her lifetime.

Anastrozole (Arimidex®) is in a class of drugs called aromatase inhibitors (AIs). Two other drugs in this class are exemestane (Aromasin®) and letrozole (Femara®). They are used to treat breast cancer and prevent its return in postmenopausal women.

While AIs are very effective treatments for breast cancer, drugs in this class can cause bone loss and an increased chance of breaking a bone. When women have estrogen sensitive-breast tumors, estrogen can cause the cancer to grow and spread. AIs help women with this type of cancer by reducing the estrogen levels in the body. Even though a postmenopausal woman already has low levels of estrogen, it is this additional decrease in estrogen that can cause bone loss.

AIs are different from other hormone related medicines used to treat breast cancer, such as tamoxifen. For example, tamoxifen does not cause bone loss in postmenopausal women, although it can cause bone loss in premenopausal women.

Before starting cancer treatment. Some healthcare providers recommend that women have a bone density test, also known as a DXA scan, of the hip and spine before they start cancer treatment. The results of this test can serve as a baseline. When a bone density test is repeated in the future, it can be compared to the results of the baseline test to find out if any bone density has been lost. Women who have low bone density or osteoporosis should consider taking an osteoporosis medicine, such as a bisphosphonate, when starting treatment with an aromatase inhibitor. Women who develop low bone density or osteoporosis while taking an aromatase inhibitor should also consider starting an osteoporosis medicine. Osteoporosis medicines help prevent further bone loss and reduce the risk of breaking a bone.

Other tests that may be useful are blood and urine tests that show changes in bone turnover. These tests are sometimes called bone turnover marker tests or biochemical marker tests. The results of some of these tests, such as serum bone alkaline phosphatase or urine N-telopeptide, might increase during cancer treatment. This could be a sign that bone loss will occur and can suggest the need for an osteoporosis medicine.

Risk factors you can control. Other steps you can take to protect your bones during cancer treatment include having a balanced diet with fruits and vegetables and getting enough calcium and vitamin D. Adults under age 50 need 1,000 mg of calcium and 400 – 800 IU of vitamin D every day. Adults aged 50 and older need 1,200 mg of calcium and 800 – 1,000 IU of vitamin D every day.

Both weight-bearing exercises and muscle-strengthening exercises can benefit your bones. Examples of weight-bearing exercises are walking, dancing, jogging, climbing stairs and playing tennis. Examples of muscle-strengthening exercises are lifting weights or using elastic exercise resistance bands. Inactivity and lack of exercise contribute to bone loss. Smoking and drinking too much alcohol are also bad for your bones. Avoid smoking, limit alcohol intake to 2-3 drinks per day, and limit caffeinated beverages to 2 per day.

Remember that if you have low bone density, your bones will break more easily. Older people especially should be aware of ways to prevent falls.

Male sex hormones, also called androgens, can cause prostate cancer to grow and spread. Because of this, androgen deprivation therapy (ADT) is one of the treatment options for prostate cancer. Some people call the treatment androgen suppression therapy or hormone suppression therapy. ADT lowers the amount of androgen hormones in the body. Studies show that men on this type of treatment for prostate cancer have an increased risk for bone loss and broken bones.

To maintain bone health during prostate cancer treatment, it is important to get enough calcium and vitamin D every day* and to exercise regularly. You should do weight-bearing exercises, like walking, jogging, climbing stairs or playing tennis and muscle-strengthening activities, like lifting weights or using elastic resistance exercise bands. Avoid smoking, limit alcohol intake to 2-3 drinks per day, and limit caffeinated beverages to 2 per day, since smoking and alcohol greatly increase the risk of bone loss for men undergoing ADT.

Have your bone density tested (also known as a DXA scan) before starting ADT to serve as a baseline. When your bone density test is repeated after you’ve been on ADT, the results can be compared to your baseline test to see if you’ve lost bone density.

If your bone density is already low on the baseline test, it’s helpful to start taking an osteoporosis medicine at the same time as starting ADT. Men usually take either alendronate (Fosamax®), risedronate (Actonel®) or zoledronic acid (Reclast®), which are all in a class of drugs known as bisphosphonates. Research shows that men taking an osteoporosis medicine while receiving treatment for prostate cancer are able to maintain or even increase bone density and reduce their risk of breaking a bone.

If you have already been treated with ADT and have not had a bone density test, talk to your healthcare provider and request a test. It’s never too late to take action to protect your bone health.

