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. They are 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.

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.

Many people prefer not to take drugs or medications because they want to treat their osteoporosis “naturally.” At this time, there are no herbal supplements or “natural” treatments that are proven to be both safe and effective for the treatment of osteoporosis and the prevention of broken bones.
There are many research studies that look at the possible bone health benefits of certain vitamins, minerals, herbs and foods. NOF reviews the results of many studies that are based on scientific evidence. Before supporting a claim about an alternative or natural treatment, these studies must have results that are consistent.
It is important to note that the U.S. Food and Drug Administration is not able 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.  For people who are interested in learning more about alternative medicine and nutrition, NOF recommends the resources listed at http://www.nof.org/aboutosteoporosis/managingandtreating/alternativetreatments .

Caffeine appears to decrease calcium absorption by a small amount. Drinking more than three 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.

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 FRAX® tool. FRAX can help to decide whether an osteoporosis medicine is necessary during the perimenopausal years. For more information about the risks and benefits of the osteoporosis medicines, please visit Osteoporosis Medicines: What You Need to Know and Choosing a Treatment.

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 five 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. NOF 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. NOF 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.

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 about four 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, NOF recommends that adults under age 50 get 1,000 mg of calcium every day, and adults age 50 and older get 1,200 mg of calcium every day.

Male sex hormones, also called androgens, can cause prostate cancer   to grow and spread. For this reason, one treatment choice is androgen   deprivation therapy (ADT). Some people call this 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 do some   regular exercise. You should do both weight-bearing exercises (examples   are walking or playing tennis) and muscle-strengthening activities   (examples are lifting weights or using elastic exercise bands). Avoid   smoking and drinking three or more alcoholic drinks a day since they   greatly increase the risk of bone loss for men undergoing this type of   treatment.

Before starting ADT, men should have a bone density test. The results   of the test 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 there has been any loss of bone density. Men who have   received ADT should have a bone density test if they have never had one.

If bone density is already low on the baseline test, then it is   helpful to start taking an osteoporosis medicine at the same time as   ADT. Men usually take either alendronate (Fosamax®), risedronate (Actonel®) or zoledronic acid (Reclast®).   These medicines are 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, you should talk to your healthcare provider. It is never   too late to take action to protect your bone health.

Note: Adults under age 50 need 1,000 mg of calcium   and 400 – 800 IU of vitamin D every day. Adults age 50 and older need   1,200 mg of calcium and 800 – 1,000 IU of vitamin D every day. Some   people may need even more vitamin D. A blood test of 25-hydroxyvitamin D   is an easy way to make sure that a person is getting enough vitamin D.

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.

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.

Resistance exercises include 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 should be done almost every day for at least   30 minutes. Resistance or muscle-strengthening exercises, on the other   hand, should only be done two to three times a week, with at least a day   of rest 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.

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. These   include 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 four 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.

NOF 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, the FDA Web site is www.fda.gov/medwatch/report.htm .

For additional information about the FDA’s ongoing safety review of bisphosphonates, visit the FDA Web site at www.fda.gov/Cder/Drug/early_comm/bisphosphonates.htm .

Studies Mentioned Above:

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

2. This study was published in the <em>Archives of Internal Medicine</em>, 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 <em>British Medical Journal</em>,   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.

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. Long-term   use of the 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.  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.

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. 

Bone healthy behaviors. 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 age 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

You may view the abstract of the study reported in JAMA by visiting this Web page: http://jama.ama-assn.org/cgi/content/abstract/296/24/2947 .

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.

NOF recommends that adults age 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 age 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.

This is an important question because the National Cancer Institute   estimates that one in eight 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 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 age 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 and   playing tennis. Examples of muscle-strengthening exercises are lifting   weights or using elastic exercise bands. Inactivity and lack of exercise   contribute to bone loss. Smoking and drinking too much alcohol are also   bad for your bones.

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.