Online Health Chat with Chad Deal, MD and Lynn Pattimakiel, MD

Tuesday, May 5, 2015 | Noon


An estimated 57 million Americans are affected by osteoporosis and low bone mass.

Osteoporosis is often called the “silent bone thief,” and it can be both debilitating and painful. However, there are things you can do now that may help prevent osteoporosis from occurring, or progressing. Proper medical care can help you slow or even reverse its progress and prevent fractures.

Osteoporosis weakens your bones, making them more susceptible to sudden and unexpected fractures. Join us to learn how you can strengthen your bones and keep them healthy into the future.

The mission of Cleveland Clinic's Center for Osteoporosis and Metabolic Bone Disease is to evaluate and treat patients with osteoporosis and other forms of disease that affect bone. Osteoporosis is common. About 57 million Americans have osteoporosis and low bone mass. About 34 million are at risk for the disease. Estimates suggest that about half of all women older than 50, and up to one in four men, will break a bone because of osteoporosis.

Since a woman has a greater than 50 percent chance of having a fracture, this is an important disease to evaluate and treat as early as possible. Osteoporosis is often called a “silent” disease because bone loss occurs without symptoms. The first symptom is often a fracture. By that time, a woman has often lost 30 percent or more of her bone mass. If evaluated at an early stage, patients can initiate prevention and treatment prior to the clinical manifestations of this silent disease.

Our goal is to evaluate patients at an early stage to prevent the major complication of osteoporosis (fractures) and to treat patients at the earliest possible stage to prevent additional disease manifestations.

About the Speakers

Chad Deal, MD, is director of the Center for Osteoporosis and Metabolic Bone Diseases and a board-certified rheumatologist at Cleveland Clinic, Cleveland, Ohio. He has specialty interests in osteoporosis and related conditions. Dr. Deal did his undergraduate work at Washington University, St. Louis, Mo. He attended medical school at the University of Arkansas, was inducted into Alpha Omega Alpha, and graduated in 1977. His internship and residency were at Boston City Hospital in Boston, Mass. He completed a fellowship in arthritis and connective tissue diseases at Boston University School of Medicine in 1982.

Lynn Pattimakiel, MD, is board-certified in internal medicine and practices at Cleveland Clinic’s Department of Internal Medicine and the Center for Specialized Women’s Health. Dr. Pattimakiel’s clinical interests are in women's health, osteoporosis, menstrual disorders and menopause. She earned her medical degree at Medical University of Debrecen and completed her residency in internal medicine at St. Vincent Charity Hospital. Her fellowship in women’s health was at Cleveland Clinic.

Let’s Chat About Osteoporosis

Moderator: Welcome to our chat about osteoporosis with Cleveland Clinic specialists Dr. Deal and Dr. Pattimakiel. Thank you both for taking the time to be with us to share your expertise and answer our questions.

Let’s get started with our questions.

Disease Details

js121499: Can you explain the difference between osteopenia and osteoporosis?

Chad_Deal,_MD: The definition is an arbitrary construct. The definitions are based on how far you are before peak bone mass (your bone mass at age 25 to 30). Osteopenia is a T-score of -1.0 to -2.5, about a decline of 10 percent to 25 percent from peak bone mass. Osteoporosis is a T-score lower than -2.5, about 25 percent below peak bone mass. The peak bone mass is based on 300-400 normals in the bone density machine’s database (not your peak bone mass since that is unknown.)

MarL: I was wondering what the difference is between osteopenia and osteoporosis? I had a DEXA test and was diagnosed with osteopenia in my back (fractured L12 last November) Thank You.

Lynn_Pattimakiel,_MD: Osteopenia and osteoporosis are on the same spectrum of bone thinning. Osteopenia is at the spectrum of early bone thinning. The bones become more porous and can be at increased risk for fracture. When the bone density is very low, the osteoporosis range, the stability of the bone is markedly compromised, which can increase risk for fracture and warrants therapy. We use the bone density scan to evaluate bone density by T scores, which can be used in our definition. A T score of -1.1 to -2.4 is considered osteopenia. A T score that is less than and equal to -2.5 is considered osteoporosis. A normal T score is greater than -1.1. For a compression fracture in the spine (if there was not a significant trauma), this could warrant a clinical diagnosis of osteoporosis.

sweller: What is the typical progression of this disease? In a prior bone scan, osteopenia was indicated in my left hip. On the results of a recent scan, the left hip is not mentioned as a low density area; however, the femoral neck and lower lumbar region are? Can it become better in one area and decline in others?

