Online Health Chat with Holly L. Thacker, MD and Chad Deal, MD

Tuesday, May 16, 2017


An estimated 54 million Americans are affected by osteoporosis and low bone mass, and it is responsible for more than two million fractures each year. There are steps you can take to prevent osteoporosis from ever occurring, and several treatments can slow the rate of bone loss. Join our experts to learn how both men and women are affected by this disease. Early detection, prevention strategies and treatment options will be discussed.

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 results in an increased loss of bone mass and strength. The disease often develops without any symptoms or pain, and it is usually not discovered until the weakened bones cause painful fractures. Most of these are fractures of the hip, wrist and spine. Our experts will discuss how both men and women are affected by this metabolic bone disease. They will address how it develops, early detection and prevention strategies that focus on balance and falls, nutrition and the variety of osteoporosis medications available.

About the Speakers

Holly L. Thacker MD, FACP, is director of the Cleveland Clinic Center for Specialized Women’s Health and professor at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. She published her second women’s health book “Cleveland Clinic Guide to Menopause.” Dr. Thacker is the executive director of national Speaking of Women's Health and directs the digital platform Her specialty interests include women’s health, perimenopause and menopause, medical management of urinary incontinence and CustomFit Physicals for women.

Dr. Thacker attended medical school at the University of Missouri – Kansas City School of Medicine, completed internships with Cleveland Clinic and was appointed to Cleveland Clinic in 1990.

Chad Deal, MD, is head of the Center for Osteoporosis and Metabolic Bone Disease and a board-certified rheumatologist at Cleveland Clinic. He has specialty interests in osteoporosis and related conditions.

Dr. Deal attended medical school at the University of Arkansas College of Medicine. He completed an internship, residency and fellowship at Boston Medical Center. He was appointed to Cleveland Clinic in 1999.

Let’s Chat About Osteoporosis

Weary of Risks

IBCLC: I've had a bone density scan and have been diagnosed with osteoporosis. I'm reluctant to use the medications. Can you reassure me regarding their safety? I'm already walking at least 30 minutes daily, taking calcium and vitamin D, eating dairy and dark greens, etc. I'm healthy and active. The medication side effects make them very unappealing to me.

Chad_Deal,_MD: One other evaluation is recommended, and that is FRAX. It estimates the patient’s 10- year fracture risk. The National Osteoporosis Foundation recommends treatment if the patient’s 10-year risk for major fracture is > 20 percent or hip fracture is > 3 percent. If the patient’s T score is less than -2.5, treatment is usually recommended; but if the 10-year fracture risk is < 20 percent or 3 percent, we sometimes follow the patient on just calcium and vitamin D. I can assure you that all medicines are safe. Every medicine has a risk and a benefit, and you have to weigh both to make a decision about treatment. Walking is a good activity for bone health, and of course, calcium and vitamin D are essential.

XOXOXO: Osteoporosis is a silent disease that might not present itself until a fracture occurs. The side effects of osteoporosis treatment could cause medical problems sooner and worse than the issue it is trying to prevent. How do doctors balance the benefits and the risks? How does osteoporosis treatment work with the strategy of “take the smallest dose for the shortest length of time”?

Holly_L._Thacker,_MD,_FACP: Taking the medicine for the shortest length of time is not a treatment guideline. More patients are undertreated than over-treated. The risk of osteoporosis treatment is exaggerated in the media. There are many treatments for osteoporosis that can be individualized for the best outcome for each patient.

BRANDEN: I'm 56 and have been diagnosed with osteoporosis. I had never really taken a lot of calcium, so my question is: If I start taking 1400 or more per day and exercise daily, will that be enough to help? I am very, very concerned with the drugs and their side effects, so I want to try and repair the damage on my own. There are many comments from people who have developed terrible issues after taking these drugs.

