Prevention of Osteoporosis

Genetic factors play a significant role in determining whether an individual is at increased risk of osteoporosis. However, lifestyle factors such as diet and physical activity also influence bone development in youth and the rate of bone loss later in life.

Advice for adults:

Ensuring a well-balanced diet and adequate calcium intake
Avoiding under-nutrition, particularly the effects of severe weight-loss diets and eating disorders
Maintaining an adequate supply of vitamin D
Participating in regular weight-bearing activity
Avoiding smoking and second-hand smoking
Avoiding heavy and regular drinking

Advice for elderly:

Ensuring an adequate intake most importantly of protein, calcium and vitamin D

Calcium supplements can be given to the elderly when dietary is insufficient to meet the recommended intakes.

It is advisable for the elderly in care to be routinely prescribed a calcium and vitamin D supplement to reduce the incidence of fracture.

Participating regularly in exercise activities

Regardless of age, bones and muscles need exercise to retain strength so a special exercise program tailored to the very elderly who are institutionalized is very important. Improved balance, posture, coordination and muscle strength are the benefits that result from sustained weight-bearing exercise.

Preventing falls

When osteoporosis is present, even minor trauma such as coughing, minor knocks or falls can lead to fractures. Older people have slower response times and more often fall to the side, suffering direct impacts to the hip.

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Preventing osteoporosis – summary of modifiable factors

Preventing osteoporosis – summary of modifiable factors
Activity	Rationale/practice tips
Smoking cessation	Associated with higher rates of fragility fracture but interventions not shown to reduce fractures. Highly recommended for other health reasons
Avoid underweight	Probably works through lower muscle mass leading to lower bone mass. Exercise and diet are also likely to be important
Hypogonadism	Should be managed in its own right; generally not treated pharmacologically just for fracture prevention
Minimise steroid use	>3 months on oral steroids is associated with increased fracture risk. High dose inhaled steroids can impact on bone mass of children
Detect and manage malabsorption and chronic inflammatory conditions	Particularly vitamin D and calcium. Consider inflammatory bowel disease, coeliac disease, surgical short gut, chronic arthritis
Recurrent falls	Good evidence for multimodal falls prevention interventions; this may reduce fractures
Adequate exercise	Prolonged sedentary periods should be considered a risk factor separate to active exercise. High impact (eg. skipping, jumping) has greater impact on BMD than walking, swimming or riding Exercise is recommended for many health reasons, however what is adequate for cardiovascular protection (walking, riding) may not stimulate bone formation. There is a lack of consensus on details in this area
Adequate vitamin D	Lack of consensus on what level is required, current expert opinion suggests minimum 50 nmol/L. Expect lower levels at the end of winter. Measurement only recommended for high risk groups. Use safe sun exposure and supplements where this is not feasible or adequate
Adequate calcium	Aim for a minimum of 1000 mg/day by diet to maintain bone density. There is controversy over the increased CVD risk from calcium supplementation
High alcohol intake	Like smoking, high alcohol intake is associated with higher fracture rates and has many health reasons to support its reduction
Pharmacotherapy for those at high risk	Suggest the use of a risk estimate calculator, discuss absolute risk and consider alendronate or other if there are specific indications

Why Calcium & Vitamin D supplement is needed?

In this elderly population there is a decrease in dietary calcium intake, usually as a result of decreased overall dietary energy intake (e.g. poorer appetite, intercurrent illnesses, social and economic factors) and a decrease in the capacity of the intestine to absorb calcium from the diet (>65), which increases the production of a parathyroid hormone that mobilises calcium from bone into the blood stream.

The poorer vitamin D status in the elderly is mainly due to less frequent exposure to sunlight (e.g. elderly who are housebound, institutionalized or have reduced mobility), but also because of a decrease in the capacity of the skin to synthesize vitamin D.

Daily calcium and vitamin D requirement:

Premenopausal—calcium 1000 mg/day (includes calcium in food and beverages + supplements). It could be calcium carbonate or calcium citrate. Vitamin D 600 IU/day
Postmenopausal—calcium 1200 mg/day, vitamin D 800 IU/day
Those at risk of fracture should avoid falls; avoid/reduce glucocorticoids, heparin and anti-epileptic drugs.