Lynn_Pattimakiel,_MD: We may see cases where there is improvement in one area and a decline in another. Often, the spine may show early decline in bone density compared to the hip. Unfortunately, arthritis can skew the results of the bone density test.

HannaB: Is osteoporosis reversible? For example, if a patient starts exercising and takes supplements of calcium citrate and vitamin D3, will the bone density increase or does it only decrease the rate of disease progression?

Chad_Deal,_MD:You can gain bone mass with treatment. Calcium and vitamin D and exercise alone usually result is stable bone mass. With the approved drugs you can increase bone mass, with bisphosphonates usually about 7 percent in three years. Six years of treatment with Prolia® can increase bone mass 15 percent.

pilatesgirl: When is the greatest loss of bone density for the majority of women? Is it right at menopause, the first year after or five years after that?

Chad_Deal,_MD: Twenty percent of women at menopause can lose up to 5 percent per year for about six years. This period is usually the time of most rapid loss in the absence of some disease that can accelerate bone loss.

faribajackson: If I eat right, take supplements and work out five to six times a week, why would my bone density test come back bad?

Lynn_Pattimakiel,_MD: There are many other factors that can lead to bone thinning. You may have had smaller bones to begin with if you have a small body frame. There are secondary reasons to have bone loss, including medications such as (heartburn medication-proton pump inhibitors, steroids) or poor absorption. Females are at risk of increased bone loss after menopause due to lack of estrogen. I would recommend that you speak with a specialist to evaluate your bone loss further. Keep up the good work with the diet and exercise!

mountain: What's the relationship between osteoporosis and shrinking in height and a hunched back?

Lynn_Pattimakiel,_MD: Patients may lose height, or develop that typical curved hump in the back (kyphosis) if they have osteoporosis. This is due to thinning of the bone, which causes compression of the actual disc height.

Questions About Calcium

rjfp: I am a 64 year-old female who had been on Fosamax® for two years without benefit. I am now on Prolia®. For someone on Prolia, what is your recommendation for supplemental calcium intake and vitamin D? Should calcium doses be split up during the day? Should they be taken with or without food? And is calcium citrate preferred over calcium carbonate or at least easier to take with fewer restrictions. How often should a follow-up bone density test be done? Thank you.

Chad_Deal,_MD: With all osteoporosis treatments you need to take adequate calcium and vitamin D. The medications are not calcium, and this mineral is the essential building block of bone. Vitamin D is needed to absorb and incorporate calcium in bone. In general, you can absorb more than 600mg of calcium in a dose, so for doses higher than that, splitting the dose is required. Calcium carbonate needs acid to be efficiently absorbed, so taking it with food is best (food stimulates stomach acid). Calcium citrate can be taken on an empty stomach since acid is not required for absorption. Bone densities are generally done every two years. If you are on steroids or have a condition called hyperparathyroidism, then the bone density is done every year.

nutzy: I heard that people with mitral stenosis could not exceed with calcium therapy. Instead of calcium, what do you recommend?

Lynn_Pattimakiel,_MD: Mitral stenosis is a condition of narrowing of the heart valve sometimes due to plaque and calcification. There is a concern of excessive calcium intake and deposition of the calcium within the arteries. We always recommend patients get dietary sources of calcium first, if possible, from food sources including milk, yogurt and green leafy vegetables. If you are unable to get enough calcium in your diet, you can make up the difference by adding calcium oral supplementation. Your goal should be a total of 1200-1500mg of calcium daily in divided doses. Excessive calcium can be harmful to you.

Clara35: Are calcium crystals in the knee from pseudogout at all related/affected by calcium intake?

Chad_Deal,_MD: No, they usually are not, although patients with hyperparathyroidism are predisposed to pseudogout so there is a relationship in this case. In general, you do not have to worry about calcium if you have pseudogout.

mataki: What is the current thinking on how much calcium to take, and what kind is best absorbed? Also, what about strontium? I've heard a lot about it lately.

Lynn_Pattimakiel,_MD: We recommend 1200-1500 mg of calcium daily in divided doses. We often recommend dietary sources of calcium first. If you are unable to get enough calcium in your diet, you can make the difference up with calcium supplementation. There are different formulations that are available for oral calcium supplementation, including carbonate and citrate. The advantage of calcium citrate is that it can be taken with or without food. There have been early studies with strontium showing improved bone density scores, but it is not known if this translates to reduced risk of fracture. At this time it is not regularly used for treatment of osteoporosis in the United States.

