etter no. 2 9 of th
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NATIONAL OSTEOPOROSIS FOUNDATION OF SOUTH AFRICA
NASIONALE OSTEOPOROSE STIGTING VAN SUID-AFRIKA
Seasons Greetings to all our NOFSA members! We hope that you all have
a lovely festive season and a well-deserved rest.
The risk of sustaining a fracture increases exponentially as we grow older,
not only due to a decrease in bone density, but also due to the increased
rate of falls amongst the elderly. Currently the elderly represents the
fastest growing segment of populations worldwide and with this
increase, the prevalence of osteoporosis and therefore fractures are on
the increase. With this in mind, the International Osteoporosis
Foundation (IOF) published the “Three Steps to Unbreakable Bones” this
year as the theme for World Osteoporosis Day. Eating well and staying physically active are two
essential components of a healthy lifestyle and probably the most important cornerstones in the
prevention of osteoporosis at all stages of life. Read more about this in the newsletter. To further this
theme, the IOF has also put a link on their web page and invite everyone to join the unbreakable
embrace, a global initiative with the aim to have 1500 members by the end of the year. Please follow
this link to show your support and join the Unbreakable Embrace www.unbreakableembrace.org.
Also remember that we are on Face Book and you can also join the embrace from there. Please leave
comments for us and like our page!
We have also included an article on dairy which remains a contentious issue and we still receive many
queries about the fact that dairy may be bad for bones. Dairy is still regarded as the best, cheapest way
to get your daily calcium fix and NOFSA and the Consumer Education Project of Milk SA, have joined
forces to reintroduce dairy to our society. You may have seen the “Rediscover Dairy for Bone Health”
banners in your local supermarkets in October and November and remember that 3 portions of dairy
per day is what you need to maintain bone health.
A number of years ago a pamphlet published in the UK, dealing with fall prevention tips for the elderly,
was aptly named “Don't mention the F-word”. Falling is something viewed by many elderly people as
something that only happens to very old, frail ladies and not something to be talked about as you may
be viewed as old and senile. Read the article on falls and if you fall into the “elderly” category, try and
make your home fall-free. This is also important for families where an elderly person is part of the
family and even more important if you are living on your own. Remember that a fall can cause a
fracture!
The combined SEMDSA/NOFSA meeting for physicians will be taking place at the President Hotel in
Bantry Bay, Cape Town from Thursday 19 April 2012 to Sunday 22 April with the NOFSA section on
Thursday and Friday. Please diarize this date and watch our web site www.osteoporosis.org.za for
further details.
Have a lovely rest (with some healthy food and exercise thrown in!) and don't forget to look after your
bones!
Tereza Hough
CEO
NOFSA
THE F-WORD!
In 2004 a patient organization in the UK dealing with elderly people, published a leaflet about
preventing falls in the aged. The title was “Don't mention the F-word”. This title reflected the
attitude of many older people who do not consider themselves old enough to fall as the general
feeling was that it can “make you feel old and senile and need to be told everything” and that falling
generally only happened to frail old ladies!
Facts about falls
•
1 in 3 women and 1 in 6 men between the ages of 65 and 74, fall every year
•
The risk of falls increases further with age
•
About 1 in 5 falls require medical attention with approximately 1 in 10 resulting in a fracture
•
Fractures (especially hip fractures) in older people can be devastating. 20% of patients with a
hip fracture die within the first year of having suffered a fracture, and more than 50% of the
rest will never be able to function independently again.
•
Even in the absence of fractures or other injuries, falls may lead to a fear of falling with a
subsequent loss of confidence.
Falls and fractures
Fractures are one of the major consequences of falls and the more you fall, the more your chances of
developing a fracture. At age 50 a woman has a 1 in 2 chance of suffering a fracture, compared to 1
in 5 men. This can probably be ascribed to the fact that women have a longer life expectancy than
men and are also more prone to have osteoporosis. Other diseases like Paget's disease may also be
associated with an increased risk of fracture. The impaired mobility and loss of independence
associated with a fracture may result in the need for the patient to be admitted to an old age home or
be dependent on family or nursing care.
Risk factors for falls
Research studies have identified a number of risk factors for falls including:
•
Muscle weakness
•
History of previous falls
•
Abnormalities in walking
•
Balance problems
•
Poor vision
•
Arthritis
•
Depression
•
Dementia
•
Medications that may cause drowsiness or low blood pressure on standing (postural
hypotension)
•
Leaving home less than 3 times per week
Each of these risk factors increases the risk of falling by between 1.5 and 3 times and the more risk
factors you have, the higher the risk of falling.
Falls assessment
Recent guidelines recommend that when a health care professional examines an older person, a
basic falls assessment should be performed. Three simple screening questions should establish (i) if
there have been two or more falls the previous year, (ii) have they been hospitalised after a fall and (iii)
whether they had difficulty with walking or mobility after a fall. If the answers to any of these are
positive, a more detailed assessment and intervention is required.
1
The emphasis should centre on reversible causes of falls. At least the following should be assessed:
(i) Medication, particularly long-acting sedatives, major tranquillisers and hypnotics (including
non-prescription medicines like cough mixtures, which often contain antihistamines), is the single
most important reversible risk factor for falls in the elderly. Antidepressants, antihypertensive drugs,
hypoglycaemic agents, laxatives and alcohol may also predispose.
(ii) Cognition and affect. A simple Abbreviated Mental Test (AMT or “mini mental” test) and
depression score are more than adequate as screening procedures.
(iii) Gait and balance. The Timed Up and Go Test (TUGT) with a 15-second cut-point is usually
sufficient, although sophisticated sway meters can accurately assess body sway. Further assessment
of proprioception, vestibular disorders, neuropathies or local foot disorders may be required as
indicated.
(iv) Cardiovascular examination. This should include assessment for postural hypotension
(reduction in blood pressure of ≥ 20 mm Hg when standing, compared with sitting and reading) and
cardioinhibitory carotid sinus hypersensitivity.
(v) Weakness and immobility. Melton has emphasised the fact that nearly half of all hip fracture
victims have some degree of muscle weakness. He coined the term “sarcopenia” to underscore this
important risk factor many years ago. Quadriceps strength is usually measured isometrically in the
0
dominant leg, with the angles of the hip and knee at 90 ,and with the patient seated.
(vi) Visual acuity (Snellen chart) and depth perception.
(vii) Environmental safety. Up to 40% of falls are accident- or environment-related. The vast
majority occur in the home during daily activities. The most important environmental risk factors are
objects that may be tripped over, slippery surfaces, inappropriate furniture and poor lighting.
(viii) Previous falls. Any fall will enhance the fear of subsequent falls, resulting in loss of
confidence, a reduction in activity, muscle strength, postural control and a further increase in the risk
of falling. Since < 5% of falls in elderly people result in hip fractures, the severity and type of fall,
over and above mere frequency, appear to be important determinants of fracture risk. Sideways falls
are thought to increase fracture risk some 30 times more than a forwards or backwards fall. One in
four falls directly on the greater trochanter is said to result in fracture. The extent of a patient's soft
tissue protection over the greater trochanter may further influence the amount of energy absorbed
during a fall, and hence limit fractures. External hip protectors can reduce hip fracture risk by as
much as 50%, particularly in the frail and elderly with significant hip osteopenia, but require a highly
motivated patient who is prepared to wear the protector at all times. Moreover, use of hip protectors
has not been demonstrated to significantly reduce the risk of hip fracture in noninstitutionalised
elderly subjects, even when they are compliant. Hip protectors are very expensive, not readily
available in this country and generally of little practical use.
2
Fall prevention
The risk of falling and the number of falls can be reduced by a fall assessment and also by providing a
list of recommendations aimed at addressing the individual risk factors for falls. These may include
physiotherapy to improve walking, exercise programmes to improve balance and muscle strength
and advice on the appropriate use of walking aids. Review and modify medication where necessary
and treat abnormal blood pressure and heart disease including abnormal heart rhythm. Identify
potential hazards in the home.
Some practical tips
•
•
•
•
•
•
•
Remove loose carpets or tack them down and substitute rugs with non-skid backing
Add lights in badly lit areas and at the top and bottom of staircases.
Use nightlights in bedrooms, bathrooms and halls
Clean up clutter- especially near staircases.
Put handrails on both sides of any steps or stairs
Add grab bars near the toilet and bath and use a non-slip rubber mat in the bath or
shower
Wear firm shoes that are not slippery on the bottom and don't walk around in loose
fitting slippers or socks.
References
1. Help the Aged Preventing Falls: Don't mention the F-word! London 2004
2. Panel on prevention of Falls in Older Persons, American Geriatrics Society and British
Geriatrics Society: Summary of the Updated American Geriatrics Society/British Geriatrics
Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc
2011;59:148-1457
3. http:/www.healthinaging.org/public_education/falls_tips.php
4. Hough FS, Ascott Evans B, Brown S et al. NOFSA Guideline for the Diagnosis and
Management of Osteoporosis. Official supplement to the Journal For Endocrinology,
Metabolism and Diabetes of South Africa 2010
3
DAIRY- GOOD OR BAD FOR YOUR BONES?