Chad_Deal,_MD: For patients at high risk for fracture, studies have shown that adding a medication to calcium and vitamin D is more effective at preventing fractures than calcium and vitamin D alone. Many patients are concerned about side effects with medications, but I try to get patients to think about the benefits of fracture prevention versus the risk of side effects. If your risk for a fracture is 10 percent in the next year, and your risk for a side effect is 1 percent, then the benefit outweighs the risk. Hopefully, the side effect would be mild and easily treatable.

fiat127: After many years of osteopenia, I have been diagnosed with osteoporosis (femoral neck -2.8 T-score) while the rest of my body is in osteopenia (total hip -2.1, spine -2.1). Eighteen months ago, I had a back fusion, and for six months I was pretty much spending lot of time in bed or sitting. I am 66 years old and small 5'2" and 108 lb. In my family history, nobody had a hip fracture. My mother had a wrist fracture when she was 80+ years old. I am very allergic to certain medications and suffer from extensive rash. My doctor suggested to return to Actonel (used for six years and stopped in 2008) or try Prolia. The other option is to wait 18 months and do another bone scan to see if my "calcium" diet and increased exercise improve my bones. I like Prolia, but I am worried that I may have a rash for many months since this medication stays in the body for many months. Is this concern justified? What would you recommend to do?

Chad_Deal,_MD: If you have osteoporosis at any site, you have osteoporosis. We treat based on the lowest T score. Most physicians would not wait to treat a patient with a T score of -2.8. If you tolerated Actonel, that is a reasonable option. Prolia is also a reasonable option. The rashes with Prolia are usually minor. I would not avoid Prolia for this reason. I personally would not wait 18 months to decide on treatment, especially if you are in bed and not performing weight-bearing exercises.

Diagnosis and Testing

pilatesgirl: What is the latest thinking about bone health testing? How often is bone density testing recommended? What about the blood tests?

Chad_Deal,_MD: Bone density testing is recommended in all women over the age of 65 and men over the age of 70. For post-menopausal women, bone density testing is recommended if there are risk factors such as family history of osteoporosis or previous fracture. Medicare will cover a bone density test every two years; however, if the bone density test is normal, bone testing at intervals greater than two years is fine. The most important blood tests are for vitamin D, calcium, kidney function and liver function. Sometimes, we do tests to measure bone turnover in either the blood or urine. If these tests are elevated, they often predict bone loss over time.

BRANDEN: How can I know what caused my osteoporosis? Is there some type of test?

Chad_Deal,_MD: The standard test for diagnosing osteoporosis is a bone density test called DXA, dual energy x-ray absorptiometry. It is a simple and safe test. This test, along with evaluation of clinical risk factors, will help determine if you need therapy for low bone mass and fracture prevention.

Speaking of Prolia

Much: I am a 70-year-old woman with osteoporosis. I have been getting shots of Prolia every six months for the last two years. How long should I keep getting these shots? Is it safe to be on Prolia long term? If my bone density has improved, should I stop for a while? Also, does it negatively affect my calcium? If it does, how much calcium do I need to take?

Chad_Deal,_MD: We have data on more than 4,000 women using Prolia for 10 years. When Prolia is discontinued, rapid bone loss may occur; therefore, the issue of a holiday with this drug is very different than with a drug like Fosamax. There is an ongoing clinical trial to assess the effect of one dose of Reclast after Prolia to see if this regime will maintain bone density long term.

lauriegs: I have been using Prolia shots twice a year for about five years. They seem to be helping. Are there any downsides to this in the current research?

Holly_L._Thacker,_MD,_FACP: Prolia (Denosumab) is an effective osteoporosis medication. Each shot only lasts for six months. There have been long-term data on this medication, which acts like a natural substance in the body to regulate the bone break-down and build-up process. If you stop therapy, you will resume bone loss; therefore, you need to be periodically monitored by your physician every year.

mathruler49: I've been advised to consider receiving Prolia for my osteoporosis, but I am hesitant because I had tested positive for TB in 1982. Later, I also tested positive with the blood test. What would be my best approach to treatment?

