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Ask the Osteoporosis Experts

Online Health Chat with Dr. Andrea Sikon and Dr. Johnny Su

May 4, 2012

Introduction

Cleveland_Clinic_Host: Learn how osteoporosis, the “silent thief of bone,” can be prevented, detected, and treated. Our experts will discuss how both men and women are affected by this metabolic bone disease. They will address early detection and prevention strategies that focus on balance and falls, vitamin D intake and the amount of calcium in your diet, along with the variety of osteoporosis medications available.

Osteoporosis is a common, preventable, and treatable form of metabolic bone disease. Ten million Americans have this condition. Four-fifths of them are women. Early identification and treatment of low bone density is most effective in increasing bone mass and avoiding painful fractures.

Andrea Sikon, MD, FACP, NCMP, CCD, is the Chair of the Department of Internal Medicine at Cleveland Clinic in Cleveland, Ohio. She is a National Certified Menopause Practitioner (NCMP) through the North American Menopause Society (NAMS) and a Certified Clinical Densitometrist (CCD) through the International Society of Clinical Densitometry (ISCD), practicing in both Internal Medicine and the Center for Specialized Women’s Health. Dr. Sikon’s clinical interests are in women’s health, osteoporosis, and menopause. She started the Primary Care Women’s Health program of the Medicine Institute at the Cleveland Clinic as its first director in 2008.

Johnny Su, MD, is a rheumatologist in the Orthopaedic & Rheumatologic Institute. He specializes in osteoporosis and general rheumatology. Dr. Su graduated from the University of Michigan Medical School and went on to complete a residency in Internal Medicine at University Hospitals of Cleveland. He also completed a fellowship in rheumatology at University Hospitals of Cleveland. He is a member of the American College of Rheumatology and the International Society of Clinical Densitometry.

To make an appointment with Johnny Su, MD, or any of the other specialists in our Department of Rheumatic and Immunologic Diseases at Cleveland Clinic, please call toll-free at 866.275.7496. You can also visit us online at clevelandclinic.org/rheum

To make an appointment with Andrea Sikon, MD, please call 216.444.3024 or call toll-free at 800.223.2273, ext. 43024. You can also visit us online at clevelandclinic.org/obgyn

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic osteoporosis experts Dr. Andrea Sikon and Dr. Johnny Su. We are thrilled to have them here today for this chat. Let’s begin with some of your questions.


TREATMENTS

JeanB: Are there alternatives for those of us who would prefer not to take drugs [risedronate (Actonel®) or alendronate (Fosamax®)]? My doctor is very adamant that I take Fosamax. She says I am at high risk because I am white and thin (132 lbs). I have been diagnosed with osteoporosis of the spine; my hips are okay. I am 68 years old and have no history of osteoporosis on my maternal side; one aunt on my paternal side had osteoporosis. I have been on/off Fosamax for over a year and have experienced side effects. Prior to that, I took Actonel for several years. I exercise daily and take calcium and Vitamin D. My general practitioner told me that taking calcium does no good. I feel I'm being pro-active for my health, but what else can I do aside from take drugs? I have been struggling with this question for a few years.

Dr__Su: Unfortunately, although calcium and vitamin D supplements are important, drugs are needed if patients have osteoporosis to treat the disease. In terms of whether you need osteoporosis drugs at this point in time, it depends on whether your bone density test is stable and how long total that you have been on either Actonel or Fosamax. A urine test, called urine NTX, can be used to determine if previous medications are effective. An appointment is recommended in order to be more specific with regard to individualized recommendations.

books4bert: I'm 57 years old, post-menopausal, with multiple sclerosis and celiac disease. My father had Paget's disease. My mother had osteoporosis and celiac disease. I was on Fosamax for 10 years, switched to calcitonin salmon nasal spray (Miacalcin®) after that. Recent DEXA testing showed osteoporosis in spine, osteopenia in hips. What should I be doing now for the osteoporosis?