It appears that there is still (and will always be!) confusion about the health benefits of cow's milk
and this is being perpetuated by many health advisors who tell the public and their clients that cow's
milk is only good for calves and the evil source of many an unexplained ailment!
Milk makes a very valuable contribution to a healthy diet as it contains all the macro-nutrients
(protein, carbohydrates and fat). Milk protein has a high biological value because it contains the
essential amino acids needed by the body. The carbohydrate, lactose, supplies energy and aids the
absorption of calcium. Milk is considered by many national and international opinion-leaders in the
bone field as the best source of calcium because of the high calcium content, the absence of factors
that may influence the absorption (such as phytates and oxalates in green, leafy vegetables) and the
presence of lactose which aids in the absorption of calcium. Milk also contains significant amounts
of minerals and trace-elements calcium, phosphate, magnesium and selenium and vitamins A, D
and B (riboflavin and niacin) needed for bone health as well as general health.
Calcium intake is especially important during childhood and adolescence as this is the time when
bone is formed quicker than it is removed, causing bones to become larger and denser. This is also
the time to put calcium in the bone bank in order to achieve a higher peak-bone density (where
one's bones reach their maximum density at +/- age 25-30), so that when you start losing bone
density as a natural part of ageing, you have enough to lose! Calcium intake remains an important
part of bone health throughout life.
Milk and bone health
The two key nutrients to consider for bone health are the mineral calcium and vitamin D. Calcium is
a major structural component of bone tissue. It is deposited in bone in the form of hydroxy-appatite
which confers strength to the skeleton. Approximately 99% of calcium is stored in the bones and
teeth (the calcium bank). Milk and other dairy foods are the most readily available sources of calcium
in the diet. Dairy foods also have the additional advantage of being a good source of protein and
other micro-nutrients. Vitamin D is essential for the development and maintenance of bone, both
for its role in assisting calcium absorption from food in the intestine, and for ensuring the correct
renewal and mineralization of bone tissue. Vitamin D will be dealt with in more detail in a next issue.
The importance of nutrition to bone health has been demonstrated in a number of research studies,
in human subjects across the age range. Intervention trials (the gold standard in supplying scientific
evidence), carried out over three years in children and adolescents have shown that
supplementation with either calcium, dairy calcium-enriched foods, liquid milk, or calcium-enriched
milk powder enhances the rate of bone mineral acquisition, compared with un-supplemented
(placebo) control groups (1-4). In general, these trials increased the usual calcium intake of the
supplemented children from about 600-800mg/day to around 1000-1300mg/day. Although these
studies were short term, it is likely that were these higher calcium intakes maintained until the
subjects were in their mid- twenties, this would have an impact on peak bone mass. Some
retrospective observational studies suggested that adults who consumed milk regularly during
childhood had a higher bone mass than those who did not, although such studies are a weaker form
of scientific evidence than intervention trials. At the population level, it is estimated that a 10%
increase in peak bone mass could reduce the risk of osteoporotic fractures during adult life by 50%.
In studies among adults, one three-year intervention study in healthy young women aged 30-42
years showed that supplementing the usual diet with dairy foods prevented bone loss in the spine,
compared with control subjects who did not increase their dairy intake (5).
4
In post-menopausal women and the elderly, several intervention studies have shown that calcium or
milk supplementation slows the rate of bone loss (6-15). In a study carried out in healthy, elderly
women living in nursing homes, calcium (1200mg/day) and vitamin D (800IU/day) supplementation
over 18months reduced the risk of hip fractures and other non-vertebral fractures (7). A similar
intervention over three years of calcium (500mg/day) and vitamin D (700IU/day) was shown to
reduce bone loss and the incidence of non-vertebral fractures in elderly men and women living at
home and not in institutions (6). In comparative intervention studies, dairy food supplements and
calcium supplements were equally effective in preserving hip-bone mass in postmenopausal women
(13,15), although these studies were not designed to evaluate reductions in fracture rates.
Does the protein in milk cause calcium loss?
In the Framingham study, elderly men and women with lower total and animal protein intakes had
greater rates of hip and spine bone loss than those consuming higher amounts of protein (16). There
is also evidence that increasing protein intake has a favourable effect on bone mineral density in
elderly men and women receiving calcium and vitamin D supplements, suggesting synergistic
effects of these nutrients in improving skeletal health (17). Randomized clinical trials in elderly
people with hip fractures have demonstrated the beneficial effects of giving protein supplements on
the clinical outcomes following surgery to repair the fracture. Protein supplementation resulted in
fewer deaths, shorter hospital stays and a greater likelihood to return to independent living (18-20).
Despite this evidence, there has been speculation that a higher dietary intake of protein could have
negative effects on calcium metabolism and could possibly induce bone-loss. This relates to the
hypothesis that the 'acid-base balance' of the diet is a potential risk factor for osteoporosis and if a
diet contains predominantly acidic foods (which include key protein sources) and does not contain
sufficient alkali-rich basic foods (fruits and vegetables), the alkaline salts of the skeleton may be
drawn on to buffer this effect and in the long term lead to bone loss (21). Although there is some
evidence from observational studies that a more alkaline diet is beneficial to bone health in pre- and
post-menopausal women (22), the theory has not been proven in more definitive clinical trials.
In summary, the majority of scientific evidence supports the beneficial effects of protein intake on
bone health, and highlights the risks associated with protein insufficiency and malnutrition.
Although protein is needed for healthy bones, it is recommended that you limit your total protein
intake to 75 grams/day.
What if I am lactose intolerant?
Lactose intolerance needs to be diagnosed by a doctor by doing certain tests as the abdominal
symptoms can be confused with other digestive disorders such as irritable bowel syndrome. It is
more common in Asians and Africans than in other races.
Lactose intolerance is a potential risk factor for osteoporosis as patients tend to avoid dairy products.
Being lactose intolerant does not necessarily preclude all dairy products from the diet and some
people can even tolerate small quantities of milk (< 12grams/meal) without symptoms. There are
even some lactose reduced milks available (e.g. EasyGest®, Parmalat). Fermented milk products like
yoghurt can be well tolerated as the live cultures actually produce the enzyme lactase which helps in
breaking down lactose to more digestible sugars glucose and galactose.
5
Why are some populations less prone to develop osteoporosis even though their dairy intakes are
low?
It is well known that certain population groups are less prone to develop osteoporosis and
osteoporotic fractures. This is not because they do not consume dairy products and milk, but rather
because of their genetic make-up.
Is salt and coffee bad for me?
A high sodium (salt) intake promotes urinary calcium excretion and is therefore considered to be a
risk factor for osteoporosis. The Dietary Approaches to Stopping Hypertension (DASH) study
showed that lowering salt intake was beneficial for bone metabolism (23).
Coffee is often implicated in the development of osteoporosis, but there is no convincing evidence
that this is the case (24). Caffeine does however produce a small increase in urinary calcium
excretion and a very small decrease in calcium absorption, but the body appears to balance this out
by reducing calcium excretion later in the day. However, if calcium intake was already low (< 800mg
per day), more than three cups of brewed coffee a day was associated with more bone loss (25).
In Summary
Dairy is good for you in more ways than one - being important in helping preserve bone mass and
strength in the young and elderly, it speeds and aids healing in those who have had a fracture and it
helps prevent further fractures.
Good nutrition alone will neither prevent nor cure osteoporosis, but in the context of a bone friendly
lifestyle (exercise, stop smoking, limit alcohol intake) it is probably the more pleasurable and less
onerous task on the list!
Recommended calcium allowances
AGE GROUP
CALCIUM PER DAY (mg)
Infants
500-700
Children and adolescents
1300
Young adults
1000
Pregnant and lactating females
1500
Post-menopausal women
• on hormone replacement
1000
• not on hormone replacement
1300
The elderly ( ›65years)
1300
6
Approximate calcium levels in foods
FOOD
SERVING SIZE
CALCIUM (mg)
Milk, whole
Milk, semi-skimmed
Milk, skimmed
Goats milk, pasteurized
Yoghurt, low fat, plain
Yoghurt, low fat, fruit
Yoghurt, Greek style, plain
Cream, single
Cheese, cheddar type
Cheese, cottage
Cheese, mozzarella
Cheese, Camembert
Ice cream, dairy, vanilla
236 ml
236 ml
236 ml
236 ml
150 g
150 g
150 g
15
40 g
112 g
28 g
40 g / average portion
75 g / average serving
278
283
288
236
243
210
189
13
296
142
101
94
75
Tofu, soya bean, steamed
Soya drink
Soya drink, calcium-enriched
100 g
236 ml
236 ml
510
31
210
Broccoli, cooked
Curley kale, cooked
112 g
112 g
45
168
Almonds
Brazil nuts
26 g / 12 whole
20 g / 6 whole
62
34
Sardines, canned in oil
Pilchards, canned in tomato sauce
Whitebait, fried
100 g / 4 sardines
110 g / 2 pilchards
80g / average portion
500
275
688
Bread, white, sliced
Bread, wholemeal, sliced
Pasta, plain, cooked
Rice, white, basmati, boiled
30 g / 1 medium slice
30 g / 1 medium slice
230 g / medium portion
180 g / medium portion
53
32
85
32
Calcium levels from reference 7: Food Standards Agency (2002) McCance and
Widdowson's The Composition of Foods, Sixth summary edition. Cambridge:
Royal Society of Chemistry.
