<h2>Practice points</h2><ul><li>Calcium and vitamin D are the mainstay therapy for both preventing and treating osteoporosis. In combination, they decrease primary fracture rates in post-menopausal women with or without osteoporosis.2</li><li>Conventional treatment works better when combined with calcium and vitamin D supplements.2</li><li>Magnesium deficiency is thought to be a risk factor for post-menopausal osteoporosis. Higher dietary intake is linked to increased bone mineral density2. Recommend up to 350 mg/day when indicated.10</li><li>Vitamin K2 therapy is indicated to correct deficiency, as people with osteopaenia and who fracture a bone have been shown to have decreased levels of Vitamin K. Vitamin K2 improves bone density, prevents osteoporosis and fractures.4</li><li>Other bone health vitamins and minerals include strontium, zinc, copper, manganese, boron, silicon, folic acid, vitamin B12 and vitamin B6.5</li><li>Counsel to avoid dietary and lifestyle factors that promote calcium excretion such as smoking, excessive alcohol, salt and sugar, excessive protein and soft drinks.5</li><li>Exercise improves overall muscle function, balance and body structure, and reduces falls risk.1</li></ul><ul><li> <ul><li> <h2>Description</h2> </li><li><ul><li>Worldwide, osteoporosis causes more than 8.9 million fractures annually. This means one osteoporotic fracture every 3 seconds.1</li><li>Osteoporosis occurs when bone resorption and breakdown (osteoclast activity) exceeds bone formation (osteoblast activity), leading to low bone mass and structural deterioration of the bone. Over time, bone mass is reduced with an increased risk of fractures, usually of the hip, spine or wrist.2</li><li>Risk factors include low body mass index (BMI), lack of exercise, a sedentary lifestyle, poor nutritional status, excessive alcohol use, smoking, oestrogen deficiency, and family history of osteoporosis.2</li><li>Secondary causes of bone loss include endocrine disorders, gastrointestinal diseases that cause malabsorption, end-stage renal disease, hyperthyroidism, malnutrition, and many other conditions.2</li><li>Corticosteroids and anticonvulsant drugs can increase the risk of osteoporosis.2</li><li>Osteoporosis is more common in women, affecting one-tenth of women aged 60, one-fifth of women aged 70, two-fifths of women aged 80 and two-thirds of women aged 90 years.1</li><li>The residual lifetime risk of experiencing an osteoporotic fracture in men over the age of 50 is up to 27%.1</li><li>In Australia, 66% of people over 50 years have poor bone health; 22% of these people have osteoporosis whilst 78% have osteopaenia.3</li></ul></li><li> </li></ul> </li></ul>

<h2>Management principles2</h2><ul><li>Preserve adequate bone mass and bone strength</li><li>Prevent skeletal fragility and reduce the risk of fractures</li><li>Ensure adequate calcium and vitamin D levels</li><li>Counsel on dietary and lifestyle interventions</li></ul>

Management

<h2>Primary recommendations</h2><h2> CALCIUM AND VITAMIN D </h2>Mechanism of action6<ul><li>Vitamin D is needed to maintain serum calcium within a normal range, enhance intestinal absorption of calcium, and increase the mobilisation of stem cells to become osteoblasts2</li><li>Calcium sufficiency is required to maximise the attainment of peak bone mass during body growth; and to limit progressive demineralisation of bones later in life. Both actions are needed to prevent osteoporosis, bone fragility, and an increased risk of fractures6</li></ul>Dosage informationVitamin D: 800 - 1000 IU/day.1<ul><li>Some practitioners recommend 1000-2000 IU/day with significantly more to correct deficiency.</li></ul>Calcium: Calcium citrate 800 mg/day or calcium carbonate 1000 mg/day for adults.4<ul><li>To maximise absorption, give calcium supplements in 2 to 3 divided doses daily and do not exceed a dose of 500 mg of elemental calcium.2</li><li>All forms of calcium are better absorbed with food. Calcium citrate is more absorbable than calcium carbonate and is a good choice for people who have low gastric acidity, such as the elderly, or are taking acid-blocking drugs.2</li><li>Calcium supplementation has very little effect on bone loss during menopause due to rapid reduction in oestrogen levels and a high bone resorption rate, which increases serum calcium levels and decreases calcium absorption in the intestines. After menopause, calcium supplementation has a significant beneficial effect on bone loss.2</li><li>Recommendations for calcium intake vary between countries. The Institute of Medicine in the US recommends 1000 mg/day of calcium for women aged 19-70 years, 1200 mg/day for post-menopausal women (51+ years) and men &gt; 70 years.1</li><li>The International Osteoporosis Foundation has an excellent resource on the calcium content of common foods at <a href="http://www.iofbonehealth.org/" target="_blank">http://www.iofbonehealth.org/</a>.</li></ul>Adverse effectsVitamin D<ul><li>Orally well tolerated.7</li></ul>Calcium<ul><li>Gastrointestinal symptoms, such as constipation and stomach upset.2</li><li>Caution with renal disease and hyperparathyroid conditions.2</li><li>Some research raised concerns that taking calcium supplementation (1000 mg/day) might increase the risk of coronary heart disease in post-menopausal women.8 However, a more recent analysis concluded that calcium (2000–2500 mg/day) is not associated with cardiovascular risk in generally healthy adults.9</li></ul>Key interactionsRefer to the <a href="~/link.aspx?_id=4471DACF65C148EA8FD82B23FD6712D4&_z=z">Complementary Medicine Interactions Guide.</a>