*Men aged 70 and younger need 1,000 mg of calcium and men aged 70 and older need 1,200 mg of calcium every day. Men under age 50 need 400 – 800 IU of vitamin D and men aged 50 and older need 800 – 1,000 IU of vitamin D every day. Some people may need even more vitamin D. A blood test of 25-hydroxy vitamin D is an easy way to make sure you are getting enough vitamin D.

Weight loss can increase the risk of bone loss and osteoporosis. Because of concerns about heart disease, diabetes and other medical problems linked to obesity and excess weight, people are generally urged to lose the extra pounds. The benefits of weight loss usually are greater than the risks. Fortunately, there are steps you can take to protect your bones while losing weight.

• Exercise regularly. Include both weight-bearing and muscle-strengthening exercises to help support your bone health. For people trying to lose weight, it is best to lose weight gradually and to exercise regularly as part of a weight loss program. Exercise not only helps you lose weight, but it helps maintain bone density too.

• Be sure to eat a balanced diet. A balanced diet that includes a variety of fruits, vegetables and calcium-rich foods will help you meet your nutritional needs. It is especially important to get enough calcium and vitamin D. While protein is important for health, a very high protein diet causes an additional loss of calcium through the kidneys. Getting an adequate amount of calcium will offset these losses.

• Avoid smoking and drinking too much alcohol. Remember that both smoking and drinking too much alcohol are harmful to the bones. To keep your bones healthy, don’t drink more than 2-3 alcoholic drinks a day. Also, inactivity and a sedentary lifestyle can cause bone loss.

• Find out which weight loss program is right for you. Talk to your doctor or other healthcare provider before you start to diet. Ask for guidance on a weight loss diet that is appropriate for you.

• Set a realistic target weight. People with low body weight are at greater risk for osteoporosis, so aim for a moderate goal. In older women and men, some studies have shown that a weight loss of 10 percent or more also places them at greater risk for breaking a hip.

• Ask if you need a bone density test. Talk to your healthcare provider about whether a bone density test should be done before you start and/or during your weight loss program. It will help you find out if an osteoporosis medication should be considered to support bone health during and/or after your diet.

Osteonecrosis of the jaw (ONJ) is a rare disorder that has been associated with the use of bisphosphonate medications, including alendronate (Fosamax®), ibandronate (Boniva®), risedronate (Actonel®, Atelvia®) and zoledronic acid (Reclast®). The overwhelming majority of patients who develop ONJ include cancer patients who have taken repeated high dosages of intravenous (IV) bisphosphonates.

At this time, there are no tests that are proven to predict ONJ. We encourage individuals to talk to their healthcare provider and dentist or oral surgeon about their risk of developing this condition. Regular dental visits and excellent oral hygiene practices may be the best way to reduce your chance of developing ONJ.

There is no one drug that is “best” for perimenopausal bone loss. The right drug for each person depends on multiple factors unique to each individual. In addition to age and menopausal status, healthcare providers should take into consideration a patient’s bone density, family history, personal preferences and other factors that influence an individual’s risk of breaking a bone. It’s also important to consider each individual’s risk of having certain side effects with specific treatments. Finally, healthcare providers should also look at a patient’s risk of breaking a bone in the next 10 years according to the Fracture Risk Assessment Tool known as FRAX® tool. FRAX® can help to decide whether an osteoporosis medicine is necessary during the perimenopausal years. There are many things to think about when choosing the right osteoporosis medicine. Visit our Medications and Treatment Adherence page for further details about which medications are appropriate for women.

Bisphosphonate medicines help to slow the breakdown of bone. When you start taking these medicines, you stop breaking down bone as quickly as you did before, but you still make new bone at a normal rate. For some people, these medicines lead to an increase in bone density. For others, these medicines help individuals maintain bone density and prevent further bone loss. Each person responds differently, but, by preventing further decreases in bone density, these medicines reduce the likelihood of broken bones.

Bisphosphonates have been shown in clinical trials to reduce the risk of broken bones in individuals with osteoporosis. In the majority of patients, bisphosphonate medicines help prevent hip fractures. However, over the past several years, there have been reports from healthcare practitioners about an unusual type of broken bone in the upper part of the femur, located below the hip. While this type of fracture is very uncommon, many of these patients were taking bisphosphonate medicines for 5 years or longer. Some patients reported that they had pain in the thigh and groin area prior to the breaking of the thigh bone, which could have been present for weeks or many months. The pain might be a clue to the existence of a partial fracture called a stress fracture, which does not fully heal.