7
REFERENCES
1.
Bonjour JP, Carrie AL, Ferrari S, et al. (1997) Calcium-enriched foods and bone mass growth in prepubertal girls: a
randomized, double-blind, placebo-controlled trial. J Clin Invest 99:1287-94
2.
Cadogan J, Eastell R, Jones N, et al. (1997) Milk intake and bone mineral acquisition in adolescent girls: randomized, controlled
intervention trial. BMJ 315: 1255-60
3.
Johnston CC jr, Miller JZ, Slemenda CW, et al. (1992) Calcium supplementation and increases in bone mineral density in children.
N Engl J Med 327: 82-87
4.
Lau EM, Lynn H, Chan YH, et al. (2004) Benefits of milk powder supplementation on bone accretion in Chinese children.
Osteoporos Int 15: 654-58
5.
Baran D, Sorensen A, GrimesJ, et al.(1990) Dietary modification with dairy products for preventing vertebral bone loss in
premenopausal women: a three year prospective study. J Clin Endocrinol Metab 70:264-70
6.
Dawson-Hughes B, Harris SS, Krall EA, et al. (1997) Effect of calcium and vitamin D supplementation on bone density in men and
women 65 years of age or older. New Engl J Med 337: 670-76
7.
Chapuy MC, Arlot ME, Duboeuf F, et al. (1992) Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J
Med 327: 1637-42
8.
Chapuy MC, Pamphile R, Paris E, et al. (2002) Combined calcium and vitamin D3 supplementation in elderly women:
Confirmation of reversal of secondary hyperparathyroidism and hip fracture risk. The Decalyos II study. Osteoporos Int 13:257-64
9.
Lau EM, Woo J, Lam V, et al. (2001) Milk supplementation of the diet of postmenopausal Chinese women on a low calcium intake
retards bone loss. J Bone Miner Res 16: 1704-09
10. Lau EM, Lynn H, ChanYH, et al. (2002) Milk supplementation prevents bone loss in postmenopausal Chinese women over 3 years.
Bone 31: 536-40
11. Chee WS, Suriah AR, Chan SP, et al. (2003) The effect of milk supplementation on bone mineral density in postmenopausal
Chinese women in Malaysia. Osteoporos Int 14: 828-34
12. Prince R, Devine A, Dick I, et al. (1995) The effects of calcium supplementation (milk powder or tablets) and exercise on bone
density in postmenopausal women. J Bone Miner Res 10:1068-75
13. Reid IR, Ames RW, Evans MC, et al. (1995) Long term effects of calcium supplementation on bone loss and fractures in
postmenopausal women: a randomized, controlled trial. Am J Med 98: 331-35
14. Shea B, Wells G, Cranney A, et al. (2002) Meta-analysis of therapies for postmenopausal osteoporosis, VII. Meta-analysis of
calcium supplementation for the prevention of postmenopausal osteoporosis. Endocr Rev 23: 552-59
15. Storm D, Eslin R, Porter ES, et al. (1998) Calcium supplementation prevents seasonal bone loss and changes in biochemical
markers of bone turnover in elderly New England women; a randomized placebo-controlled trial. J Clin Endocrinol Metab 83:
3817-25
16. Hannan MT, Tucker KL, Dawson-Hughes B, et al (2000) Effect of dietary protein on bone loss in elderly men and women: The
Framingham Osteoporosis Study. J Bone Miner Res 15:2504-12
17. Dawson Hughes B, and Harris SS. (2002) Calcium intake influences the association of protein intake with rates of bone loss in
elderly men and women. Am J Clin Nutr 75: 773-79
18. Delmi M, Rapin CH, Bengo JM, et al. (1990) Dietary supplementation in elderly patients with fractured neck of the femur. Lancet
335:1013-16
19. Schurch MA, Rizzoli R, Slosman D, et al. (1998) protein supplements increase serum Insulin-like growth factor-1 levels and
attenuate proximal femur bone loss in patients with recent hip fracture. A randomized, double-blind, placebo-controlled trial.
Ann Intern Med 128: 801-09
20. Tkatch L, Rapin CH, Rizzoli R, et al. (1992) Benefits of oral protein supplementation in elderly patients with fracture of the
proximal femur. J Am Coll Nutr 11: 519-25
21. Barzel US and Massey LK. (1998) Excess dietary protein can adversely affect bone. J Nutr 128: 1051-53
22. MacDonald HM, New SA, Fraser WD, et al. (2005) Low dietary potassium intakes and high dietary estimates of net endogenous
acid production are associated with low bone mineral density in premenopausal women and increased markers of bone r
esorption in postmenopausal women. Am J Clin Nutr 81:923-33
23. Lin PH, Ginty F, Appel LJ, et al.(2003) The DASH diet and sodium reduction improve markers of bone turnover and calcium
metabolism in adults. J Nutr 133:3130-66
24. Heany RP (2002) Effects of caffeine on bone and the calcium economy. Food Chem Toxicol 40: 1263-70
25. Harris SS and Dawson-Hughes B (1994) Caffeine and bone loss in healthy, postmenopausal women. Am J Clin Nutr 60: 573-78
8
VITAMIN D, CALCIUM AND EXERCISE
www.iofbonehealth.org
9
normal bone
osteoporotic bone
WHAT IS OSTEOPOROSIS?
Osteoporosis is a disease characterized
by low bone mass and deterioration
in the microarchitecture of bone
tissue, leading to an increased risk of
fracture. Osteoporosis occurs when
the bone mass decreases more quickly
than the body can replace it, leading
to a net loss of bone strength. As a
result the skeleton becomes fragile,
so that even a slight bump or fall can
lead to a broken bone, (referred to as
a fragility fracture). Osteoporosis has
no signs or symptoms until a fracture
occurs – this is why it is often called a
'silent disease'.
Osteoporosis affects all bones in the
body, however fractures occur most
frequently in the vertebrae (spine),
wrist and hip. Osteoporotic fractures
of the pelvis, upper arm and lower leg
are also common. Osteoporosis itself
is not painful but the broken bones
can result in severe pain, significant
disability and even mortality. Both hip
and spine fractures are also associated
with a higher risk of death - 20% of
those who suffer a hip fracture die
within 6 months after the fracture.
A COMMON DISEASE
A GROWING PUBLIC HEALTH
PROBLEM
It is estimated that worldwide an
osteoporotic fracture occurs every 3
seconds. At 50 years of age, one in
three women and one in five men will
suffer a fracture in their remaining
lifetime. For women this risk is higher
than the risk of breast, ovarian and
uterine cancer combined. For men,
the risk is higher than the risk for
prostate cancer. Approximately 50%
of people with one osteoporotic
fracture will have another, with
the risk of new fractures rising
exponentially with each fracture
The risk of sustaining a fracture
increases exponentially with age due
not only to the decrease in bone
mineral density, but also due to the
increased rate of falls among the
elderly. The elderly represent the fastest
growing segment of the population.
Thus as life expectancy increases for the
majority of the world's population, the
financial and human costs associated
with osteoporotic fractures will increase
dramatically unless preventative action
is taken.
Fractures due to osteoporosis can
cause significant disability
and loss
10
in quality of life
Eating well and staying physically
active are two essential components of
a healthy lifestyle. These are also the
pillars of osteoporosis prevention at all
stages of life. Although genetics
largely determine the size and density
of your bones, lifestyle factors such as
regular exercise and good nutrition
also play key roles.
Good nutrition fuels our bone
health by providing our body with
the necessary quantities of vitamins,
calcium, and high quality proteins that
are required to maintain bone and
muscle strength. Vitamin D has been
found to be of particular importance
to bone health. In this report, we raise
awareness of the broad prevalence of
vitamin D deficiency and recommend
supplementation with vitamin D in
all adults age 60 years and older
for its proven reduction of falls and
fractures. Notably, vitamin D plays
a critical role in bone development
in children and correlates positively
with bone density in younger adults.
Apart from its benefit on calcium
uptake in the bowel, vitamin D has a
direct effect on muscle. As sufficient
vitamin D is not obtained from an
otherwise healthy diet and direct
daily sun exposure, which is the main
stimulus from vitamin D production
in the skin, is limited in most adults,
supplementation should be
considered.