Dr__Su: Since you were on Fosamax for 10 years, the most important two things to determine are whether the Fosamax is still having an effect since it has been stopped and if your bone density is stable or not. If the bone density is stable, and you were on Fosamax for 10 years, nothing may need to be done unless a urine test called urine NTX shows that you are losing the effects from previous Fosamax use.

books4bert: Should I continue the Miacalcin, or is it ineffective?

Dr__Su: Miacalcin does help increase your bone density but does not help prevent fractures. I would need to know results for your bone density tests and other medical history to see if you should continue it.

Metaphor: My question relates to conflicting medications and supplements: Is it safe to take omeprazole (Prilosec®) or esomeprazole (Nexium®) while also trying to assure calcium absorption is adequate? Does having had a zoledronic acid (Reclast®) infusion offset these? How does a family history of severe osteoporosis contribute? Is Citracal® slow-release calcium adequate (2 pills/day) as a supplement? My bone density numbers are slowly going down, and I have had two stress fractures in the last 3 to 4 years. I also had cortisone shots in my back for osteoarthritis over several years. No doctor seems to have a comprehensive answer.

Dr__Sikon: There are many questions here! Products like Prilosec, Nexium, famotidine (Pepcid®), and ranitidine (Zantac®) are all antacids that can decrease the absorption of certain types of calcium supplements. To be safest, you can either ingest your calcium in your diet by eating/drinking food that is high in calcium, like skim milk and dark green leafy vegetables, or you can take a calcium citrate supplement instead of calcium carbonate. Calcium citrate does not need an acidic environment to be absorbed and thus should not interfere with Prilosec, Nexium, etc. Reclast should not change this. Family history dramatically increases a person's own risk of osteoporosis and bone breaks/fractures, but does not necessarily weigh in on the calcium absorption issue above. I recommend doing a calcium calculator, of which many can be found online by searching "calcium calculators" to find out exactly how much calcium you are likely taking in your diet and how much you then would need in a supplement to make up the difference. Postmenopausal women need 1200-1500 mg calcium/day. If you are taking enough calcium, taking enough vitamin D and getting Reclast, and you are still breaking bones, you should likely be checked for other causes of osteoporosis, called secondary causes, which may be missed. Doctors who specialize in bone health, such as women's health doctors, rheumatologists, and endocrinologists, can all help to guide such an evaluation and next best treatment steps.

yless1: I have osteoporosis and severe acid reflux. I am off the Nexium that had an impact on my back (curving), but I am taking 20 mg. of Pepcid twice a day to keep the reflux in check. Also, taking large doses of calcium really aggravates my stomach. First, will taking the 2 doses of Pepcid a day have the same effect as the Nexium? Is it the reduction of acid or the medication that causes the mal-absorption? What medication do you recommend for patients with both conditions? I feel like I have to choose between my stomach and my bones! Please tell us how you treat people with severe acid reflux and osteoporosis. Is taking two 20mg doses of Pepcid every day the same as taking a proton-pump inhibitor (PPI)?

Dr__Sikon: The answer to metaphor's question should help you. I recommend that patients try to get their calcium preferably from their diet, rather than supplements, when possible. For some, it is too hard to do, especially those with lactose intolerance, as dairy products have the most calcium concentrations. If a supplement is needed, calcium citrate is a type of calcium supplement that does not need an acidic environment in the stomach to be absorbed and can be used when antacids are necessary.

DJOHNSON: I have been advised by my physician to get a Reclast IV treatment or denosumab injection (Prolia®). I am researching the side effects. I would like information about these from you. I was found to have holes in the L1-L2-L3 (vertebrae). They told me that if I fell, these would collapse, and I would be in very bad pain. I do have acid reflux and years ago tried Actonel and Fosamax, which really messed with the reflux. What does this Reclast do? My insurance will pay for it, but I have to find out about the Prolia. I am taking calcium with vitamin D x2/day 1200 mg. Please help me decide what I need to do. Thank you in advance.