For people with osteoporosis who take bisphosphonate medicines, unusual fractures of the thigh bone are uncommon, unlike fractures of the hip, spine and wrist. BHOF is closely evaluating ongoing research in this area so that we can learn more about these fractures. This will help us to better understand the potential relationship between unusual thigh fractures and bisphosphonate medicines. BHOF believes the benefits of bisphosphonate treatment in patients at high risk of osteoporotic fracture strongly outweigh the risks from treatment for most individuals. As with all medicines, the risks and benefits of treatment must be carefully considered. All decisions related to treatment should be made under the guidance of each person’s healthcare provider.

Although Reclast® is given intravenously (by IV) once a year, most of the medicine is absorbed by your bones, and the rest leaves your body in about 24 hours. So, it affects mostly bone, which is what you want.

Reclast® belongs to a class of drugs called bisphosphonates. In general, its side effects aren’t any more serious than those of the bisphosphonate medicines that are taken as pills to treat osteoporosis. These other medicines are Actonel® (risedronate), Boniva® (ibandronate) and Fosamax® (alendronate).

Side effects that are different from those seen with the bisphosphonate pills can occur shortly after receiving Reclast®, usually within one or two days. These side effects include flu-like symptoms, fever, headache and pain in muscles or joints. They are temporary and usually last only 2 or 3 days. You are less likely to have them the next time you have an IV infusion of Reclast®. Also, the side effects you may experience after taking IV Boniva® are similar. Most people who have taken bisphosphonate pills in the past do not have these side effects when they receive the IV Reclast® medicine.

Rare side effects, such as severe bone, muscle or joint pain and osteonecrosis of the jaw (ONJ), are not any different from those of the other bisphosphonate medicines. Because Reclast® is given directly into the bloodstream, it does not cause any stomach or throat irritation.

A healthcare provider gives Reclast® as an IV dose of 5 mg in a doctor’s office or other outpatient setting. It takes at least 15 minutes for the yearly infusion. Patients need to have two blood tests before each IV dose: one is a test for creatinine to check the kidneys, and the other is a test to check blood calcium levels.

As you would with any medicine, it’s important to tell your healthcare provider if you think you are having a side effect. People can have unexpected side effects with any medicine.

For Reclast® to work, you need to get enough calcium and vitamin D and to exercise regularly. BHOF recommends that adults under age 50 get 1,000 mg of calcium and 400-800 IU of vitamin D every day. Adults aged 50 and older need 1,200 mg of calcium and 800-1,000 IU of vitamin D every day.

Two studies on alendronate (brand name Fosamax®) suggested a connection between alendronate and atrial fibrillation(1, 2). (Atrial fibrillation is a serious type of irregular heartbeat.) However, a number of other studies did not find a connection, including a much larger Danish study(3) and other major research studies done in the past on many more thousands of women.

In 2007, the results of a major research study(4) suggested an increased possibility of atrial fibrillation in a small number of postmenopausal women given zoledronic acid (brand name Reclast®). The study’s findings were not conclusive and after reviewing the research results, the Food and Drug Administration (FDA) approved zoledronic acid to treat osteoporosis in postmenopausal women. A second study(5) of this same medicine in older people with more medical problems did not show any increase in atrial fibrillation.

Atrial fibrillation is more commonly found in people 65 years and older, which is the age range of many women in these studies. Both alendronate and zoledronic acid are in a class of drugs called bisphosphonates. To-date, the FDA has approved bisphosphonate medications to treat osteoporosis.

Due to concerns about atrial fibrillation, the FDA began a safety review of bisphosphonates in 2007. Until more information becomes available, the FDA says there is no need to stop using bisphosphonates. Based on what is currently known, most experts agree that the benefits of taking these medications for osteoporosis outweigh the possible risk of atrial fibrillation.

BHOF encourages you to discuss concerns about possible side effects from a medication with your healthcare provider. Let your healthcare provider know if you have any heart problems or other health conditions. People taking an osteoporosis medication should review and discuss their treatment plan each year with their healthcare provider.

Always report any possible medication side effects to your healthcare provider and the FDA. The toll-free number for the FDA is (800) 332-1088. To complete a report online on MedWatch, the FDA’s medical product safety reporting program for health professionals, patients and consumers, go to: https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program

For additional information about the FDA’s ongoing safety review of bisphosphonates, visit the FDA Web site at https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-safety-update-osteoporosis-drugs-bisphosphonates-and-atypical.