Chad_Deal,_MD: In the clinical trial that led to the approval for Prolia, 12 patients out of 3,800 had a skin infection called cellulitis. It was generally mild and did not result in discontinuation of the medication. However, this led to the inclusion on the label that warns about using Prolia with immunosuppressive agents. If your TB is treated, Prolia should be safe. Most experts feel the infection risk with Prolia is minimal.

SisterC: If one makes use of Prolia (twice a year injections), must use continue for life?

Chad_Deal,_MD: We have data on more than 4,000 women using Prolia for 10 years. When Prolia is discontinued, rapid bone loss may occur; therefore, the issue of a holiday with this drug is very different than with a drug like Fosamax. There is an ongoing clinical trial to assess the effect of one dose of Reclast after Prolia to see if this regime will maintain bone density long term.

Diet and Exercise

Jie: I would like the view of an expert as to whether nutrition and exercise can increase bone density without use of medication. I am classified as having osteopenia (spine -1.6, left femur neck -2.0, left femur total -1.8, right femur neck -2.4 and right total -2.1). If I follow a diet with proper nutrition and the correct type(s) of exercise, can I improve my current T-scores and thereby increase my bone density. If so, how much improvement could I expect? Where can I find the best information on proper exercise and best diet? I prefer not to take medication if possible.

Holly_L._Thacker,_MD,_FACP: Hygienic measures such as proper nutrition, regular weight-bearing exercise, ingestion of calcium in the diet and ensuring adequate vitamin-D in the diet are necessary, but not always sufficient. The cause of bone loss in many women over 50 is estrogen deficiency. Hygienic and lifestyle measures do not treat that condition. It is important to get a bone density test on the same machine within two years. If there is documented bone loss, you need to pursue therapy. For health tips on exercise and vitamin-D, and getting enough calcium in your diet, visit

Nurse56: Just to reiterate, are calcium-fortified products (almond milk, orange juice and coconut milk) as good sources of calcium as milk and yogurt, in which calcium occurs naturally? Thank you.

Chad_Deal,_MD: As best we know, calcium-fortified products are as good as products with naturally occurring sources of calcium.

Rosa K.: Swimming laps is my main form of exercise, but I know it isn't considered a weight-bearing one. Is it still helpful to my osteoporosis?

Holly_L._Thacker,_MD,_FACP: Aerobic exercise is good, but like you mentioned, it is not weight bearing and, therefore, not helpful for osteoporosis. Sometimes, weight-bearing exercise is not enough to help your osteoporosis, and you need to work with your physician on an individualized treatment plan.

pilatesgirl: How does Pilates help with bone density? By pulling on the bones in all different directions with body force, does it help maintain bone density?

Chad_Deal,_MD: Pilates is great exercise especially for core strength. The best exercise for bone is weight-bearing exercise such as walking. General muscle strengthening is good for balance and fall prevention. I would add weight-bearing exercise to your Pilates regime.

General Medication Messages

davel: I understand that the drug Forteo is the only drug that can increase bone density. How successful is it?

Holly_L._Thacker,_MD,_FACP: Forteo is not the only drug that improves bone density. It is an anabolic bone-building drug given by injection. Recently, there was another FDA-approved medication called Tymlos (abaloparatide), also an anabolic bone-building agent. It's best for you to visit with your bone specialist physician to determine what the best course of therapy is for you.

Rose12: I was in the one percent to two percent who had horrible side effects from Actonel, and in general have a lot of medication sensitivities. Are all bone density drugs similar in their chemical composition? What alternatives might you recommend for people with drug sensitivities?

Chad_Deal,_MD: If you've had a side effect with Actonel, you may not have a side effect with either Fosamax or Boniva. Many patients who have a side effect with an oral bisphosphonate will choose to go on Prolia, which is an injection every six months is and not a bisphosphonate.

catherine472: I had a traumatic fall and broke my arm some months ago. I am currently taking Forteo. My bone density is -2.5. Would Evista be an option after the two years on Forteo? I can't take estrogen due to breast cancer, and dentists have cautioned me not to take bisphosphonates due to some dental issues. Thank you.