Dr__Su: Both Reclast and Prolia prevent bone from being reabsorbed as fast as it is currently being reabsorbed, leading you to have osteoporosis. Prolia is stronger than Reclast and may actually help you make more bone. Both of these medications are better alternatives than the pills due to the reflux. Websites for the two drugs are www.reclast.com and www.prolia.com. I recommend an appointment to better assess which medication is more suitable for you individually.

Goferbroker: Please comment on medications appropriate for restoring bone density. I have very low testosterone levels that have been causing loss of bone density. I am using testosterone gel (Testim®) rubbed on my shoulders and calcitonin nasal spray. Dr__Su: Appropriate medications for treatment of low bone density depend on how low the bone density is and whether you have fractured any bones. In addition to treating low testosterone level, medications such as Reclast, Boniva, Actonel, or Fosamax may be needed to treat low bone density. But if you already had fractures related to bone density, medications such as teriparatide (rDNA origin) (Forteo®) or denosumab (Prolia®) may be more appropriate. Choice also depends on other concurrent medical conditions that you are being treated for.

ferg: Do you think Prolia is safe and effective for treating osteoporosis in an 82-year-old female? What drug do you think is the most effective?

Dr__Sikon: Prolia is an agent that has come available last year and has been used with success to date to treat certain patients with osteoporosis that are at high risk for fracture. Generally, as aging is one of the most significant risk factors for aging and that Prolia can be used even if kidney function is reduced, which is also common in the elderly, it is generally a very nice option. There have not been head to head studies to date that I know of between Prolia and bisphosphonates to be able to answer which is "most effective." In general, I recommend that all therapy for bone should be individualized after a thorough history, physical, and lab testing is done as well as discussion with a patient's individual preferences. In general, all of the therapies for bone are safe, especially so if tailored based off of an individual's risk profile.

Marvin: I have several spinal fractures which are causing pain. Would a testosterone patch applied to the fracture site on my back be likely to ease pain and help the condition? I understand of course that I would need a prescription for the patch. I have received zoledronic acid (Zometa®) infusions every other month for nearly two years, but they do not seem to be having any effect.

Dr__Sikon: Spinal fractures, unfortunately, can as you well know, cause significant pain. When one vertebra breaks, it causes a change in the positioning of the spine and can put stress on the vertebra above and below, causing more pain and increasing the risk of breaks in other vertebra as well. Testosterone therapy is not used to treat the pain from osteoporosis but rather if there is low testosterone levels as a cause from OP. You should, if you have not already, have a full secondary evaluation to find out if there is a specific condition that is causing your low bone density and breaks.

crofram: I am a 68 year old female who had been on Fosamax/generic since the age of about 53. My recent bone density test indicated that I have a T Score = 0.7. Should I take a "holiday" off for a few years? I have never had a problem with the medications. My MD says we can discuss this, but has not come up with a conservative solution. I have never broken any bones and am somewhat concerned to go off this since all is going well for me. Thank you.

Dr__Su: Given that you have been on Fosamax for 15 years, you should probably go off Fosamax. Whether you need to be on another medication instead depends on the trend of your bone density test results. What is more important on your recent bone density is change from last bone density rather than T-score. If bone density is stable based on actual bone mass numbers, then no alternative medication needs to be started when going off Fosamax. If there is decrease in bone mass, another medication needs to be started instead of Fosamax.

yless1: I have osteoporosis and severe acid reflux. I am off the Nexium that had an impact on my back (curving) but I am taking 20 mg. of Pepcid twice a day to keep the reflux in check. Also taking large doses of calcium really aggravates my stomach. First...will taking the 2 doses of Pepcid a day have the same effect as the Nexium? Is it the reduction of acid or the medication that causes the mal-absorption? What medication do you recommend for patients with both conditions? I feel like I have to choose between my stomach and my bones!

