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Osteoporosis Why is Osteoporosis of concern?

  • Over 80% of all fractures in people 50+ are caused by osteoporosis.
  • Causes a great deal of disability and is a burden on the health care system.
  • Modern diet and lifestyle predispose to osteoporosis.
  • Increased life expectancy makes osteoporosis prevalent, compared to the 1700s-1800s
  • Preventable disease?

Risk Factors : 

  • Measured height loss greater than 6 cm since peak height (in young adult years), or loss of more than 2 cm within the past year.
  • Recurrent history of fractures/falling
  • Chronic or acute back pain (vertebral compression fracture)
  • History of use of certain medications: eg: corticosteroids, aromatase inhibitors, antiretroviral therapy…ect.
  • Chronic endocrine diseases: Hyperthyroidism/Hyperparathyroidism, Cushing syndrome… ect.


  •  Usually labs are normal, including Calcium and Vitamin D.
  • TSH if thyroid problem is suspected.
  • Diagnosis is confirmed through Xray and BMD measurement (eg: DEXA scan).
  • There are some “Fracture risk assessment tools”, which can predict the risk of fracture in the future, based on the BMD and age. Those were developed to assess the patients for eligibility to Pharmacological therapies as a preventative measure. Examples of such scores: CAROC and FRAX. 

The non pharmacologic choices include:

  • Exercise, especially impact exercises .
  • Fall prevention.
  • Smoking cessation.
  • Diet (mostly prevention): according to the CTC: encourage protein, calcium and vitamin D, reduce alcohol (less than 2 drinks/day) and caffeine (less than 4 cups/day).

Calcium: Best available evidence suggests that Calcium supplementation’s risks outweigh the benefits. Best practice is to consume calcium from food. If supplementation is necessary, it should not be for the long term.

Hazards of calcium supplementation: • Increase cardiovascular events. • Kidney stones. • GI symptoms, sometimes so severe, require hospitalization. However, Combining calcium and vitamin D seems to be beneficial. In a 2016 meta-analysis, pooling of data showed that supplementation of calcium+vitamin D reduced the risk of total fractures by 15%, and the risk of hip fractures by 30%.

Vitamin D: In a 2014 Cochran review, they concluded that Vitamin D alone is unlikely to prevent fractures in older people. However, both vitamin D and Calcium supplementation may prevent hip and/or total fractures. The combination of calcium and vitamin D showed a small increase in the GI symptoms and renal disease, however, it did not affect mortality.

Milk and dairy products: Best available evidence encourages the consumption of animal milk and dairy products, in all age groups, specially kids and adolescents, for the following known reasons: • Source of high availability protein • Source of Calcium • Source of Vitamin D • Source of Phosphorus • Promotes healthy gut microbiome, which increases the absorption of calcium and other important minerals. It also promotes the production of short fatty acids and serotonin, which directly impact bone health.

Can I use a plant milk alternative? Benefits are not equal, unless it’s fortified, with calcium and vitamin D. Best option is SOY, because it’s the closest to cow’s in mineral/vitamin/protein content.

Is skimmed milk ok? According to WHO, skimmed milk is not recommended in infants under 12 months. They need the essential fatty acids and the fat soluble vitamins in milk. Partially skimmed milk can be introduced to children 1 year or older.

How much dairy is enough? 3 portions of dairy, or 3 cups of skimmed/low fat milk, are enough to get you your daily requirement of calcium, vitamin D and high quality protein.

Vitamin K?

A meta-analysis of 10 RCTs showed that supplementing calcium with Vit K increased BMD, especially lumbar.

Protein? Protein is a component of bone, essential for bone health. The question is, Animal or plant protein?

Animal versus plant protein and adult bone health: A systematic review and meta-analysis from the National Osteoporosis Foundation Consumption of soy protein is not more advantageous than animal protein, or vice versa.

Are vegetarians at risk? Vegetarian diet lacks the following: • High quality protein • Calcium • Vit D You can consume high quality legumes, whole grains, fruits and vegetables, soy products to compensate, however, supplementation might be necessary in long term vegetarians.

Acid balance? Theoretically, a diet high in acid precursors increases the burden on the Kidney. If the kidney is unable to clear/balance the excess acid, this will directly impact bone health. Therefore, acid balance might be problematic to bone health, as one ages.


Gaby 2011