Engaging in physical activity has many
health benefits and is absolutely
essential for strong bones and muscles.
Thus, it is important to strengthen your
muscles and bones to reduce your risk
of osteoporosis, falls and fractures.
Walking 4 hours a week at a brisk
speed has been associated with about
a 40% reduction in hip fractures1.
Simple targeted exercise programmes
have been shown to improve bone
density and functional mobility,
resulting in 10 to 50% fewer falls in
frail and active older adults2,3,4. As for a
Heike A. Bischoff-Ferrari MD DrPH
Director Centre on Aging and Mobility, University of Zurich
and City Hospital Waid
SNF-Professor Dept. of Rheumatology and Institute of
Physical Medicine, University Hospital
healthy diet, it is never too soon or too
late to start. There is always a benefit,
regardless of age.
The combination of staying active,
eating a diet rich in calcium and
ensuring that you are not vitamin
D deficient offers tremendous
opportunities to improve bone and
muscle health and reduce the risk of
osteoporosis. Importantly, the benefits
derived from healthy nutrition with
adequate vitamin D may be enhanced
by greater physical activity. This is
why this year's 'World Osteoporosis
Day' campaign message merges these
three components in "Embrace a bone
healthy lifestyle". Applied together
each component enhances the other
for optimal bone and muscle health.
The overall objective of this year's
World Osteoporosis Day campaign is
11
to raise awareness of the importance
of maintaining sufficient daily levels
of vitamin D, calcium, protein and
physical activity to maintain bone
health, at all ages. However, as
underlined by our special focus
on vitamin D, we wish to address
a growing public health concern:
falls and fall-related fractures in
our ageing populations. Seventy
-five per cent of all fractures occur
in individuals age 75 and older.
As muscles weaken elderly people
become frail, experiencing functional
decline and a tendency to fall. The
ultimate goal of our public healthcare
policy (and certainly the personal
goal of everyone as they age!) is
to have seniors remain physically
independent and active members of
their communities. Muscle and bone
health are the key targets to help
achieve this goal.
A primary risk factor for a fracture is
a fall, with over 90% of all fractures
occurring after a fall5. Thus, critical
for the understanding and prevention
of fractures, especially at older age,
is the close relationship between falls
and muscle weakness. Individuals
with better muscle strength have
stronger bones, fall less, and have
fewer fractures. Mechanistically, the
circumstances5 and the direction6 of
a fall determine the type of fracture,
whereas bone density and mechanical
factors such as better muscle strength
or better padding around the hip,
critically determine whether a fall will
result in a fracture7. Moreover, falling
may result in self-imposed reduction
in physical activity due to fear of
further falls, but which, paradoxically,
may result in reduced bone density
and muscle strength with a
consequent increase in risk of further
falls8. Thus, strengthening bone and
muscle is critical for the prevention of
falls and fractures.
Better muscle strength for the
prevention of falls is also important
as falling is a frequent event at older
age. Thirty percent of those 65 years
or older, and 40-50% of those 80
years or older, report having had a
fall over the past year9, 10. Serious
injuries occur with 10-15% of falls,
resulting in fractures in 5% and hip
fracture in 1-2%11. As an independent
determinant of functional decline12,
falls lead to 40% of all nursing home
admissions13. Recurrent fallers may
have close to a 4-fold increased
odds of sustaining a fall-related
fracture compared to individuals with
a single fall14. As the proportion
12
of individuals aged 65 and older is
predicted to increase from 25% to
40% by 2030 in Europe15-19 and in
large parts of the Western World20, 21,
the number of fall related fractures
will increase substantially. As both
vitamin D and exercise have been
proven to improve bone health and
reduce falls by 20 to 50%, this report
promotes these two effective, welltolerated and easy to implement
strategies for unbreakable bones.
Our skeleton is sensitive to mechanical
loading ,and bone mineral density
can be improved by weight-bearing
physical activity. In addition, our
bones have nutritional needs. Thus, the
combination of staying active, eating a
healthy, calcium-rich diet plus taking a
vitamin D supplement offers
tremendous opportunities to improve
bone and muscle health and reduce
the risk of osteoporosis. Moreover, the
benefit of a "bone healthy diet rich
in natural calcium sources with added
vitamin D" may be enhanced by greater
physical activity or reduced by the lack
of it. This is why this report merges
all concepts — applied together each
concept elevates the other for optimal
bone and muscle health.
Bone is a living and metabolically
active tissue and therefore undergoes
constant renewal throughout life. As
with other organs, our bones need to
be fueled with key nutrients and
energy. A healthy and balanced diet
for strong bones will provide key
micronutrients (vitamins and minerals)
as well as macronutrients (protein, fat,
carbohydrates) to provide the building
blocks for bone and the energy
needed for its renewal. This report
highlights the importance of two
significant nutrients, calcium and
protein, which are building blocks for
healthy bones and muscles plus one
nutrient, vitamin D, that allows optimal
availability of calcium from a healthy
diet and has a direct effect on muscle
strength. All three nutrients have been
shown to be important for preserving
bone mass
Calcium, protein and vitamin D - all
three nutrients are important for
preserving bone mass throughout the
life cycle
13
throughout the life cycle. In addition,
vitamin D supplementation has been
shown to improve function and reduce
the risk of falls and fractures among
older adults.
While our calcium needs can be
covered by a nutritious diet, it is
important to realize that the same is
not true for vitamin D. It is nearly
impossible to get enough vitamin D
from food as it is only found in small
amounts in certain foods; secondly, it
is difficult for most adults (especially
older people) to get enough daily
sunlight exposure to also reach
adequate levels. Therefore
supplementation is recommended in
those over 60 years. For calcium, as
highlighted in this report, dietary
sources are the preferred option and
supplementation with calcium should
only be targeted to those who do not
get sufficient calcium from their diet
and who are at high risk for
osteoporosis.
Calcium is a key structural component
of bone and is built into bone as a
mineral complex that includes calcium
and phosphate. Our skeleton houses
99% of our body's calcium stores.
Calcium built into bone also serves as
a calcium reservoir for maintaining
calcium levels in the blood. Calcium is
absorbed in the small intestine both
by passive diffusion and by active
absorption regulated by vitamin D.
Individuals who have more vitamin
D are able to absorb more calcium22.
Therefore, in combination with vitamin
D, it is thought that a minimum total
calcium intake of about 800 mg per
day may be sufficient23,24. This amount
of calcium can be achieved by a
healthy diet that contains a daily dose
of calcium-rich foods (for example: 1
glass of milk or slice of hard cheese =
300 mg calcium; 1 glass of calciumrich mineral water = 200 mg calcium;
4 sardines = 500 mg; 28 grams of
almonds = 75 mg calcium).
APPROXIMATE CALCIUM LEVELS IN FOODS
Food
See food table on right
Individuals who have more vitamin D
are able to absorb more calcium
Serving Size
Calcium (mg)
Milk, whole
236 ml
278
Milk, semi-skimmed
236 ml
283
Milk, skimmed
236 ml
288
Goats milk, pasteurized
236 ml
236
Yoghurt, low fat, plain
150 g
243
Yoghurt, low fat, fruit
150 g
210
Yoghurt, Greek style, plain
150 g
189
Fromage frais, fruit
100 g
86
Cream, single
15 g
13
Cheese, cheddar type
40 g
296
Cheese, cottage
112 g
142
Cheese, mozzarella
28 g
101
Cheese, Camembert
40 g
94
Ice cream, dairy, vanilla
75 g
75
Tofu, soya bean, steamed
100 g
510
Soya drink
236 ml
31
Soya drink, calcium-enriched
236 m
210
Broccoli, cooked
112 g
45
Curley kale, cooked
112 g
168
Apricots, raw, stone removed
160 g
117
Orange, peeled
160 g
75
Figs, ready to eat
220 g
506
Almonds
26 g
62
Brazil nuts
20 g
34
Sardines, canned in oil
100 g
500
Pilchards, canned in tomato sauce
110 g
275
Whitebait, fried
80 g
688
Bread, white , sliced
30 g
53
Bread, wholemeal, sliced
30 g
32
Pasta, plain, cooked
230 g
85
Rice, white, basmati, boiled
180 g
32
Food Standards Agency (2002) McCance and Widdowson's The
Composition of Foods, Sixth summary edition. Cambridge: Royal Society
of Chemistry
14
embrace calcium rich foods
Dietary sources of calcium are
preferred to supplementation for
several reasons:
3. calcium tablets can reduce
intestinal phosphate absorption26,
which may be detrimental as a
balanced calcium-phosphate
ratio is needed for bone
mineralization. The latter may be
primarily a concern in the senior
population27, where phosphate
deficiency is found in about 10
to 15% of women over 60 years
old28. Each increase in calcium
supplement intake by 500 mg/
day decreases phosphorus
absorption by 166 mg26, so a
calcium supplement of 1000 mg
may shift an elderly person on a
relatively low phosphorus intake
into phosphate deficiency26,29.