Studies Mentioned Above:

1. In a letter to the editor, a review of the FIT study results was published in the New England Journal of Medicine, May 3, 2007. The name of the article is “Alendronate and Atrial Fibrillation.”

2. This study was published in the Archives of Internal Medicine April 28, 2008. The name of the article is “Use of Alendronate and Risk of Incident Atrial Fibrillation in Women.”

3. This study was published in the British Medical Journal April 12, 2008. The name of the article is “Use of Bisphosphonates Among Women and Risk of Atrial Fibrillation and Flutter: Population Based Case-Control Study.” It is available for free at www.bmj.com.

4. The HORIZON study was published in the New England Journal of Medicine, May 3, 2007. The name of the article is “Once-Yearly Zoledronic Acid for Treatment of Postmenopausal Osteoporosis.” It is available for free at www.nejm.com

5. The HORIZON Recurrent Fracture Trial was published in the New England Journal of Medicine, November 1, 2007. The name of the article is “Zoledronic Acid and Clinical Fractures and Mortality after Hip Fracture.”

Note: This article was published in The Osteoporosis Report, Fall 2008.

Most healthcare providers check a Bone Density Test (DXA scan) periodically to assess how a medication has impacted bone density at the spine and hip. When comparing an earlier DXA scan with a more recent scan, it is important to ask whether or not the comparisons are accurate, exactly what the test results showed and what it means.

For some people, medicines lead to an increase in bone density. For others, these medicines help individuals maintain bone density and prevent further bone loss. Each person responds differently, but by preventing decreases in bone density, these medicines reduce the likelihood of broken bones.

Sometimes if the bone density does not show the expected changes over a reasonable period of time on treatment (which varies depending on the formulation, dose and prior treatments) , measuring the biochemical markers of bone turnover through lab tests can be helpful to see if there are the changes one would expect. Sometimes new or newly mineralized bone may not show up on a bone density scan.

Whenever one does not have an expected response to an osteoporosis medication, it’s important to assess any changes in an individual’s health history, such as a new medical condition or new medication. It may indicate a need to be re-evaluated for underlying causes of osteoporosis and assessment of calcium and vitamin D intake.

To be effective, osteoporosis medication must be taken as prescribed. It is also important to have adequate blood levels of calcium and vitamin D for the medicine to work optimally and to perform weight bearing exercise. If you decide that a particular treatment is not right for you, discuss your concerns with your healthcare provider before stopping or interrupting treatment to make sure you do not experience rapid bone loss contributing to fractures.

Following discontinuation (stopping) of Prolia, fracture risk increases, including fractures in the spine. Prior spine (vertebral) fracture is a predictor of multiple spine fractures after Prolia discontinuation. One should not stop, skip, or delay taking Prolia without talking to their doctor or health care professional. If Prolia treatment is stopped, one should switch to another antiresorptive osteoporosis medication. Please visit https://www.prolia.com/possible-side-effects for additional information.

To check a person’s bone density, experts recommend using a DXA machine. DXA stands for dual energy x-ray absorptiometry. A central DXA test of the hip and/or spine is the preferred method to diagnose osteoporosis.

There are weight and height restrictions for most central DXA scan machines.

Weight restrictions. Most central DXA machines cannot measure bone density in people who weigh over 300 pounds, and some central DXA machines have a weight limit of 250 pounds. Although new central DXA machines have recently been introduced that measure BMD in people who weigh up to 400 pounds, they are not widely available yet.

Height restrictions. In addition, for most DXA devices, the height limit is 78 inches (6 feet. 6 inches or 1.98 meters) for the scanning area.

Peripheral Bone Density Tests. For people who cannot have a bone density test by a central DXA machine, there are several other ways to measure bone density. These are called peripheral bone density tests. These tests measure bone density in the extremities, including the heel, wrist, finger or forearm (between the wrist and elbow). A peripheral test can be used with a person who is too heavy for a central DXA test of the hip and/or spine. Some healthcare providers recommend having both a peripheral DXA test of the radius bone of the forearm and a peripheral test of the heel or another bone. Doing both of these tests might give more complete information.

Botha DXA and peripheral bone density test are non-invasive. This means there are no needles or instruments placed through the skin or in the body. They usually take only a few minutes, and the patient remains fully dressed for the test.