Dr__Su: The curving in your back may or may not be related to Nexium. If it's scoliosis, where curvature is to right or left, than it is probably not related to osteoporosis. If it is a humpback type of curving, then it may be related to osteoporosis. If Nexium played a role in osteoporosis, it is likely minor compared to other risks. Medications like Nexium are probably better than Pepcid in terms of blocking acid. The reduction of acid may impair absorption of calcium carbonate types of calcium contributing to osteoporosis. In your case, I would use Nexium if needed for reflux and treat your osteoporosis as appropriate, with first treatment recommendation being Reclast. Reclast, being an intravenous medication, does not make reflux worse.

amber: Any contraindications or side effects for Reclast & how often is it administered?

Dr__Sikon: Reclast is a bisphosphonate (BPS), similar to Fosamax, Actonel, ibandronate (Boniva), etc. It is conveniently given once yearly via a brief intravenous infusion and makes treatment very easy. In general, it is extremely safe, as all of these medications are, as they are very specific to the bone. Patients who have very low kidney function should avoid Reclast and all of the BPS. Like any medication, it is not for everyone. A small subset of patients who have never had prior exposure to BPS can get brief flu-like symptoms (achiness) with the first infusion which does not usually recur with future infusions. Patients are encouraged to drink lots of water the day of and following the infusion and try acetaminophen to minimize any symptoms. Patients with low calcium or low vitamin D levels should not get it until those levels are restored to normal.

Harry1937: My wife is taking Forteo and is -4. She started 2 weeks ago. How long before any signs of improvement?

Dr__Sikon: In general, bone density is only one way, and the most common way, we follow an individual's risk of breaking a bone and response to medications to prevent such breaks. Changes in bone density, though, are slow and take a while to be seen on a bone density test. This is why a bone density will not likely be recommended, even if she is on treatment, until 2 years later. In the meantime, some doctors use markers of bone breakdown, which are urine and/or blood tests, to help follow response during treatment. These can be checked more frequently to see if there is a response, but these tend to be tricky to measure and interpret, and are thus sometimes less accurate. This doesn't mean that she has to wait two years to see benefits. Many studies of medications to treat osteoporosis show reductions in fracture risk within the first 6 months of treatment. There is not an ideal way to measure this reduction, though, other than the tests mentioned above.

Metaphor: What is the latest thinking on hormone replacement therapy and bone density?

Dr__Su: Given the health risks of cancer and cardiovascular events associated with hormone replacement therapy, it is no longer recommended as first-line treatment for women with low bone density. Usually bisphosphonates are recommended as first-line treatment for women with low bone density.

nance: It is recommended that people take a break from Fosamax after using it for many years. Is this also true for raloxifene (Evista®)?

Dr__Sikon: The concept of taking "drug holidays" after many years of treatment with bone agents is somewhat new and not completely validated yet. Studies have been done in patients NOT AT HIGH RISK for fracture/breaks after 5 and 10 years of risedronate and alendronate. Bone breakdown markers did start to increase after stopping risedronate in that group. Evista is usually used for 5 years as well. More studies are needed to determine the optimum duration of therapy for individuals with different risk factors as well as who have been treated with different combinations of different meds. Getting adequate calcium and vitamin D is necessary throughout a person’s entire life.

rthrboutdrs: My doctor is a PA and I will not be seeing her again for some time. Hip fracture for my maternal grandmother, many years ago, had very sad results. What drug do you recommend for possible hip fractures? Thank you for this very informative chat session.

Dr__Su: The recommendation for first-line treatment is most likely going to be a bisphosphonate such as Reclast, Boniva, or Actonel. All of these medications are effective for treatment of hip fractures if that is how diagnosis of osteoporosis was made. If there is a hip fracture, and there is bone density showing osteoporosis, then Forteo or Prolia would be the first-line treatment over bisphosphonates.

marilynmann: I am 56. In 2008 I had a DXA. My hips were normal, spine -1.5. I have been on tamoxifen for 4 and 1/2 years. I reached menopause in 2007, the same year I started the tamoxifen. How soon should I be retested? My mother has osteoporosis but has not had a hip fracture. I occasionally use inhaled corticosteroids if I have an asthma flare-up, but that is usually only a few weeks per year. No history of fracture except a couple broken toes.