Conversely, dairy products provide
both calcium and phosphate
1. calcium-rich foods such as dairy
(milk, yoghurt, cheese) and nuts
contain additional nutrients
valuable for bone and muscle
health, especially high-quality
protein;
2. high-dose calcium
supplementation (1000 mg and
more) may not be beneficial for
cardiovascular health25 whereas
calcium-rich foods are not
associated with an increased
cardiovascular risk;
IOM* DIETARY REFERENCE INTAKES FOR CALCIUM
Calcium
Life Stage Group
Estimated Average
Requirement (mg/day)
Recommended Dietary
Allowance (mg/day)
Infants 0 to 6 months
-
-
Infants 6 to 12 months
-
-
1-3 years old
500
700
4-8 years old
800
1,000
9-13 years old
1,100
1,300
14-18 years old
1,100
1,300
19-30 years old
800
1,000
31-50 years old
800
1,000
51-70 year old males
800
1,000
51-70 year old females
1,000
1,200
>70 years old
1,000
1,200
14-18 years old, pregnant/
lactating
1,100
1,300
19-50 years old, pregnant/
lactating
800
1,000
* Institute of Medicine of the National Academies in the USA
**For infants, Adequate Intake is 200 mg/day for 0 to 6 months of age and 260 mg/day for 6 to
12 months of age.
15
HOW DOES CALCIUM IMPROVE
BONE HEALTH?
Calcium performs various functions
in the body and is needed for muscle
contraction and as a building block of
bone. A calcium-rich diet is especially
important to build bone during the
highest rate of bone growth, which
is in childhood and adolescence.
Supporting bone health early in life
will help protect us from developing
osteoporosis later in life. As well, when
bone density is decreasing in later
years, a calcium-rich diet helps us to
maintain bone mineral density. This
applies to men and women of all ages.
While calcium supplements in later
life have shown a small benefit on
bone mineral density30,31, calcium
supplements in vitamin D deficient
individuals have not been shown to
reduce the risk of fracture27. Also,
calcium supplementation without
vitamin D supplementation may
contribute to an increased risk
of hip fracture27. Thus, vitamin
D supplementation plays a key
role in bone health — calcium
supplementation alone is insufficient
to prevent fractures. The focus in
fracture prevention has therefore
shifted to vitamin D supplementation
in combination with a healthy calciumrich diet. See table on left
Notably, these recommendations
of total calcium intake do not take
additional vitamin D supplementation
into consideration. As discussed in the
text above, individuals who have more
vitamin D are able to absorb more
calcium. Therefore, in combination
with vitamin D, a lower total calcium
intake of about 800 mg per day is
likely sufficient. This is the amount
of calcium that can be achieved by a
healthy diet that contains a daily dose of
calcium-rich foods.
HOW DOES PROTEIN IMPROVE
BONE HEALTH?
Protein is a building block for strong
bones and muscles. Similar to
calcium and vitamin D, insufficient
protein intake is detrimental to
bone development32 and bone mass
maintenance later in life33-36. As well, a
low protein intake is associated with a
reduction in muscle mass throughout
the life cycle and seniors with decreased
protein intake are more vulnerable to
muscle weakness, sarcopenia (agerelated decline in muscle mass and
function) and frailty, all contributing to
an increased risk of falling37-39.
As with vitamin D, protein intake
has a dual benefit on osteoporosis
prevention, as it helps build stronger
bones and muscles. One of the
mechanisms by which a higher
protein intake may have a positive
influence on bone and muscle health
is via an increase in blood levels of
Insulin-like Growth Factor -1 (IGF-1).
Regular daily milk intake results in a
measurable increase in IGF-1 blood
levels in children40. This may also be
achieved with protein supplements
as demonstrated in one study among
senior hip fracture patients35. IGF-1,
produced by the liver, promotes bone
and muscle formation, and supports
the conversion of vitamin D into its
active form (1,25-dihydroxyvitamin D)41.
The latter mechanism (via vitamin
D) explains in part how a higher
protein intake promotes calcium and
phosphate uptake in the intestine. In
addition, some amino acids (protein
components) have a direct stimulatory
effect on calcium uptake in the
intestine42. In children, a higher protein
intake has been shown to increase the
benefit of exercise on bone mineral
content43, confirming that the benefit
of staying active for stronger bones is
enhanced with protein-rich nutrition.
ARE THERE ADVERSE EFFECTS
OF A HIGHER PROTEIN INTAKE
ON BONE HEALTH?
Some studies have claimed that a
high protein intake may contribute to
increased calcium loss via the kidneys
and have suggested that a protein
rich diet may be detrimental for bone
health. This hypothesis has been
disproved as the increased calcium
excretion after a protein-rich meal does
not contribute to a negative calcium
balance44. Furthermore, it could not
be confirmed that animal proteins, by
increasing the acid load in our body,
lead to bone loss. In fact, there is no
Low protein intake is associated
with a reduction of muscle mass
throughout the life cycle
16
convincing evidence that plant protein
sources are superior to animal protein
sources44. Both plant and animal
protein sources appear to promote
stronger bones and muscles for
osteoporosis prevention.
SOURCES OF PROTEIN
Dairy products are a good dietary
source of protein necessary for
stronger bones and muscles. Additional
protein sources include nuts, legumes,
fish and meat. The current
Recommended Daily Allowance
(RDA)* is 1.5 g/kg each day in infants,
1.1 g/kg each day in children age
1 to 3 years, 0.95 g/kg each day
in children age 4 to 13, 0.85 g/kg
each day in teens age 14 to 18, and
0.8 g/kg per day for adults aged 19
and older. Notably, based on recent
epidemiological and clinical studies, a
protein intake higher than the current
RDA (1.0 to 1.2 g/kg per day) may be
beneficial for bone and muscle health
among the senior population39.
PROTEIN BENEFITS SPECIFIC TO
SENIORS AT RISK OF HIP
FRACTURES
Elderly hip fracture patients are the
most vulnerable to malnutrition and
protein deficiency. Low protein intake,
like vitamin D deficiency, contributes
to an increased risk for hip fracture36,45,
although a higher milk intake did not
reduce the risk of hip fracture in a
summary of available data from large
cohort studies among women, while
a benefit among men could not be
excluded46. Notably, several clinical
PROTEIN SOURCES
Food
1 ounce meat, fish, poultry
Protein (g)
7
1 large egg
6
4 ounces milk
4
4 ounces low-fat yoghurt
6
4 ounces soy milk
5
3 ounces tofu, firm
13
1 ounce cheese
7
1/2 cup low-fat cottage cheese
14
1/2 cup cooked kidney beans
7
1/2 cup lentils
9
1 ounce nuts
7
2 tablespoons peanut butter
8
1/2 cup vegetables
2
1 slice bread
2
1/2 cup of most grains/pastas
2
*Recommended Daily Allowances; US Department of Agriculture
17
trials with protein supplementation in
senior hip fracture patients resulted
in fewer deaths, shorter hospital stay,
and a higher likelihood of return to
independent living35,47,48. In one of
these studies it was demonstrated that
blood IGF-1 levels increased in seniors
who received protein supplements35.
Furthermore, increasing protein
intake has a beneficial effect on bone
mineral density in senior men and
women taking vitamin D plus calcium
supplements, suggesting an additive
benefit of these nutrients49.
There are other important lifestyle factors that impact negatively on bone health. These include
smoking, excessive alcohol and low body mass index.
ALCOHOL
Studies have shown that more than two units of alcohol per day can increase the risk of osteoporotic
and hip fractures in both men and women50. More than four units of alcohol per day can double the
fracture risk. While some of this increased risk is due to decreased bone mineral density, some of the
risk is also due to other poorly understood factors, which may include general deterioration of health
and the increased likelihood of falling, especially in the elderly51.
SMOKING
Smoking also increases the risk of osteoporotic fractures52. Studies of nearly 60,000 people in
Canada, U.S.A., Europe, Australia and Japan show that smoking increases the risk of hip fracture by
up to 1.8 times52. Conversely, the risk of hip fracture declines after smoking cessation53. Although
the risk of fracture from smoking increases with age, cigarette smoke has an early effect on
bones. Studies have shown that young male smokers, 18-20 years old, have reduced bone mineral
densityand an increased risk of osteoporosis later in life 54,55.
LOW BODY
MASS INDEX
The body mass index, or BMI, is a measure of how lean someone is and can be used as a guide
to measure his or her osteoporosis risk56. A BMI of 20 to 25 is generally considered to be ideal. BMI
below 19 is considered underweight and a risk factor for osteoporosis.