Chad_Deal,_MD: After two years of Forteo, you must go on another osteoporosis drug to maintain and build bone. If you do not, you will start to lose bone off therapy. I have used Evista after Forteo. In your case, however, most physicians do not recommend using Evista if you have had breast cancer. You will need to discuss this with your oncologist. Dental issues can be a concern with bisphosphonate medications and have been associated with osteonecrosis of the jaw. The incidence of this side effect is approximately one in 10,000 per patient a year, so it is very rare. It is higher in patients who have invasive dental procedures.

Rose12: I have a lot of drug sensitivities and had a severe reaction to Actonel. What alternatives exist?

Holly_L._Thacker,_MD,_FACP: There are several other options besides medicines like Actonel. There are other classes of medicines such as hormones and serums (like Evista/Raloxifene), which are usually very well tolerated, similar to a placebo pill. In addition, there are injectable and systemic therapies that bypass the intestines and should have no gastrointestinal side effects.

Barney33: I am on medication because of atherosclerosis (multiple stents placed). Could any of the medications I take to treat the heart condition be related to the osteoporosis I have been diagnosed with? I take Lipitor 80 mg, Ezetrol 10 mg, Bisoprolol, Lisinopril, and Plavix.

Chad_Deal,_MD: No. None of these medications are associated with bone loss and osteoporosis.

btp: I am 63 years old and on hormone therapy (estrogen and progesterone) for osteoporosis. In planning for the near future, does Medicare cover prescription costs for HT for osteoporosis? I am planning on purchasing Plan B. Or, will I have to choose an alternative?

Holly_L._Thacker,_MD,_FACP: There may be more limited coverage of medications under Medicare. You need to check with your insurance provider or whatever secondary supplemental insurance you obtain. One particular medication that is a hormone therapy regimen and has approval to treat osteoporosis is Duavee. Here is some information on how to keep the costs of medications down:

Ctmon : Is there any consensus on supplementing with estrogen as a treatment for osteoporosis?

Holly_L._Thacker,_MD,_FACP: Estrogen/hormone therapy can be used to prevent and treat osteoporosis. However, some women will lose bone density despite being on estrogen, so they still need to be followed. One of the most effective hormone therapies for osteoporosis is Duavee.

Forteo Facts

CCF0501: I have been on Forteo for six months. When should I have a repeat bone density scan? Would it do any good to have a scan once I am on the medication for one year? Thank you.

Chad_Deal,_MD: Forteo is a drug used for two years. In most cases, insurance will only cover a bone density test every two years. If you are on prednisone or have a disease called hyperparathyroidism, bone density testing can be done at one year. This means that you often don't know the effect of Forteo while you are taking this medication, which is always concerning for patients. There is a blood test called Procollagen that increases if Forteo is working, and many experts recommend this test at baseline and two to three months after starting Forteo.

Barney33: I have been diagnosed with osteoporosis (male, 57 years old) after breaking two vertebrae without obvious cause. My measurements are BMD 47.7 mg Ca-HA/ml, T-Value - 4,16, Z-Value - 2.34. My endocrinologist has prescribed a treatment with vitamin D and calcium supplement (endocrinologist had determined about a year ago that I had a low vitamin D level, in the low thirties). At an osteoporosis center that I also visited, they wanted to start treatment with bisphosphonates right away given the severity of my osteoporosis. Can the bisphosphonate treatment be combined with the vitamin D/calcium treatment or is the bisphosphonate treatment instead of the vitamin D/calcium treatment?

Chad_Deal,_MD: Most experts would recommend taking an anabolic agent with two vertebral fractures and a T score of -4.1. That drug is Forteo. You should discuss this medication with your physician.

Body in Balance

pilatesgirl: Do you think nail and tooth health have any connection to bone health?

Holly_L._Thacker,_MD,_FACP: Dental conditions such as periodontal disease and tooth loss are linked to osteoporosis. Nutritional status, including getting adequate protein and minerals, not only helps your skeleton, but also your teeth and nails.