Dr__Sikon: Tamoxifen can actually improve bone density, as it is in the same class as a medication approved to treat osteoporosis, Evista/raloxifene. As tamoxifen is usually stopped after 5 years of therapy, you may consider getting another baseline DXA /bone density test when you are completing therapy with the tamoxifen and then again 2 years after that to check for losses. You should get that DXA if at all possible on the same scanner, so that you can tell if there are losses or not. If you get it on a different scanner, you will not be able to accurately compare the values you had on your 2008 study.

amber: How does a history of taking tamoxifen for 5 years, post breast cancer, increase my development of osteoporosis?

Dr__Sikon: Similar to an earlier answer provided to the question by marilynmann, tamoxifen can actually increase your bone density or help preserve it. The other powerful anti-estrogen treatments for breast cancer, like letrozole (Femara®), which are often started after 5 years of tamoxifen treatment, can decrease bone density significantly, though. Many might consider actually starting a preventative bone agent during such treatment to help preserve bone density during such therapy, which usually lasts 5 years. rthrboutdrs: What drug do you see (without adverse effects) as the best to rebuild bone?

Dr__Sikon: In general, most all of the medications for bone are safe. As with all medications, including vitamins and supplements, everything comes with risks and benefits, and choosing between these should be individually tailored to an individual's profile, risks, other illnesses/conditions, and preferences. Cost is another consideration. Not all of the medications for bone act on the same areas of bone or reduce hip fractures. Thus, choosing if you need a bone agent and then choosing the right medication for you, really has to be based on a discussion with a doctor who has knowledge of the different agents, like a women's health specialist, rheumatologist, or endocrinologist.


OSTEOPENIA-RELATED QUESTIONS

amov: Hello, I am a 66 year old woman in generally good health (apart from hypothyroidism, which is under control with medicines that supplement thyroid hormones). Last year I had bone density scan, and was diagnosed with osteopenia (“young adult t-score”: -1.7, “aged-matched z-score”: -0.3). In your opinion, do I need any special medical treatment for my degree of osteopenia? My second question is about taking calcium supplements. Should I follow general recommendations for women in my age group or it better for me to modify the amount of calcium because of my hypothyroidism? Thank you very much.

Dr__Sikon: To help guide the need for additional medications besides adequate calcium and vitamin D for all women in postmenopause, there is a tool that has been developed internationally called the "FRAX" tool. Your doctor has access to it and can input your specific information and risk factors to help determine if additional bone therapy is needed. Decisions to treat are complex and need to be individualized, as every patient has different family and other history that impacts her risk of breaking a bone. I also would ensure you are getting enough calcium, vitamin D, and weight-bearing exercise, not smoking, and limiting alcohol intake. Get another bone density on the same scanner in 2 years. If it drops, then I would be especially apt to recommend a bone agent, once you were evaluated for secondary causes of osteoporosis/osteopenia/low bone density first. Hypothyroidism and its treatment do not directly impact calcium targets that I know of. Being over-treated and/or getting too high of a dose of thyroid supplement can cause bone loss. Bone loss can happen also to those who have naturally overactive thyroid activity in their bodies.

Beatrice: What medication would you recommend for someone with osteopenia who is 84 yrs old and has had bleeding ulcers of the stomach, with the base of the stomach removed many years ago? I also have acid reflux. I walk 5 days a week for one mile and do my own housework. Thank you.

Dr__Su: First recommendation for medication would be Reclast unless there are other contraindications, depending on other medical conditions that you have.

nance: The side effects of Fosamax (painful GERD) prevent me from taking this drug. I have osteopenia and take Vitamin D and calcium. What else do you recommend for 80 year old woman?