18
embrace vitamin D
• it improves strength and
function61, increases bone mineral
density24, and reduces the risk
of falls and fractures by about
20%, including fracture of the
hip (based on evidence from
clinical trials of oral vitamin D
supplementation60,62)
HOW DOES VITAMIN D IMPROVE
BONE HEALTH?
Vitamin D is essential for bone
development and maintenance
throughout life. Vitamin D has several
key functions:
• it assists in calcium absorption22
thresholds, a similar distribution is
found in children.
Most vulnerable to vitamin D
deficiency are:
• seniors in general and especially
those living in nursing homes or
institutionalized care
VITAMIN D DEFICIENCY
• it has a downward regulatory effect
on parathyroid hormone level23
resulting in reduced bone loss57
• individuals living in northern
latitudes with minimal sunshine
exposure
Prevalence
Depending on the threshold (see
has been
established that 50 to 70 percent of
the European and 30 to 50 percent of
the US adult population is vitamin D
deficient. When applying the same
• it ensures correct renewal and
mineralization of bone58
Thresholds on page 12) it
• it has a direct stimulatory effect on
muscle tissue59 and thereby
reduces the risk of falling60
• individuals who are obese
• individuals who have a
disease that reduces vitamin D
uptake from the intestine (i.e.
inflammatory bowel disease)
Dual action of
VITAMIN D
bone
muscle
Vitamin D helps calcium
absortion, important
bone development and
maintenance
Vitamin D has a direct
effect on muscle and
reduces the risk of
falling
19
• individuals who have a darker
skin tone
• individuals who for medical or
cultural reasons cannot expose
their skin to the sun
Definition
Defining universal diagnostic
thresholds of vitamin D status is
complicated due to the lack of
standardized testing methods and
the variability across population
groups. However, as a general
guidance, vitamin D deficiency
can be defined as a 25(OH)D
level of less than 50 nmol/l (< 20
ng/ml) , where increased bone
resorption and increased parathyroid
hormone (PTH) levels have been
documented. Levels lower than 25
nmol/l (< 10 ng/ml) are considered
severe deficiency, and can induce
adverse effects such as rickets in
infants and osteomalacia in adults.
Between 50 and 74 nmol/l (20–29
ng/ml), vitamin D levels are not
considered optimal and therefore
termed insufficient. In this range,
PTH levels may be in the normal
range, but fracture risk reduction
may not be achieved. Vitamin D
adequacy is defined in adults as a
threshold of at least 75 nmol/l (30
ng/ml), the threshold where fracture
risk reduction was achieved in
randomized controlled trials62.
Vitamin D adequacy needs to be
established in children, however in
younger (age 19-49),middle-aged
(age 50-64) and senior adults (age
65+) most data suggest that a level
of no less than 75 nmol/l is needed
for optimal bone health (hip bone
density – data in younger, middleaged, and senior adults73, fracture
prevention – data in senior adults62).
Based on large cohort studies,
additional safety advantages of
reaching the desirable threshold
of 75 nmol/l include a reduction in
cardiovascular risk and colo-rectal
cancer74. These additional benefits
of vitamin D need to be confirmed in
large clinical trials.
See table below
Who should be tested for
vitamin D deficiency with a 25hydroxyvitamin D
measurement?
We can assess vitamin D status by
measuring 25-hydroxyvitamin D in
the blood. International guidelines
recommend this measurement should
not be used as a screening tool in a
large majority of the population, but
should be targeted to those at risk
for severe vitamin D deficiency that
may need greater doses of vitamin D
than recommended at the population
level. In people with osteoporosis, a
25-hydroxyvitamin D measurement
is advised. People at risk of
osteoporosis and generally everyone
aged 60 years and older are advised
to take vitamin D supplements at a
dose of 800 – 1000 IU per day based
on the 2010 IOF Position Statement
on vitamin D75.
This recommendation is based on:
• the broad deficiency of vitamin D,
• the evidence from clinical trials
that showed that vitamin D
OVERVIEW
OF VITAMIN
D THRESHOLDS
OVERVIEW
OF VITAMIN
D THRESHOLDS
< 25 nmol/l (< 10 ng/ml)
= severe deficiency
25 - 49 nmol/l (10 -19 ng/ml)
= deficiency
50 -74 nmol/l (20 -29 ng/ml)
= insufficiency
75 - 110 nmol/l (30 - 44 ng/ml)
= adequacy
20
supplementation at a dose of 700 to
1000 IU per day reduces the risk of
falls60 and fractures62 by about 20%,
• and the safety of such a
recommendation74.
Therefore, measurement of serum
25-hydroxyvitamin D level in the
blood to evaluate vitamin D status
should be targeted to individuals at
risk for severe vitamin D deficiency
and the potential need of larger
vitamin D doses to correct their
deficiency. Individuals who:
• have a minimal trauma fracture
• have dark skin tone
• are obese
• are taking anti-epileptic drugs
• have malabsorption
• have medical conditions that
prevent them from going into the
sun without protection
• cover most of their body for cultural
or religious reasons
We do not recommend broad
population screening for vitamin D
deficiency in individuals who are not at
risk because the prevalence of vitamin
D insufficiency is high and the cost of
screening far exceeds the minimal cost
of supplementation.
IOF vitamin D recommendations are
800 to 1000 IU/day for fall and fracture
prevention in adults aged 60 and older
Why seniors are most
vulnerable to vitamin D
deficiency
Vitamin D deficiency is very common in
the elderly. The reasons for this are:
• In the elderly, the skin produces
4-times less vitamin D when
exposed to the sun, as compared
to younger people.
• Seniors tend to avoid direct
sunshine exposure – avoiding
the hot weather by staying cool
at home or using sun protective
measures such as wearing a hat
and sunscreen.
• Seniors generally have a
decreased consumption of fish
(possibly driven by economic
reasons and decreasing protein
intake with age).
Why children and younger adults
are at risk of vitamin D deficiency
• The average person exposes only
about 5% of their skin to the sun.
• Nowadays, most people are
aware of the dangers of sunburn
and skin cancer and wear sun
protective clothing and sunscreen.
However, a sunscreen of factor 6
already blocks most of the vitamin
D production in the skin.
• In today's society, children tend to
spend less time playing outdoors.
The majority of adults work
indoors, for example in offices,
stores or factories.
21
SOURCES OF VITAMIN D –
SUNLIGHT, FOOD,
SUPPLEMENTATION
Sunlight
The main source of vitamin D is
sunlight (UVB irradiation). Our skin
can make vitamin D from exposure
to sunlight. However, for the reasons
outlined below, sunlight is not a
reliable source of vitamin D and there
are also associated risks of skin ageing
and cancer.
Reasons why sunshine exposure is
not a reliable source of vitamin D
• All of Europe (and in many other
parts of the globe...) does not get
sufficient UVB irradiation intensity
during the months November
to end of March, allowing for
minimal skin production of vitamin
D independent of age during the
winter season. Notably, at latitudes
of above and below 33° , vitamin
D synthesis in the skin is low or
absent during most of the winter.
This area includes all of Europe
(and also the Mediterranean).
• As the half-life of vitamin D is 3 to
6 weeks, there is a seasonal peak
of vitamin D status in northern
latitudes in September, followed by
a rapid decrease, with the lowest
point beginning in November
and reaching an all-time low in
early spring. Thus, even if we
get sufficient vitamin D during
the summer, this may not secure
vitamin D status in the winter
months and early spring time.
• Skin production of vitamin D
declines with age, leaving seniors
with a 4-times lower capacity to
produce vitamin D in their skin
compared to younger adults63.
Further, seniors tend to avoid
direct sun exposure which
explains the large segment of
seniors with vitamin D deficiency
residing in southern areas with
ample sunshine availability
(e.g. Mediterranean, Northern
Australia).
• The use of sunscreen and sun
protective clothing reduces skin
production of vitamin D
independent of age64,65. Several
studies have shown that clothing
worn for cultural or religious
reasons can have an adverse effect
on vitamin D status and bone
health66. A sunscreen factor of 6
already blocks most of the vitamin
D production in the skin65. Solar
elevation angle (i.e. time of day),
cloud cover, air pollution, altitude,
and surface reflection have an
impact on vitamin D production in
the skin67. Exposure measurements
are related to a horizontal plane,
while vertical surfaces such as the
Natural Nutritional Sources of
Vitamin D
IU vitamin D
Wild salmon
600 to 1000 IU per 100 grams
Farmed salmon
100 to 250 IU per 100 grams
Sardines, canned
300 to 600 IU per 100 grams
Mackerel, canned
250 IU per 100 grams
Tuna, canned
236 IU per 100 grams
Cod liver oil
400 to 1000 IU per table spoon
Shiitake mushrooms, fresh
100 IU per 100 grams
Shiitake mushrooms, sun dried
1600 IU per 100 grams
Egg yolk
20 IU/yolk
22
face, arms and legs receive much
lower UVB doses compared to a
horizontal plane. Thus, in practice
much longer exposure times than
expected are needed to produce
a certain amount of vitamin D.