Xomue: There's much conflicting information about how much (and even whether) calcium is needed when you have osteoporosis. The latest research from the Harvard University website says only 800 mg is needed. Of course, the most common recommendation is 1300 (for elderly osteoporotic women). However, some authorities suggest that taking calcium as a supplement does more damage than taking none, regardless of the amount in the diet. Norwegians have the highest rate of osteoporosis in the world and also have the highest dietary daily intake of calcium in the world. What is your opinion on this confusion?

Chad_Deal,_MD: A study from Yugoslavia shows that patients in dairy districts (presumably more calcium intake) have fewer fractures than those in non-daily districts. The RDA is 1200-1500mg. If your intake is below 800mg, you usually start pulling calcium out of your bones to supply your body’s calcium need.

pilatesgirl: What is the current thinking about nutrition and bone density? Is there concern about overprescribing calcium without enough vitamin D & K2? How significant is magnesium and other minerals as part of the big picture?

Chad_Deal,_MD: Nutrition is important, especially adequate calcium and vitamin D. Other minerals, like magnesium, may also be important for calcium absorption. We may be overprescribing calcium. The doctor should take a diet history and add supplements, if needed, to get to an intake of 1200-1500 mg per day. If I don't consume enough calcium in my daily food intake, is consuming "calcium enriched" products (certain orange juices) better than taking calcium supplements (Os-cal® etc.)?

Chad_Deal,_MD: Recently, there have been studies suggesting that calcium supplements may be associated with and increased risk of cardiovascular disease and that calcium from foods is not. This is not definitive but when patients ask me about this I try to steer then to food-based calcium.

rjfp: What dosage of supplemental calcium do you recommend?

Chad_Deal,_MD: The RDA for calcium is 1200-1500mg. You need to know how much you get in your diet. You can go to the web to get a form to estimate dietary intake. If you get 1200mg in your diet, you don't need any supplement.

Bunnie: Does taking calcium with vitamin D help with osteoporosis?

Lynn_Pattimakiel,_MD: Calcium is one of the essential building blocks/minerals needed during bone formation to help maintain the strength of your bones. Adequate vitamin D is needed to help with calcium absorption. These are essential for everyone. They alone are not considered therapy for the treatment of osteoporosis.

Everything Exercise

lauriegs: What are the best weight bearing exercises to do to build bone density?

Lynn_Pattimakiel,_MD: Examples of good weight bearing exercises include brisk walking, yoga at your own pace/level and Tai Chi (which can also help with balance). Also lifting small weights under proper supervision is good for the bones.

VM: I want to know about the risks and benefits of using a weighted vest during exercise.

Chad_Deal,_MD: Adding some type of weight increases body weight and increases the force with each step – thus increase weight bearing. As long as you can add weight and stay balanced without a risk for falling, this is a good idea. Don’t overdo the weights, do what is comfortable for you.

cosmona: Can someone with osteoporosis practice yoga and enroll in the school of yoga teacher training offered at Cleveland Clinic? Thank you.

Chad_Deal,_MD: Generally yes, just tell the instructor you have osteoporosis. You will want to avoid certain exercises that put a strain on the spine, such as trunk flexion against resistance.

mountain: I have osteopenia. I wear a 10-pound weight vest for at least one hour five days a week. I weigh 112 pounds. Is this a good way to build bone mass in my spine?

Chad_Deal,_MD: Anything that increases weight bearing helps. Heel strike activity is the best, and a bit of added weight should provide additional benefit. Remember that exercise can only increase bone mass 1 percent to 2 percent at most. But lack of exercise can sometimes result in large losses.

mountain: I took Fosamax for three years then stopped because my mother suffered a fractured femur and osteonecrosis as a result of taking Fosamax for years. What are the best weight bearing exercises to increase bone mass in place of taking drugs?

Chad_Deal,_MD: Heel strike activity, such as walking, is the best, but you can't increase bone mass more than 1 percent to 2 percent.

Xomue: Can you suggest a website (or program) that has an exercise program (such as weights and stretching) that's safe for osteoporosis patients?

Chad_Deal,_MD: Go to the NOF (National Osteoporosis Foundation) website and it will direct you to a good place.

Testing and Timing

jambara: How often are men tested for osteoporosis? Should it be routine or merely symptomatic?