Dr__Su: If you cannot take Fosamax because of GERD, switching to a monthly pill such as Boniva or Actonel may help with GERD symptoms. If those also cause problems, switching to intravenous medication such as Reclast is also an alternative.

suzyq: I have Devic’s disease and was misdiagnosed initially with MS and so had several courses of steroid treatment my first year until they found out I have Devic’s. Osteoporosis runs on my mother’s side of the family. My grandmother, aunt, and mother all have it. I now have osteopenia. Could that have been from the steroids? Prior to my diagnosis, I never tested positive. Also, now my treatment for Devic’s is rituximab (Rituxan®) two times a year. Can that also increase the chances of osteopenia becoming osteoporosis? I currently take 1,500 mg of vitamin D3 and 1,000mg of calcium. Thank you.

Dr__Su: Yes, chronic steroid use can contribute to bone loss leading to osteopenia, but may not be the only reason, since you have a significant genetic risk for low bone mass. The Rituxan should not affect your bone loss, so it should not turn osteopenia into osteoporosis.

rthrboutdrs: For a 65-year-old who has osteopenia, how long does it take for a drug such as Evista to rebuild bone?

Dr__Su: Evista actually does not help your body rebuild bone in terms of making new bone. It actually helps your body slow down rate of bone loss so that your bone density can remain stable. If by slowing down the rate of bone loss leads to you gaining bone through your body's natural rate of bone building, it is considered icing on the cake.

rthrboutdrs: I have osteopenia and arthritis. How can I best treat both and not have adverse drug interactions?

Dr__Su: For treatment of osteopenia, it depends on the severity of the condition to determine whether treatment is needed. Most medications for bone health, such as bisphosphonates (i.e., Reclast and Boniva) and anabolics (i.e., Forteo) with the exception of Prolia, should not interfere with medications for treatment of arthritis. Interaction with Prolia is only a consideration if you are on a biologic medication for treatment of inflammatory arthritis, such as rheumatoid arthritis or psoriatic arthritis.


CALCIUM

Cat666: Can you suggest a calcium supplement that is easy to digest and does not cause constipation?

Dr__Sikon: When patients experience constipation from their calcium supplement, I make several recommendations: Do you need it at all? (Please see answer to metaphor's question above re: searching calcium calculators and seeing if you can get the amount of calcium you need from your diet instead of a supplement.) If you do need calcium, make sure you are not taking too much. Determine this using the answers you get from the calculators as well. If you determine that you do need a calcium supplement, try one that has magnesium in it which can help to counter the constipation, unless you have kidney failure. If you do have kidney failure, you should limit your magnesium ingestion.

sam23: I have osteoporosis and take Citracal® (500 mg) with vitamin D (1,000 mg) twice a day and Actonel (risedronate) (35 mg) once a week. I hear AlgaeCal® (calcium supplement) increases bone density. Should I switch to that? Thank you.

Dr__Sikon: I am not familiar with this specific type of calcium supplement. Please see my answer to metaphor re: determining calcium needs and how much calcium supplements you really need. There has been some suggestion, not proof, that people can take too much in the way of supplements and that some vitamins can actually be harmful, so I recommend taking the amount you need- more is not necessarily better. Also, I do not know of any specific type of calcium that directly boosts bone density over others- that may just be marketing.

nance: Calcium prevents absorption of levothyroxine (Synthroid®). How does one manage to take 1,200 mg of calcium when the calcium can only be absorbed a little at a time? Synthroid is taken in early morning. However, when 1,200 mg of calcium are recommended for an elderly woman, how does one ingest the calcium pills so they, too, will be absorbed? Thank you.

Dr__Su: Calcium pills usually have 500-600mg of calcium per pill since your body can only absorb that amount at a time. When taking a combination of Synthroid and calcium supplements, you can take Synthroid in the morning on empty stomach as instructed, and then take one calcium pill at lunch 3 to 4 hours after taking Synthroid and one calcium pill at dinner. Another way to get calcium without worrying about pills is increasing the calcium in your diet.

johnnnita: I'm not sure if I asked this before the session, but here goes: I've been diagnosed with osteopenia. My doctor has advised I take calcium citrate (600 mg twice a day) and Vitamin D3 (4,000 units per day for one month, and then 2,000 units per day forward). I started this regimen, and after less than a week, I started to experience cramps and some constipation (although I did have some bowel movement every morning as before). I notified him of this change, and he now has recommended I stop the calcium citrate and continue with the D3 dosage (2,000 units). He said it's not uncommon to experience cramps from the calcium citrate, but shouldn't be an issue with the D3 dosage. Does this make sense? What are your thoughts on side effects of these supplements? Does it matter where you buy these supplements?