The UVB exposure time needed to
produce 800 IU vitamin D differs
by skin type and season. For an
8% body surface exposure (face
and hands) during midday the
exposure time will vary between
about 30 minutes to 1 hour in the
summer time, and up to about 20
hours in the winter 68-70.
fortification. Vitamin D that is taken
orally as a supplement is best absorbed
if taken with food as it is a fat-soluble
vitamin72. When compared in clinical
trials, vitamin D3 has been shown to
be more efficient than vitamin D2 in
reducing falls60 and fractures62.
Vitamin D supplementation and
recommendations
Safety of vitamin D
supplementation
There are two international
recommendations regarding vitamin
D that are relevant to the population
at large and individuals at risk of
osteoporosis. For the population at
large the Institute of Medicine of the
National Academies in the USA (IOM)
defined vitamin D recommendations
throughout the life cycle with the
goal to reach a 25-hydroxyvitamin
D threshold of about 50 nmol/l (see
76
recommendations below) . The IOM
recommends 600 IU vitamin D per day
in all individuals age 1-70, and 800 IU
in adults age 71 years and older.
Vitamin D is a fat soluble vitamin.
Therefore very high doses may lead
to intoxication. A safe upper intake
level has been defined for all age
groups76. The safe upper limit intake
recommendation is 1000 IU/day from 0
to 6 months, 1500 IU/day from 6 to 12
months, 2500 IU from age 1-3 years,
3000 IU from age 4-8 years, and 4000
IU from age 9 and older, including
pregnant and lactating women.
Natural nutritional sources of vitamin
D are limited. Larger amounts are only
present in fatty fish, such as salmon72.
Nutritional sources of vitamin D
Food sources of vitamin D are rather
limited, and include fatty fish, such as
salmon, mackerel, and herring. Farm
salmon will provide only half as much
vitamin D as wild salmon71. We would
have to eat two servings of fatty fish a
day to reach a recommended intake of
800 IU vitamin D per day for fracture
reduction72. Additional sources are
eggs and liver (1 egg contains about
40 IU of vitamin D). Some countries
fortify margarines and milk with
vitamin D. For example, in the USA,
one glass of milk is fortified with 100
IU vitamin D.
The IOF had a different target
in their 2010 position paper for
vitamin D, designed to ensure
optimal fall and fracture reduction75.
Based on this target, IOF defined
a 25-hydroxyvitamin D threshold
of 75 nmol/l. Given the broad
prevalence of vitamin D deficiency,
IOF recommends 800 to 1000 IU in
all adults at 60 years and older for
Vitamin D comes in two forms.
Vitamin D3 (cholecalciferol) is the
version of vitamin D that is made in
our skin and found in fatty fish and
eggs. Vitamin D2 (ergocalciferol) is
a closely related molecule of plant
origin. Both vitamin D2 and vitamin D3
are used in supplements and for food
Age Group in Years
See table on previous page
fall and fracture reduction without
prior testing for vitamin D deficiency.
Thus, both institutions have similar
recommendations on the dose of
vitamin D as this reflects the vitamin D
doses tested in clinical trials,
however, they differ in their threshold
recommendation. For osteoporosis
prevention and the prevention of falls
and fractures, the higher threshold
of 75 nmol/l is recommended by this
report. See table below
In a 2010 benefit-risk assessment
of vitamin D the authors found no
pattern of evidence to suggest that
risk (hypercalcemia – increased blood
calcium levels) is elevated from daily
intakes of vitamin D up to 10,000 IU or
serum 25(OH)D up to 240 nmol/L74,
which are far higher intakes and
blood concentrations than those
necessary to achieve the benefits for
bone and muscle strength (800 IU
vitamin D intake per day and target
25-hydroxyvitamin D blood level of
75 nmol/l).
Public Intake Recommendations
for Vitamin D
Institute of Medicine
Public Intake Recommendations
for Vitamin D
IOF
0-1
*
Not assessed
1-59
600 IU/day
Not assessed
60-70
600 IU/day
800 to 1000 IU/day
71+
800 IU/day
800 to 1000 IU/day
Target 25(OH)D level in nmol/l
50 nmol/l for bone health in all ages
75 nmol/l for fall and fracture
prevention
*adequate intake is 400 IU/day
IOF includes all individuals with osteoporosis independent of age and states that higher intake levels may be needed in some individuals
to reach a serum blood level of 75 nmol/l 25(OH)D
23
Our skeleton is sensitive to gravity and
weight-bearing physical activity as a
stimulus to maintain and build bone
and prevent muscles from wasting.
HOW DOES PHYSICAL
ACTIVITY IMPROVE BONE
HEALTH?
It is thought that exercise, especially
during childhood and adolescence,
may change bone structure and
geometry (such as greater diameter
of bones and stronger trabecular
architecture), which may reduce
the risk of fracture later in life77.
Throughout the life cycle, there
is a strong positive relationship
between physical activity and bone
health. Being active benefits bone
and muscle strength regardless of
age1,78. In contrast, immobilization of
the skeleton (in the form of bed rest,
casting or spinal cord injury) leads
to bone loss, muscle wasting, and
increased susceptibility to fracture
within a few weeks79. A perfect
example of unloading of the skeleton
can be seen with astronauts, who
lose considerable bone and muscle
mass due to prolonged periods of
weightlessness in space.
Measurable differences in fracture
risk are also observed between those
habitually active (non-athletic) and
sedentary individuals81.
Studies confirm a
have shown that the most physically
active young girls gain about 40%
more bone mass than the least active
girls of the same age. Other studies
benefit of exercise
on BMD, muscle strength and the
prevention of falls
THE IMPORTANCE OF PHYSICAL
ACTIVITY IN YOUTH
Laying down the 'bone foundation'
in youth gives advantages later in life.
Most people reach their 'peak bone
mass' in their 20s. This is when bones
have achieved their maximum density
and strength. For example, in girls, the
bone tissue accumulated during the
ages 11 to 13 approximately equals
the amount of bone lost during the 30
years following menopause. Studies
The rapid bone loss with
immobilization mimics many years of
'ageing' and may help us understand
how detrimental inactivity is to our
bones and how important it is to
maintain a physically active lifestyle.
Clinical studies which compare
individuals who exercise with groups
who do not have demonstrated
significantly higher BMD in those who
exercise regularly80. Exceptions occur
with high-intensity non weight-bearing
activities, such as swimming, and in
amenorrhoeic athletes (hormonal
changes due to high-intensity
sportive activities), who may have a
BMD similar or worse than controls.
24
have shown that boys who did the
most vigorous daily activity had 9%
more bone area and 12% more bone
strength than less active boys81.
The concern is that, with the advent of
computers, TV and electronic games,
many children and teenagers are living
increasingly sedentary lifestyles. To
ensure that their children are getting
enough exercise, parents need to
encourage daily weight-bearing
physical activities and sports.
embrace an active lifestyle
Several observational studies support
a beneficial association between a
greater lifetime physical activity and
preservation of BMD, as well as a
lower risk of hip, humerus and
vertebral fracture, at older age1,82. It
was also suggested that exercising
prior to age 40 is associated with a
lower risk of falling in seniors83. Thus,
we get rewarded for being active
when we were young even much later
in life.
bearing aerobic exercise (such as
brisk walking, hiking, stair climbing
or jogging), high intensity progressive
resistance training (lifting weights)
and high impact exercise (such as
jumping or rope skipping) increase
BMD by 1 to 4% per year in pre- and
postmenopausal women84. More
vigorous exercise interventions seem
to produce greater effects84. It should
be noted that casual walking may not
reduce fracture risk. However, a large
cohort study supports a benefit of
brisk walking on reducing the risk of
hip fracture (more than 4 hours a week
may reduce hip fractures by 41%1).
WHICH EXERCISE
PROGRAMMES ARE EFFECTIVE?
FACTS ABOUT EXERCISE AND
BONE HEALTH
While we lack evidence from large
trials that test exercise in the
prevention of fractures, several studies
confirm a benefit of exercise on BMD,
muscle strength, and the prevention
of falls. Based on these studies78,
moderate to high intensity weight-
•
LIFETIME PHYSICAL ACTIVITY
AND PRESERVATION OF BONE
HEALTH AT OLDER AGE
•
Effective activity does not have to be
weight-bearing. Resistance training
(lifting weights) is an effective non
weight-bearing activity.
•
Aerobic activity that is non
weight-bearing (such as
swimming or cycling) does not
enhance bone density.
•
Lifting heavy weights is more
effective than lifting light weights.
•
Lifting heavy weights rapidly
(power training) seems to be
more effective than lifting heavy
weights slowly (traditional
resistance training).
•
Rapid movements are more
stimulating than slow movements.
•
Muscles connected to the bones
that are most susceptible to
fracture (hip, wrist, thoracic spine)
should be targeted with
specific exercises.