SisterC: Therapy with AIs results in more than usual bone loss. Once AI therapy is stopped, how quickly do bones regain at least some of what has been lost?

Holly_L._Thacker,_MD,_FACP: Aromatase inhibitors (AIs) are used to treat breast cancer and wipe out cellular estrogen, and are therefore very hard on the bones. Many women on AIs will need osteoporosis treatment while on the therapy. When you stop the AIs, determining whether you need the osteoporosis treatment depends on many factors, including your medical condition, age, bone density and risk factors for osteoporosis. This needs to be individualized for each person with his or her physician.

pilatesgirl: I have celiac disease and was diagnosed at age 50. I am now 62 years old. I have osteopenia at the far end toward osteoporosis. I eat well and exercise. What do you think I can do to help my bone health? Diet? I exercise daily. I am a Pilates instructor. My father had multiple myeloma, which I think was related to untreated celiac and, therefore, immune dysfunction. Do you have any thoughts or insights?

Chad_Deal,_MD: Celiac disease decreases both calcium and vitamin D absorption from the gastrointestinal tract. If you are on a gluten-free diet, calcium and vitamin D absorption should be normal. You should have your physician calculate your 10-year fracture risk using FRAX and make additional treatment decisions. Of course, weight-bearing exercises are important.

Nutritional Needs

pilatesgirl: What minerals and in what forms do you recommend for bones? Is it important to have chelated calcium? What do you think of calcium/magnesium ratio? What about boron, K2 and silica?

Holly_L._Thacker,_MD,_FACP: It is best to get calcium in your everyday diet. Most people need 1,000 to 1,200 mg per day in divided doses. It does not need to be chelated. However, if you've had a history of kidney stones, and you have low calcium in your diet, the only supplement of calcium you should take is calcium citrate. There is no need to add other substances to the calcium. If you're on calcium supplements because you don't get enough in your diet, and you are getting constipated, you may want to add a magnesium supplement, about 250 to 400 mg per day, if you don’t have kidney failure. Vitamin K can be obtained by eating a healthy diet with green, leafy vegetables. You don't need to take supplements with heavy metals in them; boron and strontium is not specifically recommended. Adequate levels of vitamin D and estrogen help the gut absorb calcium in the diet.

Nurse56: Hi. I'm a 61-year-old female, and I have osteopenia. My serum calcium usually is 10.5, and my primary physician assumes I will have primary hyperparathyroidism at some point. Because of this, my rheumatologist changed my calcium supplement of calcium plus D, 600 mg to Citracal plus D 315 mg daily. Within three months, my calcium level is 9.8. My questions: 1) Is the Citracal 315mg enough calcium for bone building? I'm conscious of a diet rich in calcium. 2) Are calcium-enriched foods, i.e., orange juice, almond milk, etc. good sources of calcium needed for bone building?

Chad_Deal,_MD: I am not sure why your calcium dropped with Citracal; perhaps because you decreased calcium from 600 to 315mg. I would still keep a close eye on your serum calcium level and perhaps get a PTH level, which is often elevated in primary hyperparathyroidism. The current recommendation for daily calcium intake is 1,200-1,500. You can get this from diet alone, or if your diet is insufficient an appropriate amount of calcium supplement is recommended to reach 1,200-1,500 mg. These foods are good sources of calcium.

Shaker mom: I've been diagnosed with osteoporosis at 52. What is the recommended amount of calcium and vitamin D I should be taking?

