Lifestyle Changes

Vitamin D derivatives are being investigated for treating osteoporosis. Calcitriol (Calcijex, Rocaltrol), for example, is a prescription-form of vitamin D that can increase bone mass and decrease the rate of spinal fractures. However, calcitriol increases the risk for high blood calcium levels (hypercalcemia) and requires frequent monitoring. Other vitamin D analogues under investigation include doxercalciferol (Hectorol), 22-oxacalcitriol (Maxacalcitol), cholecalciferol, and alfacalcidol.

Vitamin K. Vitamin K has properties that protect bone and prevent fracture. Intestinal bacteria produce vitamin K, and the vitamin is found in leafy vegetables, so deficiencies are rare, although there is some evidence that people may not be consuming enough of this nutrient. Vitamin K affects blood clotting, and supplements are not recommended without specific doctor instruction. Vitamin K2 (menatetrenone), a form of vitamin K, may help prevent fractures in people with osteoporosis.

Click the icon to see an image of the benefits of vitamin K.

Click the icon to see an image of the sources of vitamin K.

Vitamin B12. One study reported that in people with osteoporosis and pernicious anemia, taking vitamin B12 (which is used to treat the anemia) also increased bone density.

Vitamin C and E. There has been some positive association between vitamin C and E intake and bone density. For example, a 2001 study reported better bone health in women who were taking estrogen therapy as well as calcium and vitamin C. More evidence is needed, however, to prove any direct benefits.

Click the icon to see an image of the benefits of vitamin C.

Click the icon to see an image of the sources of vitamin C.

Click the icon to see an image of the benefits of vitamin E.

Click the icon to see an image of the sources of vitamin E.

Vitamin A. High amounts of dietary vitamin A reduce bone density and may even increase the risk for fracture in postmenopausal women. (A form of vitamin A, retinoic acid, has been found to stimulate bone breakdown.)

Dietary Recommendations

The DASH Diet and Low Sodium. Perhaps a good general approach for people at risk for osteoporosis (or almost any adult) is the DASH diet plus sodium (salt) restriction. The DASH (Dietary Approaches to Stop Hypertension) diet is used to help people with hypertension maintain healthy blood pressures. A 2003 study also reported that it might help protect bones and improve cholesterol levels. This diet not only is rich in important nutrients and fiber but also includes foods that contain far more potassium, calcium, and magnesium, than are found in the average American diet. All of these minerals are important for bone protection. The dietary recommendations are as follows:

• Avoid saturated fat (although include calcium-rich dairy products that are no- or low-fat). When choosing fats, select monounsaturated oils, such as olive or canola oils. These fats are also found in some fish. Although no one wants to be overweight, even a slight excess of fat helps protect bones. In fact, in one 2000 study, women who ate more fat in their diet were, on average, better able to absorb calcium than were women who had been put on a low-fat, high-fiber diet.
• Choose whole grains over white flour or pasta products. Include nuts, seeds, or legumes (dried beans or peas) daily.
• Choose fresh fruits and vegetables every day. Many of these foods are rich in potassium, magnesium, and other minerals that are important for bone (as well as heart) protection.
• Choose protein preferably from fish, poultry, or soy products. Soy in combination with fiber-rich foods or supplements may have specific benefits. Oily fish may also be particularly beneficial. They contain omega-3 fatty acids, which have been associated with heart and nerve protection.

Salt Restriction. Reducing salt may protect both the heart and the bones. High sodium intake interferes with calcium retention. Note: Fast foods and commercial snacks are usually high in sodium and have been linked with weak bones.

Dairy Products and Calcium-Rich Foods. Although some studies have reported that dairy products benefit the bones, it is not entirely clear if high-calcium diets reduce the risk for fractures compared to adequate intake of vitamin D. Until more is known, people should be sure their diets have sufficient calcium. Dietary calcium is available from many good sources.

• Milk and Dairy Products. The best source of calcium in the diet is from milk fortified with vitamin D. Four glasses of milk provide about 1,200 mg of calcium. (Skim milk and yogurt products, unfortunately, are often low in vitamin D, which is important for calcium absorption.) According to a 2003 study, girls who have low milk intake increase their risk for fracture in adulthood. One report even suggests that milk proteins actually slow bone break down. It is not clear, however, if drinking milk after menopause offers any significant bone protection.
• Other Calcium-Rich Foods. Other calcium-rich foods include shrimp, canned salmon or sardines, black strap molasses, calcium-fortified tofu, and almonds. A number of commercial foods, including orange juice and some cereals, are now calcium fortified. Dark green vegetables (broccoli, kale, turnip greens) are rich in calcium but little of it is absorbed (kale is best).

Click the icon to see an image of milk and the facial bones.

Mineral-Rich Fruits and Vegetables.