Lynn_Pattimakiel,_MD: We recommend that men be screened for osteoporosis starting at the age of 70 or if they have risk factors, such as a history of stress fracture or long-term steroid use.

pilatesgirl: How does a person's body size effect the accuracy of the bone density scan results. I have heard if you are a small person (120 pounds, 5'2"), there might be a lower reporting of density than what would be most accurate. Also, how does weight loss or weight gain of five to 10 pounds affect bone density results?

Chad_Deal,_MD: Small bones and small people may have lower bone density based on a size effect. I am not sure how large the effect is in adults. It is bigger in children (but we rarely measure them). A change of five to 10 pounds will not affect the bone density.

pilatesgirl: What have we learned over these decades of bone density scanning? As far as post-menopausal regularity of scanning, should it be bi-yearly or less? What have you learned about effects of celiac disease on bone density? My celiac disease was discovered due to my first bone density scan. It seemed my lower numbers were due to celiac, and the endocrinologist didn't think other treatments would benefit.

Lynn_Pattimakiel,_MD: We have learned that the information we obtain from bone density testing can predict the strength of your bones and risk for fracture. We recommend screening every two years in patients diagnosed with osteopenia or osteoporosis. If someone has increased risk factors, or is on medication that can increase progression of bone breakdown (such as oral steroids), we recommend once yearly screening. Celiac disease has been shown to be a secondary cause of osteoporosis. This is due to gluten intolerance from food, which affects the bowel’s absorption of calcium and vitamin D. This leads to the insufficient building blocks to help build your bones. The first steps in treating low bone density would be to correct the underlying condition and follow a gluten free diet. Also, make sure you are getting enough calcium and vitamin D in your diet. You may not need therapy if your bones show improvement, but you should continue to be monitored closely.

Talking Treatments

coconuts: I am currently 41 years old and was diagnosed with osteoporosis three years ago. I've been on Fosamax for a year now and understand that this treatment is time limited. Five years is the limit, right? If that's the case, then I'll be finished by age 45. What then? My endocrinologist told me that there isn't much research on long-term treatment of osteoporosis, and I haven't been able to find anything online that could enlighten me. I already have a compression fracture in my spine, so I'm concerned about prevention. Thanks for any information you may have or can point me toward.

Lynn_Pattimakiel,_MD: Unfortunately, you are very young to be diagnosed with severe osteoporosis. It is important to be evaluated for secondary causes that may have put you at increased risk for osteoporosis. There is no strict time limit for how long you should stay on therapy. It is based on your response to therapy and also the severity of your disease. If you have shown good response to therapy with improving bone density tests and stable bone turnover markers, a drug holiday may be indicated in the future. During this time, the bones will still be protected because the half-life of the medication works in your bones for a longer time. Continue to focus on your dietary supplementation with calcium and vitamin D, as well as your balance and weight bearing exercises.

megr: Are generic medications just as good ? Should I be seen by a specialist regarding my treatment for osteopenia? I am almost 70, exercise six days a week for over an hour, am in very good shape physically but my bone density still went down. I was on aromatase inhibitors for five years after my breast cancer surgery. I am cancer free now for 10 years. My past history includes anorexia and bulimia in my 30's. I don't use caffeine and I take calcium (whole food organic pdt.) daily. I'm not sure what else I can do to improve my bone density. The medication I'm taking is atorvastatin 20mg.

Lynn_Pattimakiel,_MD: It sounds like you are doing a great job with your diet and exercise regimen. Unfortunately, you may have had smaller bones to begin with, and after menopause the rate of breakdown of bone is initially at a higher rate. The medication that you mentioned is for cholesterol lowering. If you are still losing bone and are not on therapy, I would recommend further evaluation with a bone specialist and/or women’s health specialist to evaluate and treat your bones.

adavincent: What type of treatment would you recommend for a 59 year-old female with a T-score for L1-L4 that is -1.5 and a T-score for the total left femur of -2.8? The patient currently does a weight training routine, takes calcium 1200mg daily and vitamin D 2000 units daily. The patient is not interested in oral bisphosphonates.

Chad_Deal,_MD: If you check your fracture risk (using FRAX), you will probably be in a high risk group (10-year hip fracture risk >3 percent). Most doctors would treat you. If you do not want a bisphosphonate, then the only other agents are Prolia or Forteo. At your age and T-score, most likely Prolia.