People having a peripheral test should be aware that there are some limitations with this type of test. Comparisons between a peripheral test and a DXA test of the hip and/or spine may not be reliable. Bone density in the hip and spine are important because they are the bones most likely to break due to osteoporosis. These types of broken bones are the most serious.

Peripheral tests are suitable for screening and predicting the risk of breaking a bone, but experts prefer the DXA test for diagnosing osteoporosis and monitoring treatment in patients with osteoporosis.

Finding out the reason for her broken hip is a good first step. Your mother is likely to have osteoporosis. If she has never had a bone density test, also known as a DXA scan, it is important that she have one. This is the only way to diagnose osteoporosis. If she has osteoporosis, she needs to talk with her healthcare provider about taking an osteoporosis medication that is right for her. Taking an osteoporosis medicine can help reduce her chance of having another broken bone and prevent bone loss.

One medicine has been specifically tested in patients who have recently broken a hip. This medicine is zoledronic acid (Reclast®). It can reduce the risk of more broken bones and even extend the life of women and men who have broken a hip due to osteoporosis.

Your mother also needs to get 1,200 mg of calcium and 800-1,000 IU of vitamin D every day. Getting enough calcium and vitamin D are important to help keep her bones strong and healthy. Vitamin D not only helps absorb calcium, but it also plays a role in muscle strength and balance and may help reduce the risk of falling.

If your mother needs to take an osteoporosis medication, it’s still important that she gets enough calcium and vitamin D every day. Many older patients are at high risk for not getting enough vitamin D. There is a possibility she might need more vitamin D than the recommended amount above. One way to find out is with a simple blood test of her 25-hydroxy vitamin D level. It is also important for her not to smoke or drink too much alcohol. Smoking and having three or more alcoholic drinks a day are not good for people’s bones.

Rehabilitation and a slow return to exercise are important after breaking a bone, especially a hip bone. At first, walking may be difficult. For this reason, many patients are transferred from a hospital to a rehabilitation facility. A good rehabilitation center has staff specially trained to help your mother become stronger and more active every day. She may start out using a walker to move herself a few steps, but slowly her balance and strength will improve. Then she will likely use a cane for a while. Sometimes this is not easy, as she may have some pain, discomfort and feel tired. She may need to continue physical therapy once she returns home, and that too is important for her recovery.

Before your mother returns home, you may wish to check her home to make sure it is fall-proof. A few basic home safety tips include:

• Remove all clutter from the floors including loose throw rugs, long electrical cords and phone cords.
• Install grab bars on bathroom walls beside tubs, showers and toilets.
• Use 100-watt bulbs in place of low-level lighting.
• Add night lights in the bedroom, hall and bathroom.
• Make sure your mother wears supportive, low-heeled shoes even at home. She should not walk around in socks, stockings or scuffs. And she should not wear backless shoes or slippers.
• Consider subscribing to an at-home monitoring service.
• Use a portable phone in the home. It’s easy to take from room to room, it prevents rushing for the phone when it rings, and it’s handy if there’s a need to call for help.
• Review all medications with her doctor as some can cause dizziness and increase the chance of falling.

Have your mother talk to her doctor about seeing a physical therapist to check her balance. Balance problems can cause a person to fall. Certain exercises help many people improve their balance. A physical therapist can teach her these exercises. Physical therapy can have many other benefits including improved muscle strength and posture.

Stiffness and pain in the legs or knees are most commonly associated with osteoarthritis and are rarely caused by osteoporosis. Back pain, however, may be due to osteoporosis or other conditions such as osteoarthritis or degenerative disc disease. It is possible to have osteoporosis and osteoarthritis as well as other conditions at the same time.

Osteoporosis is called a “silent disease” because there are generally no symptoms or pain until you break a bone. For the pain you are having, we encourage you to speak with your doctor or other healthcare provider to determine the cause and to help you find relief from your pain.

When a person with osteoporosis in the spine has back pain, this may be caused by a broken bone in the spine. When you have osteoporosis and are having back pain, you should see a healthcare provider to find out if you have broken a bone in the spine. A lateral x-ray of the spine or a vertebral fracture assessment (VFA) can be used to look for broken bones in the spine.

For people with osteoporosis in the spine, it is important to protect the spine from broken bones by moving properly during exercise and daily activities. For example, do not bend over from the waist and avoid twisting motions of the trunk. Also, don’t carry packages that are too heavy or reach for objects on a high shelf.