Primary

<h2>Diet and lifestyle</h2><ul><li>Eat a balanced diet with a focus on adequate protein and aim for a quality protein source with each meal and snack.</li><li>Increase vegetables (5 to 8 serves a day, serve = 1 cup of salad greens, ½ cup of cooked vegetables and ½ cup of cooked beans) and fruit (2 to 3 pieces a day) to encourage a more alkaline diet.</li><li>Increase soy isoflavone foods daily, such as tofu, tempeh, miso and soy beans.</li><li>Increase foods rich in calcium including dairy, tofu, canned fish with soft edible bones such as sardines and salmon (the calcium is in the bones), nuts (especially brazil nuts and almonds), seeds (e.g., sesame seeds), legumes (e.g., chickpeas) and green leafy vegetables (e.g., kale, silverbeet, pak choy, bok choy, lettuce and parsley).</li><li>Increase foods rich in vitamin D such as oily fish (e.g., mackerel) and milk.</li><li>Increase foods rich in magnesium including green leafy vegetables, fruits, nuts and seeds, legumes and grains such as brown rice.</li><li>Avoid dietary factors that promote calcium excretion including salt, sugar, excessive protein and soft drinks.</li><li>Participate in exercise e.g., an effective program for postmenopausal women aged 48–60 years consists of four sessions per week - with two group sessions lasting 60 to 70 minutes each and two home training sessions of 25 minutes each.2 Include weight-bearing exercise plus strength training.5 Weight training two or more times a week is recommended.</li><li>Reduce alcohol intake.</li><li>Avoid smoking and exposure to second-hand smoke.</li></ul>

Diet & lifestyle

<h2>References</h2> 1. International Osteoporosis Foundation. https:// www.iofbonehealth.org/ (Accessed 16 November 2018). 
 2. Natural Medicines. Natural Medicines in the Clinical Management of Osteoporosis. http://naturaldatabase.therapeuticresearch.com/ce/ CECourse. aspx?cs=naturalstandard&amp;s=ND&amp;pm=5&amp;pc=17-101 (Accessed 14 November 2018).
 3. Watts J et al. Osteoporosis costing all Australians. A new burden of disease analysis 2012 to 2022. Osteoporosis Australia. 2013.
 4. Kotsirilos V. A guide to evidence-based integrative and complementary medicine. 2011. Australia, Churchill Livingstone, Elsevier, 700.
 5. Hudson T. Osteoporosis. In Pizzorno, J et al. Textbook of Natural Medicine. St Louis, Missouri, Churchill Livingstone, Elsevier. 2013, 1662-1677.
 6. Homik J et al. Calcium and vitamin D for corticosteroid-induced osteoporosis. The Cochrane Database of Systematic Reviews 1998, Issue 2. Art. No.: CD000952. DOI: 10.1002/14651858.CD000952.
 7. Natural Medicines. Vitamin D. Last reviewed 26th October 2018. https://naturalmedicines.therapeuticresearch.com/databases/food,- herbs- supplements/professional.aspx?productid=929 (Accessed 16th November 2018).
 8. Bolland M J et al. Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial. BMJ. 2008 Feb 2;336(7638):262-6.
 9. Chung et al. Calcium Intake and Cardiovascular Disease Risk: An Updated Systematic Review and Meta-analysis. Ann Intern Med. 2016 Dec 20;165(12):856-866.
 10. Braun L et al. Magnesium. Herbs &amp; Natural Supplements. An evidence-based guide. Vol 2 Elsevier Australia, 2015, 677-692.

Osteoporosis

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