Marie1: I am 75 years old and took Miacalcin® for years for osteoporosis. The disease appeared stabilized. However, my doctor took me off it about two years ago. I have tried Fosamax and Actonel®, but stopped both due to terrible burning in the esophagus area that lasted for months, even after stopping them. I also took Boniva® by IV but it caused bad jaw/ear pain. I tried it a couple of times but it only got worse. I also tried medications where you give yourself a shot in the stomach; however, my heart raced over 150 so I stopped it. I have a history of leukemia, heart valve problems, bronchitis and osteoporosis since 1999. I weigh 100 lbs. Do you have any suggestions to help worsening of osteoporosis except calcium/vitamin D? I also suffer from tachycardia and POTS.

Lynn_Pattimakiel,_MD: Unfortunately, it sounds like you have had many bad side effects to osteoporosis therapy. Another medication that you have not mentioned that may be worth looking into is an anti-resorptive medication called Prolia, which is given as an injection every six months. Due to your other medical conditions, it is important that you have a specialist evaluate if this could be a safe treatment option for you.

Medication Management

Gypsy: Is there a recommended lifetime limit on the number of Reclast® infusions?

Lynn_Pattimakiel,_MD: We never recommend that patients stay on any medication indefinitely. Before each Reclast infusion is administered, you should have an office visit to evaluate if the benefits still outweigh the risks of the medication. Your response to therapy also helps guide therapy. If you have had numerous stable and or improved bone density tests, you may benefit from a drug holiday.

Valpat: Should you reduce your calcium intake – dietary and/or supplements – when on Forteo®? Is intermittent Forteo use, three months on and three off, or six months on and six months off with an anti-resorptive, a recommended protocol? Does it help to stabilize transient elevated calcium levels? Is the anti-resorptive medication after completion of Forteo necessary because Forteo-induced bone growth, while quickly stimulating osteoblasts to grow bone, also overstimulates the osteoclasts to more quickly reabsorb the new bone growth? Is the follow-up resorptive taken temporarily or permanently? Thank you.

Chad_Deal,_MD: About 10 percent of patients on Forteo will have hypercalcemia. It is usually mild but occasionally calcium can be significantly elevated. The most common cause is too much calcium intake – a combination of diet and/or supplements. In most cases, reducing calcium intake will take care of the problem. There is no fracture data using Forteo 3 months on/off, but there are some trials using this regime. The idea is to maximize Forteo’s effect on bone formation, which happens early, and minimize Forteo’s resorption effect. After you finish a course of Forteo, you need to follow with an anti-resorptive agent. If you do not, you will lose much of the increase in bone mass that occurred with Forteo.

Valpat: Does the IV bisphosphonate, ibandronate, also irritate the esophagus similar to oral BPs? Are there any tests or screenings available to identify who might be more susceptible to the side effects of any of the osteoporosis drugs?

Lynn_Pattimakiel,_MD: The benefit of the IV bisphosphonates is that it bypasses the GI tract, therefore, there is no risk of esophageal irritation. There are not specific tests that would help predict who will have side effects. It is important to take your vitamin D regularly, which could help prevent any muscle aching.

pilatesgirl: What is the cancer risk for people taking Forteo? My family has a history of bone and cartilage cancers. It seems a bad risk to take Forteo. And what are the latest findings about the successes and failures of this medication?

Chad_Deal,_MD: There is a black box warning for osteosarcoma (bone cancer), but this is based on a rat study. There was no cancer in primates. In the 13 years since Forteo has been in release, there have been a few case reports of bone cancer; but based on the background incidence of cancer, it does not appear to be more than expected. If you ask 100 experts if they think Forteo causes cancer, 100 will say no. Patients with a disease called hyperparathryoidism have high levels of PTH (the drug in Forteo) and have no increased risk for cancer. There are 45,000 Forteo patients in a disease registry to answer this question.

mataki: What are medication options other than bisphosphonates? I took Fosamax for seven years and do not want to take any of the bisphosphonates again. Thank you.

Lynn_Pattimakiel,_MD: There are many different formulations of bisophosphonate therapy, including oral daily, weekly and monthly medications. There are also injections and yearly IV bisphosphonate infusions that are considered anti-resorptive agents. There is another anti-resorptive agent called denusamab (Prolia) that is approved for postmenopausal osteoporosis. This is given through injection in the office every six months. There are also bone building agents that are used for severe osteoporosis or for patients who do not respond to therapy. This is called Forteo and it is given as a daily injection. Depending on your response to therapy, and the severity of your bone density tests, you may be due for a drug holiday, but your bones should still be closely monitored.

Valpat: Can Prolia be taken by patients with high cholesterol that is controlled by medication? Also, can Prolia be used by patients who have an autoimmune disorder?