• Potassium. Potassium may be very important for strong bones and may help counteract negative effects of high-protein diets. Potassium-rich fruits include bananas, oranges, prunes, and cantaloupes, and vegetables that contain potassium include carrots, spinach, celery, alfalfa, mushrooms, lima beans, potatoes, avocados, and broccoli.
• Magnesium. Some studies have observed that low levels of magnesium may contribute to thinning bones. Some studies suggest that magnesium supplements help suppress the cycle that leads to bone loss. Experts recommend 350 mg a day for supplements. However, excessive magnesium may be harmful in people with diabetes or kidney disease. Foods rich in magnesium include dairy products, spinach, potatoes, beets, nuts, sole, and halibut.
• Other Minerals. Phosphorous, boron, and zinc have also been associated with bone protection.

Protein. Both low and high protein intake has been associated with bone loss. Protein deficiencies appear to trigger hormonal changes that increase bone breakdown. Protein may also be important for frail older people for improving muscle strength. On the other hand, high protein intake increases urinary calcium loss, which can impair bone density in people with low calcium diets. High protein diets, however, do not appear to cause bone loss if calcium intake is also high. The bottom line, then, is to have sufficient protein but to balance this with plenty of calcium- and other mineral-rich foods.

The protein source (meat, soy, or fish) may have some effect on bone density, although the effects are not clear. Studies are mixed on whether protein from meat has a positive or negative effect on bone loss. A 2003 study found no differences in bone calcium levels between women on high- or low-meat diets. In any case, the best sources of protein for bone protection may be from oily fish or soy.

• Choosing protein from fish (especially oily fish such as salmon, mackerel, fresh tuna, herring) may be a good option. Oily fish are high in vitamin D, which is bone protective. (Note: American brands of canned tuna generally contain no significant amounts of vitamin D.) Such fish are also heart protective.
• Studies on soy have suggested some modest protection against bone loss. Soy is high in estrogen-like plant chemicals called isoflavones, which may actually improve bone health in older women. (However, other studies indicate that soy has no effect on bone density in healthy premenopausal women.) Soy food products, such as tofu, that also contain calcium may be particularly beneficial. In such cases, 3 oz of tofu supply 60% of daily calcium requirements.

Alcohol. Alcohol has different effects on bones depending on how much is consumed. A 2000 study found that women older than age 65 who drank one to two drinks (1 - 2 oz) of alcohol weekly had higher bone density than non-drinkers. Alcohol in moderate amounts may reduce parathyroid hormone and increase estrogen levels. Excessive drinking, however, has been associated with brittle bones.

Cola, Coffee, Tea and Caffeine. A 2002 study suggested that drinking tea regularly may help protect bones. Nevertheless, there has been some concern that caffeine consumption, particularly from coffee, may increase calcium levels in urine and reduce levels in the body. In one trial, consumption of lots of coffee, (9 or more cups per day, was associated with an increased risk of hip fractures in women, but not in men. However, not all studies support a risk. Some evidence, in fact, suggests that caffeine may pose a danger for bone loss only in elderly thin women -- but not in those who have normal or high weight. Drinking carbonated beverages, particularly cola, may increase the risk for bone fractures in people with low bone density.

Oral Contraceptives

The effect of OCs on bone density is unclear and may depend on dosage levels, the specific formulas, and timing. A Canadian study that followed a group of young women found that OCs resulted in lower bone density and higher risk for fractures, possibly because taking OCs at younger ages interferes with achieving peak bone mass. Some evidence suggests, however, that low-dose OCs may protect against bone loss in women during the perimenopausal period. In addition, specific progestins (such as norethindrone or norgestimate) may be bone protective.

Quit Smoking

Everyone who smokes should quit. The risk for osteoporosis from smoking appears to diminish after quitting.

Preventing Falls and Fractures

An important component in reducing the risk for fractures is preventing falls. Risk factors for falling include:

• Slow walking
• Inability to walk in a straight line
• Certain medications (such as tranquilizers and sleeping pills)
• Low blood pressure when rising in the morning
• Poor vision

Recommendations for preventing falls or fractures from falls in elderly people include:

• Exercise to maintain strength and balance if there are no conflicting medical conditions. In one study of older people, this was the single best intervention for preventing falls.
• Do not use loose rugs on the floors.
• Move any obstructions to walking, such as loose cords or very low pieces of furniture, away from traveled areas.
• Rooms should be well lit.
• Have regular eye checkups.
• Try wearing hip pads. Hip pads are specially designed to protect hipbones against falls and are worn under clothing. Evidence on their protection against fractures is weak, however, particularly since compliance is poor. Nevertheless, newer hip pads that are thinner and made with newer materials may be helpful and more appealing.
• Wear thinner, hard-soled shoes. Studies indicate these shoes are just as comfortable as the popular resilient-soled footwear, but they may be difficult to find. Soft-soled high-resilient so-called athletic footwear may contribute to impaired balance and dangerous falls, in part, because these cushioned shoes offer less stability.