85
Rapid, short bursts of high
intensity and/or high impact
activities such as jogging, jumping
and rope skipping are more
stimulating to bone cells than
sustained, low impact activity such
as walking.
Staying active by brisk walking or other weight-bearing physical activities directly addresses key risk factors for osteoporotic
fractures. These include low bone mineral density, muscle weakness, poor balance, falling and fear of falling. The first
step is to overcome being inactive - in your daily life. Include simple strategies to keep moving!
1
Take the stairs instead of
the elevator.
2
Walk small distances
instead of relying
on the car or public
transportation.
3
Make it a habit to go for
a walk (or some other
activity) each day – set
daily and weekly goals.
25
4
Stand on one leg while
performing tasks of daily
living: i.e. while brushing
your teeth, waiting for
the coffee machine,
washing up.
EXERCISE PRECAUTIONS IN
PEOPLE WITH DIAGNOSED
OSTEOPOROSIS AND
FRACTURES
•
•
•
•
•
With existing osteoporosis, caution
should be applied with activities
and sports that have the potential
of severe injury, such
as ice skating, downhill skiing,
mountain biking.
People at risk for osteoporotic
fracture should avoid deep
backbends and activities that
involve forward bending of the
spine, particularly while carrying
an object (for example, lawn
bowls, sit ups with straight legs
or simply bending over to pick
up something from the floor), as
this movement in the presence of
osteopenia increases the risk of
anterior compression fractures of
the thoracic vertebrae.
Involve a health care professional
(your doctor, physiotherapist,
exercise physiologist) in your
exercise programme design as
supervised, targeted exercise
programmes are recommended.
Programmes that include muscle
strengthening, balance training
and coordination exercises are
highly recommended.
In frail seniors with poor balance,
mobilization without balance and
strength training may increase the
risk of fracture. Thus, mobilization
should be supervised by
physiotherapists and supported by
strength and balance training.
ADD EXERCISE TO YOUR DAILY
ACTIVITIES
Find ways to incorporate short exercise
intervals into normal daily activities.
For many people, this may be more
successful than planning structured
exercise classes away from home.
• insert a few jumps during
television commercials.
Strengthening the upper extremities is
also important for falls prevention.
• jump or hop rather than walk up a
flight of stairs.
Notably, these exercise programmes
are effective in seniors living in the
community and those living in nursing
care. Further, recent studies suggest
that instructed but unsupervised
exercise programmes are effective and
demonstrate a significant reduction
of falls, both in seniors living in the
community86 and seniors with an acute
hip fracture87.
• stand on one leg while washing
the dishes or while you wait for
the coffee machine.
• use stairs instead of elevators.
• walk briskly for 10 minutes or
more several times a day.
Weight-bearing exercise programmes
that improve gait speed, muscle strength
and balance in seniors can translate into
a 25-50% reduction in falls
EXERCISE BENEFITS ON FALLS
PREVENTION
Many studies demonstrate that simple
weight-bearing exercise programmes
improve gait speed, muscle
strength, and balance in seniors,
which translates into a 25-50% fall
reduction2,3,4. As falls are the primary
risk factor for fractures, the rationale is
that these interventions should also
protect against fractures, although this
needs confirmation in large clinical
studies. The recommendation is that
exercise programmes for fall and
fracture prevention should include
balance training and lower and
upper extremity strength training.
26
Tai Chi has been successful in reducing
falls among healthy older individuals,
and physically inactive communitydwelling older individuals, while frail
older individuals and fallers may not
benefit as much. Programmes that
support cognitive function within an
exercise programme may be of great
value for fall prevention. Earlier studies
suggested that fall risk is increased
in seniors unable to walk while
talking (stop walking when talking –
reduced ability to perform two tasks
simultaneously). This concept was
tested in a music-based multitask
exercise programme, which improved
gait and balance and reduced fall risk
in community-dwelling seniors4.
1
about 50 jumps (approximately
8 cm high) three to six days per
week.
2
two or three sets of 8 to 10
repetitions of each of 6 to 8
weight lifting exercises three
days per week.
27
3
45 to 60 minutes of weightbearing aerobic exercise three
days per week (i.e. brisk
walking)
LOVE YOUR
BONES
EXERCISE
• Move it or lose it! Longer term
immobilization, such as through
bed rest, leads to rapid bone
loss and increased susceptibility
to fracture.
• Studies comparing groups of
individuals who exercise compared
to those who don't have
demonstrated higher BMD in the
athletic group.
FAST FACTS
• Exercising prior to age 40 is
associated with a lower risk of
falling in seniors.
NUTRITION & EXERCISE:
THE BUILDING BLOCKS
embrace an active lifestyle
FOR HEALTHY BONES
28
• Moderate to high intensity
weight-bearing aerobic exercise,
high intensity progressive
resistance training (lifting weights)
and high impact exercise (e.g.
jumping or rope skipping) has
been shown to increase BMD
by 1 to 4% per year in pre- and
postmenopausal women.
• Rapid, short bursts of high
intensity and/or high impact
activities such as jogging, jumping
and rope skipping are more
stimulating to bone cells than
sustained, low impact activity
such as walking. Aerobic activity
that is nonweight-bearing (such
as swimming or cycling) does not
enhance bone density.
• Simple targeted exercise
programmes have been shown to
improve bone density and
functional mobility, result in 25 to
50% fewer falls in frail and active
older adults.
• Mobilization in frail seniors should
be supervised and supported by
strength and balance training.
CALCIUM &
PROTEIN
•
Calcium is a key structural
component of bone.
•
Natural calcium sources, such as
dairy products, sardines and nuts,
are preferred calcium sources and
also provide high-quality protein.
embrace calcium rich foods
•
• Vitamin D assists calcium
absorption and has a direct effect
on muscle.
• Vitamin D deficiency is common
and a healthy nutrition cannot
compensate deficiency.
• Above and below latitudes of
approximately 33°, vitamin
D synthesis in the skin is low
or absent during most of
the winter (which includes
all of Europe, including the
Mediterranean area).
Individuals who have more vitamin
D are able to absorb more calcium.
Therefore, in combination with
vitamin D, a minimum total calcium
intake of about 800 mg per day is
likely sufficient in most individuals.
This amount of calcium can be
achieved by a healthy diet that
contains a daily dose of calciumrich foods.
• Skin production of vitamin D
declines with age, leaving seniors
with a 4-times lower capacity to
produce vitamin D in their skin
compared to younger adults.
Calcium supplements should
be combined with vitamin D for
optimum effect.
•
Both plant and animal protein
sources appear to promote stronger
bones and muscles for osteoporosis
prevention.
•
In children, a higher protein intake
has been shown to increase the
benefit of exercise on bone mineral
content.
•
Seniors with decreased protein
intake are more vulnerable to
muscle weakness, sarcopenia,
and frailty, all contributing to an
increased risk of falling.
•
Several clinical trials with protein
supplementation in senior hip
fracture patients resulted in fewer
deaths, shorter hospital stay, and
a higher likelihood of return to
independent living.
embrace vitamin D
•
VITAMIN D
29
• Evaluation of vitamin D status
should only be targeted to
individuals at risk for severe
deficiency: people who have
suffered a minimal trauma
fracture, have dark skin tone,
are obese, have malabsorption,
have medical conditions which
prevent them from going
outdoors without protection
or cover most of their body for
cultural or religious reasons.
• Vitamin D supplementation has
been shown to reduce the risk of
falls and fractures by about 20%,
including fractures of the hip.
• IOF recommends vitamin D
supplementation for people at
risk of osteoporosis and generally
everyone aged 60 years and older
(recommendation: 1000 IU
vitamin D per day).
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PROF CYRUS COOPER
Chair of the Committee of Scientific Advisors, IOF
WorldOsteoporosisDay
October20,2011
World Osteoporosis Day 2011 Global Sponsors
in collaboration with
AUTHOR
Prof Heike A Bischoff-Ferrari, MD
Centre on Aging and Mobility, University of Zurich
SNF-Professor, Dept. of Rheumatology and Institute of Physical Medicine,
University Hospital Zurich
EDITORS
Judy Stenmark IOF
Laura Misteli IOF
REVIEWERS Prof Bess Dawson-Hughes, MD
Professor of Medicine, Tufts University School of Medicine
Prof Cyrus Cooper, Dr Nick Harvey, Dr Chris Holroyd
MRC Lifecourse Epidemiology Unit, University of Southampton, UK
Dr Denys Wahl IOF
DESIGN
Gilberto D Lontro IOF
©2011 International Osteoporosis Foundation
32
Special Acknowledgements
Exercise & Fracture Prevention - A Guide for GPs &
Health Professionals report by Osteoporosis Australia
(2007)
Bone Appetit - The role of food and nutrition in
building and maintaining strong bones report by B.
Dawson-Hughes on behalf of the International
Osteoporosis Foundation (2006)
International Osteoporosis Foundation
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