Chad_Deal,_MD: There is no reason to avoid Prolia with cholesterol medications (statins). Prolia can be used in patients with autoimmune disorders. The package insert suggests avoiding Prolia in patients on immunosuppressive agents. Experts take this to mean biologic agents (TNF inhibitors such as Enbrel® or Humira® among others).

Valpat: Are odanacatib and romosozumab still promising medications to treat osteoporosis? How do they compare in treatment and side effects with the other anti-resorptive and anabolic drugs currently available? Any there other new treatments in progress? How soon will they be available for patients?

Chad_Deal,_MD: We are still waiting on the filing and FDA approval for odanacatib, perhaps the end of 2015. The drug is effective. The trial was stopped when it met its endpoints for fracture. The concern is side effects. We will see. Romosozumab is very promising. It looks to be more potent as an anabolic than Forteo based on early trials. Amgen says they may be ready to file with the FDA in 2017.

linden: I have been diagnosed with severe osteoporosis and have had six compression fractures recently. The only two medications recommended by my doctors are Forteo and Prolia. While Forteo, the preferred drug, is cost prohibitive, I am concerned about starting Prolia. Once this is in your system, it lasts six months; if you have a bad reaction to the drug, there isn't anything you can do. How safe is Prolia? It does not seem as though the drug has been tested for a long enough time. Is it effective enough to risk side effects?

Chad_Deal,_MD: Taking Prolia is much safer than doing nothing if you have had six fractures already. Remember, the side effect of doing nothing is more fractures. Forteo would be the preferred drug. There are foundations that provide co-pay assistance for the drug. Ask your doctor about this. Prolia is safe with few serious side effects, and in you, the benefit outweigh the risks.

Cat666: How effective is Evista® in treating osteopenia? Should it be taken with anything else to treat this condition?

Chad_Deal,_MD: Evista is effective. The MORE trial showed that the drug reduced the risk for vertebral fracture 50 percent in patients with no pre-existing fracture and 30 percent if you have a vertebral fracture. However, there is not demonstrated reduction in hip or non-vertebral fractures. So, it is usually used when the lumbar spine density is lower than the hip density. You also need calcium and vitamin D and weight bearing exercise.

my bone my bone: What medication do you suggest for a person who has had blood clots and uterine cancer and is worried about breast cancer?

Chad_Deal,_MD: Evista is a good osteoporosis drug for women at high risk for breast cancer. But it has the same risk for phlebitis as estrogen, so with a history of clots you shouldn't use it. The other drugs like Fosamax do not decrease or increase breast cancer risk.

bugden1: I have two friends who had the two shots per year therapy and had terrible side effects with their esophagus. Is this common since my doctor suggested one more year of Boniva and then to go on the shots twice a year.

Chad_Deal,_MD: The shots that are given twice a year are Prolia. To my knowledge, there are no esophageal effects. There are potential esophageal effects with oral bisphosphonates like Boniva if you don't take them properly with lots of water and they stick to the esophagus.

Prevention Possibly

tomnjerry: I am 25 years old with severe osteopenia and a T-score and Z-score of -2.3. If I take enough supplements, can I change this value, prevent osteoporosis and increase bone density?

Lynn_Pattimakiel,_MD: You are very young to have such a low bone density test. It would be important to have a secondary work up to make sure there is nothing else that is causing excessive bone loss. If there is another cause identified for your bone loss, it should be addressed first to help prevent further bone loss. Getting the proper amount of calcium in your diet and vitamin D supplementation does provide the essential building blocks to help build up and protect your bones.

pan: Can you prevent osteopenia from becoming osteoporosis without taking supplements if you are on a vegetarian diet?

Lynn_Pattimakiel,_MD: Making sure that you get four to five servings of calcium a day in your diet is very important. It is more difficulty to get the vitamin D through diet alone, especially in less sunny environments. Therefore, we would recommend a vitamin D supplement. Don’t forget to do your weight bearing exercises and work on your balance.

Carolee888: I have sarcoidosis and my DEXA scans are normal except for the area near my hip, where I have osteopenia. But people with sarcoid can have normal scans and have a higher risk for fractures. How can I prevent fractures in my case?

Chad_Deal,_MD: Patients with sarcoid are not at increased risk for fracture unless they are treated with steroids. If you have sarcoid lesions in bone, they can cause an area of weakness and increase fracture risk.