Holly_L._Thacker,_MD,_FACP: Calcium and vitamin D are necessary, but not sufficient. In general, most women need about 1,000-1,200 mg of calcium daily, in divided doses, preferably from the diet, and 1,000-2,000 IUs of vitamin D3 daily. Your physician can check a 25-OH vitamin D level. The goal level should be between 40 and 60. However, if you have osteoporosis, you likely need therapy. If there is any concern about your calcium metabolism, and/or if you've ever had kidney stones, a 24-hour urine collection for calcium should be obtained.

catherine472: I am on Forteo. Pre-Forteo, my vitamin D (25 OH) levels were between 54 and 60 ng/ml on 2500 units of D3 daily. My 25 OH levels after three months on Forteo dropped to 37 ng/ml. My serum calcium 24 hours after my last Forteo dose was 9.2 mg/dL. I am an RN and know Forteo will drop 25-OH hydroxyvitamin D level, but result in an increase in 1,25 dihydroxyvitamin D levels. My question is: Should I increase my intake of Vitamin D3? I have found nothing in the literature that addresses this phenomenon in relation to Forteo and whether or not I should increase my dose of vitamin D3. I have received differing opinions from two of my providers. One said I should increase my vitamin D dose to 5000 units daily, and another said I should not as I would be risking hypercalcemia. Can you provide any more information? My current intake of calcium is between 1000 and 1300 mg daily and includes food intake. My vitamin D3 supplementation is 2500 units daily. I also take magnesium 400 mg daily. Thank you.

Chad_Deal,_MD: A couple of things: The precision error of vitamin D measurements is significant, and there may not be as large of a difference between 54 and 37 as it would appear. Remember, levels between 31 and 80 are considered normal, and most physicians would be happy with a level of 37. I do not feel it necessary to supplement based on this decline. I would think your current vitamin D intake is fine.

mbib104: Is skim cow's milk (if tolerated) a good source of supplemental calcium? I was told milk can deplete dietary calcium? How does almond milk fare as a source of calcium? What has been your experience with Prolia? Some of the side effects are scary. After 10 years on Boniva, would a change be in order? Thanks for your service and time.

Holly_L._Thacker,_MD,_FACP: Skim milk is an excellent source of dietary calcium. Low-fat dairy products, such as yogurt and low-fat cheese, are also good sources of calcium. If you want to avoid dairy because of allergy or intolerance, there are non-dairy milks, such as almond, coconut and soy milk that are all rich in calcium. Generally speaking, after five to 10 years of being on a medication such as Boniva (Actonel, Fosamax), some physicians may recommend a "drug holiday" if you are otherwise stable and not at high risk for fracture. Typically, "drug holidays" are around two years and then the patient is re-evaluated. Prolia is an excellent, well-studied medication that is generally well-tolerated.

Sueb: Is there a risk associated with taking calcium supplements daily?

Chad_Deal,_MD: There are contradictory studies on side effects with calcium supplementation. Some studies show an increased risk for cardiovascular events. Those studies seem to imply that dietary calcium is safer. Many other studies have disputed this finding, and I would say that most experts are not certain of an association of calcium supplements with cardiovascular events. Stay tuned for more information in the future.

lauriegs: What is the best type of calcium supplement to take?

Chad_Deal,_MD: There is no correct answer; however, if you have low stomach acid, calcium citrate is better absorbed than calcium carbonate. This might occur in patients on high doses of acid blockers for heart burn or ulcer disease. A disease called pernicious anemia is associated with no stomach acid, and in this case, calcium citrate is a must.

About Bisphosphonates

djpm: I was on Fosamax for five years, but was taken off for a "vacation" a few years ago. Now, at age 65, my latest bone scan shows that some of my spine has gotten worse. If I go back on medication, which one would be the best for me? (An osteoporosis specialist in Pittsburgh suggested Reclast, but I would like another opinion.) Thank you.

Chad_Deal,_MD: Drug holidays are recommended for most patients on bisphosphonate medications. If bone loss occurs off medication, then it is appropriate to restart therapy. The particular medication could be the same, Fosamax as before. Reclast is an intravenous bisphosphonate, whereas Fosamax is an oral bisphosphonate. Both are effective. Many patients like the idea of giving a medication once a year like Reclast and not having to take a pill every week. You should discuss this with your physician.

pghgrandma: Do many women experience side effects from the Boniva infusions?