Dr__Su: I agree with your doctor's recommendations. Calcium supplements can sometimes cause cramps. To avoid needing to take supplements, you can take more calcium through increases in your diet with foods such as milk, yogurt, spinach, collard greens, etc. Dietary calcium usually does not cause cramps. There are not usually side effects with vitamin D. Location of purchase for calcium and vitamin D usually does not make a difference. Vitamin D3 is preferred to vitamin D2.

gibbonm: Is Vivactiv® an effective form of calcium supplementation?

Dr__Sikon: Yes, this is a nice way to get your calcium, as they are flavored chews and taste good, so can be used as an after meal treat which can help you to remember to take it! It should be taken immediately following a meal. However, it contains calcium carbonate, so if you are taking an antacid, you might want to try a calcium citrate form instead.

Cruiser500: Which calcium supplements do you recommend - Citracal® or Caltrate®? Which is better absorbed for bones?

Dr__Su: Calcium in the form of calcium citrate, such as Citracal, is better absorbed than in the form of calcium carbonate, i.e., Caltrate. I usually recommend Citracal over Caltrate.

LJK: From the questions and answers it seems to me I have been getting a lot more calcium than I should—1,200 mg tablets and 4 glasses of milk a day plus a lot of cheese. Why is this bad?

Dr__Su: Increased calcium intake above 2,000 mg daily can increase risk of kidney stones, and excessive calcium intake can also predispose a person to increased atherosclerosis, leading to higher risk of heart attacks and strokes. The goal for calcium intake is 1,200 mg to 1,500 mg daily between diet and supplements.

Metaphor: Slow-release Citracal® lists calcium carbonate before calcium citrate. Is it an adequate form of calcium?

Dr__Su: Slow-release Citracal is an adequate form of calcium supplement. In general, calcium citrate products are easier to absorb but are more expensive than calcium carbonate products. Calcium citrate products are definitely recommended over calcium carbonate products for patients on medications for heartburn or ulcers such as Nexium, Prilosec, and Prevacid.

Bonegirl: Hi! I am a certified bone density technologist and educate all my patients about calcium and Vitamin D. I saw you mentioned a calcium calculator, but I have often found errors with charts from the government and osteoporosis foundation on these varying charts. I recommend patients look at individual labels and find the percentage of calcium listed on the label. Add a "0" to the percentage and this will give them a more accurate amount of calcium. It is amazing how much a different yogurt will vary within the same brand, so to tell someone that yogurt has "x" amount of calcium, as provided on these calcium calculators, just seems wrong to me. What are your thoughts?

Dr__Sikon: Kudos for helping to educate about good bone health! I agree that there is lots of variation in such information. I counsel patients to search and complete 3 different calcium calculators and then average the answers to get a truer estimate of their daily dietary intake. Of course, as you note, this is only an estimate. I do also encourage people to read labels, not just for calcium and D, but for sodium, calories, and fat as well. We should all be in the habit of reading labels to know what is really in what we ingest; otherwise, it can be very deceiving. Things we may think of as healthy, like low-fat frozen meals, often have a sodium content that would approach daily recommended totals! I am hesitant to use percentages of daily intake as a guide for vitamin D, though, as the national recommended daily allowance is often way too low for many patients, especially those who live in northern climates like Cleveland. If one just follows the percentage of vitamin D recommended, say in a glass of milk, you may well be getting too little of vitamin D daily.


DIET and EXERCISE

Qutie: Is taking strontium effective in treating osteoporosis? Is eating 10 prunes a day an effective treatment for osteoporosis?