Marie1: I have osteoporosis, as did my mother and my sister. I have gotten reactions to all the different medications so I cannot take them. I also have POTS (postural orthostatic tachycardia syndrome), so I’m unable to do standing exercises. Is there anything else you can suggest that I do along with taking calcium that may be helpful to prevent worsening of disease? I appreciate your response.

Chad_Deal,_MD: I need more information to answer this question.

cosmona: I am a 50 year-old female diagnosed with osteoporosis. I have been taking Forteo for one year now. I walk, run, do TRX, some yoga and am very active in general. I am hoping the Forteo helps when I have my next bone scan. My calcium and D levels are good. I have three to four glasses of wine a week. Is there anything else I should do/ not do? Thanks.

Chad_Deal,_MD: No, you are doing the most you can do. When you finish two years of Forteo, you will need to go on another osteoporosis drug to maintain the effect of Forteo.

ahmc: To avoid the long list of side effects from available medications, what are the best things a woman in her sixties can do to forestall osteoporosis, apart from load-bearing exercise?

Lynn_Pattimakiel,_MD: Make sure that your diet is well balanced. Aim for 1200-1500 mg of calcium daily in divided doses. Great examples include skim milk, low-fat cheese, yogurt, green leafy vegetables (spinach/kale etc.) Keep your vitamin D levels up with supplementation (some milks and juices may be fortified with D, as well as cod liver oil). Avoid medications, when possible, that can contribute to bone loss, such as heart burn medication (PPI's). Also, work on maintaining your balance. Excellent exercises include Tai Chi and yoga (but under proper supervision).

Simply Supplements

g4mejeanne: I prefer homeopathic supplements as opposed to medications. I am taking vitamin D, Catalyn®, Cataplex® F and calcium lactate daily (in addition to the calcium I get from foods), coupled with weight bearing exercises. Will this regimen suffice?

Chad_Deal,_MD: The question is suffice for what? If you want evidenced-based medicine answers, all randomized controlled trials compare the active drug with calcium and Vitamin D and show greater fracture reduction with the active drug.

daveluft: Is there any benefit in taking the K2 vitamin?

Chad_Deal,_MD: We are not sure. K2 is a medication used in Asia – Japan for treatment of osteoporosis. My personal feeling is that it is not as effective as medications we have for use in the US.

donna rush: I am a 58 year-old woman who went through 25 radiation treatments two years ago to my pelvic region. Before radiation, I had a vitamin D level of 49. Now, it is 25. It had gone down a few times. I am not a typical candidate for osteoporosis. I am 5'10" and weigh 170 lbs. I suffered with two compression fractures in my lower lumbar area and insufficiency fractures in my pelvis a year post treatments. I have been on vitamin D for years. I drink milk, eat yogurt, etc. Right away my doctor did not think the radiation treatments caused this decline and put me on mega doses of vitamin D and Prolia. Prolia caused some side effects, so I stopped this treatment. Do you have any other suggestions for this sudden decline, and what can I do for better treatment? Thank you for your time.

Chad_Deal,_MD: You did not mention what your bone density was. The vitamin D of 25 would not account for the fractures. The level is only a bit below normal levels of 31ng/ml. Vitamin D is absorbed mostly in the upper GI tract, small bowel. It sounds like the radiation was in the lower bowel (colon) and should not affect vitamin D absorption. Some patients get radiation colitis and diarrhea and can have some trouble with vitamin D absorption. If your bone density is low and you had side effects from Prolia, you need to consider another agent for osteoporosis, especially with fractures. You can occasionally see fractures after radiation since the x-rays can cause cell death in bone. This is a difficult form of fracture to treat.

Gail Ann: Due to having kidney stones and hypothyroidism, my doctors have instructed me to eliminate taking vitamin D. Taking calcium during the day has to be delayed because of taking a thyroid pill. This, at times, leaves me with ingesting less calcium than I should be having daily. What type of doctor would you suggest I consult to evaluate this situation and help me ensure I am getting enough of this vitamin and mineral? Thank you for answering my question.

Chad_Deal,_MD: You do not need to restrict vitamin D. Most kidney stones are oxalate (70 percent), and calcium in the diet may actually decrease the risk of stones. If you have kidney stones, we usually recommend taking calcium citrate for the calcium supplement.

General Information

mandy: I had surgery for scoliosis about 25 years ago and have a Harrington rod in my thoracic spine. I was recently diagnosed with osteoporosis in my lumbar spine in the first two vertebra below the rod (L3&4). Would there be any extra torque or stress on the two vertebrae because of the rod/fusion right above them that might make them more prone to fracture? Also, the bone scan was only of my lumbar spine. Should I have any other part of my spine scanned or imaged in some way?