Chad_Deal,_MD: The most common side effect with intravenous bisphosphonates like Boniva or Reclast is a flu-like syndrome that lasts for 24 to 48 hours and is usually mild and treated with fluids and Tylenol. Occasionally, bone pain can be more severe, and if this reaction occurs, many patients will not want to repeat the infusion. However, only 10 percent of patients who had that reaction on the first infusion will have a reaction on the second infusion.

XOXOXO: I understand the convention is to use the worst osteoporosis number as the treatment level. All osteoporosis treatments have risks and side effects. For example, bisphosphonates do not allow the osteoclasts to do their work of clearing out old bone so new bone can be formed. What do these drugs do to my good bones, which are in balance with the replacement cycle?

Chad_Deal,_MD: Bone loss occurs when bone resorption exceeds formation. Bisphosphonates work by decreasing resorption, and for several years, formation continues. This increases bone mass. Studies show that bone quality with bisphosphonates is fine, and bone strength is improved. The concern has arisen with long-term bisphosphonate therapy, which has been associated with atypical femur fractures. This is why major bone organizations recommend consideration of a drug holiday after three to five years, sometimes as long as 10 years.

Shaker mom: I've been given the option of either Fosamax or Boniva as treatment. Other than the different timing of the medicine (weekly versus monthly), what are the advantages and disadvantages of each medication?

Chad_Deal,_MD: There are three oral bisphosphonates: Fosamax, Actonel and Boniva. They are very similar in efficacy and side effects, and in most cases, patients choose based on weekly versus monthly dosing. The other factor is always cost. Many pharmacy benefit groups will charge the least for Fosamax, often only $3 to $5 per month.

Literature Review

XOXOXO: In the Surgeon General Report on Bone Health and Osteoporosis, it states that “women have a two phases of age-related bone loss – a rapid phase that begins at menopause and lasts four to eight years, followed by a slower continuous phase that lasts throughout the rest of life.” If medication is necessary, will the medication chosen be more aggressive if the person is in the first phase compared to the second phase?

Chad_Deal,_MD: Rapid bone loss occurs around the time of menopause because of the declining estrogen and increasing bone resorption. You are correct in that it lasts around four to eight years. Some women can lose up to 5 percent of their bone mass every year for this period of time. This is why it is important to measure bone density at menopause and make a decision to treat and prevent this rapid bone loss, especially if bone density is low. Most medications work well during this period of rapid bone loss.

XOXOXO: In the Surgeon General Report on Bone Health and Osteoporosis, it states that “DXA tests underestimates the density of small bones and overestimates the density of large bones. Therefore, the size of the bone should be taken into account when deciding whether or not to medicate.” In my case, the only bones that were not in the normal osteoporosis category were the small bones in my spine. Does this mean that my condition is not as drastic as the numbers indicate?

Holly_L._Thacker,_MD,_FACP: Women tend to lose bone first in their spine. So even though you have smaller bones in your spine, the size isn't the reason for the bone loss. When you make the diagnosis of osteoporosis, it's based on the bone with the lowest density in the body. You should talk to your doctor to see if you need therapy for osteoporosis.

XOXOXO: In the book Osteoporosis Prevention by Renee Newman, spinach is listed as a vegetable that reduces calcium absorption because of oxalic acid. Spinach is also listed as a good source of vitamin K, which is needed for bone health. How do you get the good properties of spinach without hurting calcium absorption?

Holly_L._Thacker,_MD,_FACP: Spinach is a great choice for a green leafy vegetable, but it does have oxalates in it. It is best to get a variety of green vegetables in your diet; broccoli and bok choy have calcium. Don't ban spinach completely, as it a great source of iron, fiber and omega-3s.


That is all the time we have for questions today. Thank you, Dr. Thacker and Dr. Deal, for taking time to educate us about Osteoporosis.

Holly_L._Thacker,_MD,_FACP: Thank you for participating in this webchat. I've enjoyed answering your questions. Be sure to take osteoporosis seriously and check in with your physician to make sure you don't outlive your skeleton!

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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 1995-2017. The Cleveland Clinic Foundation. All rights reserved.