Dr__Su: Taking strontium as an over-the-counter supplement can help in the treatment of osteoporosis. However, it is not approved as a drug for use in the US by the FDA as it is in Europe. Eating 10 prunes a day is not an effective treatment for osteoporosis that I am aware of.

Rhinestonegal: Does weight exercise help for osteoporosis? What is the source for types of exercise?

Dr__Su: Weight bearing exercises, such as walking and using an elliptical machine help with osteoporosis. Weight training with light weights to maintain muscle strength and tone to prevent falls also helps for osteoporosis.

goferbroker: Are back-strengthening exercises helpful? Where can I find information about exercise routines?

Dr__Su: Back-strengthening exercises are helpful. Best way to make sure that you are doing back exercises that help you without putting you at risk for stressing your vertebrae and causing fractures is by scheduling an appointment with a physical therapist through your doctor, so the most appropriate exercises can be prescribed.

man3: How does the nutrition/diet of a child throughout its growing years affect his or her chance of getting osteoporosis as an adult? Can bad early diet be corrected as an adult to reverse early damage?

Dr__Su: Making sure that there is adequate calcium and vitamin D intake as a child can help prevent osteoporosis later on in life. If there is bad early diet, unfortunately nothing can be done to reverse early damage. However, by getting adequate calcium and vitamin D as an adult and treatment with medications for osteoporosis, it can prevent further damage.

 

johnnnita: What foods do you recommend that are high in calcium and promote bone density?

Dr__Su: Foods that have good amounts of calcium include milk, ice cream, yogurt, cheese, spinach, kale, collard greens, beans (i.e., navy and lima), and almonds. The goal for calcium intake between diet and supplements is 1,200 mg to 1,500 mg daily, but not to exceed 2.000 mg daily.

howdo: When drinking milk, as you suggested getting calcium naturally through diet, is chocolate milk okay? I really do not like the taste of white milk, but I do like the low-fat chocolate milk.

Dr__Su: Chocolate milk is fine. Whether it is low-fat, skim, 2%, or whole does not make a big enough difference to matter. Metaphor: Yogurt appears to be at least twice as high in calcium as milk. Is this a good source of calcium?

Dr__Sikon: I generally note that drinking 3 cups (i.e., 8 oz each) of skim milk daily or the equivalent can provide you with your daily intake of calcium, approximately 1,200 mg/day. You can easily look online for charts that compare the intake of calcium/food item to help you gauge an adequate substitute if you prefer other foods to milk. Low-fat yogurt is also generally a great source of calcium, as is low-fat cottage cheese. Individuals, even children older than 2 years of age, do not need full fat items, especially when considering heart health.

Metaphor: Thanks to the doctors at Cleveland Clinic and to all of us who asked these questions! A helpful session!

Dr__Sikon: Thanks so much for joining us!

 


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic osteoporosis experts Dr. Andrea Sikon and Dr. Johnny Su is now over. Thank you both for your time to answer our questions today about osteoporosis.

Dr__Su: Thank you all for your wonderful questions and participating in our webchat. Remember that more individualized recommendations can be made when a full evaluation is performed for your bone health by your doctor. Please make an appointment to see a physician at Cleveland Clinic if desired.

Dr__Sikon: Thank you for all of your wonderful questions. I am impressed at the knowledge that is out there and so happy to know that people are appropriately thinking about their bone health. So often, this gets overlooked due to the misperception that it is not a major problem. As osteoporosis does not cause symptoms until there is already a fracture/break, it is often not paid attention to. Keep up your prevention and treatment!


More Information

To make an appointment with Johnny Su, MD or any of the other specialists in our Department of Rheumatic and Immunologic Diseases at Cleveland Clinic, please call toll-free at 866.275.7496. You can also visit us online at clevelandclinic.org/rheum

To make an appointment with Andrea Sikon, MD please call 216.444.3024 or call toll-free at 800.223.2273, ext. 43024. You can also visit us online at clevelandclinic.org/obgyn.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult

If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!

Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link clevelandclinic.org/webcontact.

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2012 The Cleveland Clinic Foundation. All rights reserved.

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