Chad_Deal,_MD: Yes there would. A lot of the movement in the vertebrae that are rodded would occur in the section that is not rodded and would increase the risk for fracture if you have low bone mass. The lumbar spine is the only region we can scan with the DXA machine.

Xomue: What is the "Z" score and how is it measured? I know what the "T" score is, but I see references to the "Z" score without any explanation offered.

Lynn_Pattimakiel,_MD: The Z score is when your bone density test is compared to someone of your similar characteristics, age/gender/race. If your Z score is much lower than expected (less than -2.0), this should prompt testing for secondary causes of osteoporosis/or bone thinning.

Xomue: I have osteoporosis with a -3.6 in the spine and -1.9 in the hip. I'm almost 75, small-boned, have had a year's worth of prednisone (tapered slowly from 60 mg) and given Reclast. My mother had severe osteoporosis and fractured her spine. My daughter, at age 45, was diagnosed with the same. I live in fear of breaking a bone. What are my odds (based on this sketchy info)?

Chad_Deal,_MD: With a T-score of -3.6, a history of steroid use and a family history of osteoporosis, your fracture risk is high and you certainly need treatment. Reclast will decrease the risk by 50 percent or more.

rjfp: For someone who has osteoporosis and is on Prolia, would it be advantageous to be followed by a rheumatologist as opposed to a primary care physician?

Chad_Deal,_MD: Not necessarily. Some PCPs do a great job. Bone specialists are usually rheumatology or endocrinology or women's health.

love2422: Is 0.6 high for immature granulocytes in a normal adult?

Chad_Deal,_MD: You would need to discuss these results with a hematologist.


Moderator: That is all the time we have for questions today. Thank you, Dr. Deal and Dr. Pattimakiel, for taking time educate us about osteoporosis.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative.

If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at

Lynn_Pattimakiel,_MD: Thank you so much for participating during our web chat and for all of your excellent questions! I enjoyed answering your questions and wish you the best of health!

Chad_Deal,_MD: Thank you.

For Appointments

To make an appointment with Chad Deal, MD, or any of the other specialists in our Department of Rheumatologic and Immunologic Diseases at Cleveland Clinic, please call toll-free at 866.275.7496. You can also visit us online at

To make an appointment with Lynn Pattimakiel, MD, please call 216.444.6601, or call toll-free at 800.223.2273, ext. 46601. You can also visit us online at

For More Information

Cleveland Clinic

The Center for Osteoporosis and Metabolic Bone Diseases at Cleveland Clinic is a national leader in osteoporosis research and other forms of disease that affect bone. Early evaluation for risk of the disease, identification and treatment of osteoporosis can help prevent clinical manifestations of what is considered a silent disease.

The center sees patients with osteoporosis and other metabolic bone diseases including Paget's disease, osteomalacia, osteogenesis imperfecta and others. The center has a state-of-the-art bone densitometer to assess bone density in the hip and spine, as well as radius and total body when clinically indicated. This technique allows the physicians to evaluate the degree of bone loss and to diagnose osteoporosis and the risk for future fracture. Pain management and physical therapy may be integrated into a treatment plan if osteoporosis is advanced or fracture has occurred.

Cleveland Clinic staff participates in major studies of new approaches for osteoporosis prevention and therapy. This may include a clinical trial of a new medication. Clinical trials are not experiments, but rather provide you with an opportunity to try a medication that will be as good as – and hopefully better than – one that is currently available.

Cleveland Clinic’s Department for Rheumatologic and Immunologic Diseases is ranked No. 2 in the nation by U.S .News & World Report and top ranked in Ohio.

At the Center for Specialized Women’s Health at Cleveland Clinic, patients are seen in a caring environment that emphasizes technological excellence and emotional well-being. In addition to wellness exams, professionals within the Center for Specialized Women's Health offer a variety of services, including evaluation and treatment for women’s health concerns.

Cleveland Clinic's gynecology program is ranked No.3 in the nation by U.S. News & World Report and top-ranked in Ohio.

Cleveland Clinic Health Information

Learn more about symptoms, causes, diagnostic tests and treatments for osteoporosis:

Clinical Trials

Managing Your Health

MyChart® is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to:

An online second opinion from a Cleveland Clinic specialist is available as a service for patients who have received a diagnosis and are unable to travel to Cleveland, OH. For more information please visit

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 1995-2015. The Cleveland Clinic Foundation. All rights reserved.