Bone Health & Calcium Disorders



Osteoporosis is a disease in which bones become weak and fragile and are more likely to fracture or break. Our body regularly makes new bone and breaks down old bone. When we're young, our body makes new bone faster than it breaks down old bone, and our bone mass increases.  Until about age 30, our body forms enough new bone to replace the bone that is naturally broken down by the body (a process called bone turnover). Our highest bone mass (size and thickness) called peak bone mass is reached between mid 20's and 30's and it declines after that. As people age, bone mass is lost faster than it's created. Our susceptibility to develop osteoporosis depends partly on how much bone mass one attains in youth. Peak bone mass is somewhat inherited and varies also by ethnic group. The higher the peak bone mass, the more bone one has "in the bank" and the less likely to develop osteoporosis as one ages. 

 Due to loss of bone tissue, bones that were once dense and strong can be unable to withstand the stress of even normal activity, such as bending over or coughing. Osteoporosis-related fractures most commonly occur in the spine, wrist and hip. In addition to bone fractures, osteoporosis can cause bone pain, loss of height and a stooped posture. All of these symptoms can lead to feelings of anxiety and depression. 

After menopause, however, women begin to lose bone at an even faster rate. Osteoporosis develops when body cannot replace bone as fast as it is broken down. Too much bone loss (osteoporosis) can lead to fractures, which can cause serious health risks, including disability and premature death 

Risk of Osteoporosis rises with age because as you get older, you lose bone faster than your body can make it. Osteoporosis can occur when the body’s creation of new bone can no longer keep up with the breakdown of old bone. Bones may become weak and brittle and are easily broken. 

Women near the age of menopause are particularly vulnerable to bone loss. On average, in the three years around menopause — one year before the last menses and two years after it — women go through a rapid phase of bone loss, losing about 2 percent of overall bone mass each year during that time. 

No one can say for sure which individuals will develop osteoporosis. But research has revealed what makes some people more likely than others to develop it. That's why it's important to be aware of the risk factors — and what you can do about them. Some osteoporosis risk factors, such as older age, can't be changed. But others are things you can control. 

Risk factors that can't be changed 

  • Age. The older you are, the more likely you are to develop osteoporosis and the more likely you are to break a bone because of it. After you've reached your peak bone mass, it's normal to begin losing a small percentage of bone mass each year. This happens because new bone formation slows with age, while bone breakdown stays the same or increases. The internal structure of bones also begins to weaken, and the outer shell thins. 

  • Gender. Women usually have lower peak bone mass than men do. Women also tend to live longer. So, in effect, women have less bone to lose but more time to lose it. In addition, during menopause, women experience a drop in estrogen levels, which usually accelerates bone loss. Osteoporosis is most common among postmenopausal women. 

  • Menopause, which usually occurs in a woman’s 40s or 50s, significantly speeds bone loss. Older men also lose bone mass faster as they age. Over time, the imbalance between bone breakdown and formation causes bone mass to decrease, so osteoporosis can develop and fractures occur more easily. 

  • Ethnicity. Caucasians and Asians are at greater risk of osteoporosis; Hispanics and Native Americans appear to have an intermediate risk, while African-Americans have the lowest risk. These various levels of risk are based in part on differences in bone mass and bone density. 

  • Genetics. Family history is a strong predictor of low bone mass. If your mother, sister, grandmother or aunt has osteoporosis, then you're at greater risk. But remember that having a family history of low bone mass doesn't automatically mean the same thing will happen to you. By taking steps to lower your risk, osteoporosis can be prevented. 

  • Body frame size. Men and women with small body frames tend to have a higher risk because they usually have less bone mass to draw from as they age. 

Health-related risk factors 

  • Individual health circumstances, including health conditions and medications, can influence osteoporosis risk. 

  • Childbearing. Pregnancy builds stronger bones by raising estrogen levels and increasing weight. Bone density decreases slowly during pregnancy and more rapidly while nursing a baby, but this bone loss recovers within six months after stopping nursing in most women. 

  • Medications. Certain medications can accelerate bone loss and increase your risk of osteoporosis. If you take any of the following medications, then talk to your health care professional about what you can do to counteract their effects on bone health. 

  • Corticosteroid medicines. Long-term use of corticosteroids, including prednisone and similar medications in the same class lowers bone mass. If you take one of these medications for more than a few weeks, then your health care provider will likely monitor your bone density and recommend preventive measures. 

  • Anticonvulsants. If you take a medication to control seizures (anticonvulsants) over a long period of time, then your liver begins to metabolize vitamin D in a way that causes a deficiency of the vitamin.  

  • Thyroid medicines. When used in excessive quantities, thyroid medications such as levothyroxine (Synthroid, Tirosint, others) can cause high thyroid hormone blood levels that accelerate bone loss. 

  • Diuretics. These drugs prevent fluid buildup in your body. But by doing so, certain diuretics can cause the kidneys to excrete too much calcium, leading to weaker bones. 

  • Other drugs. Certain blood thinners, such as heparin, can cause bone loss when used over a long period of time. So can aromatase inhibitors, a class of drugs used to treat breast cancer, and drugs that are used to treat endometriosis and prostate cancer (gonadotrophin-releasing hormone agonists). 

  • Medical Conditions. Certain medical conditions can increase the risk of osteoporosis by slowing bone formation or speeding up bone breakdown. They include: 

  • Endocrine disorders: Osteoporosis is more common in people who have too much or too little of certain hormones in their bodies.  

  • Sex hormones. Lowered sex hormone levels tend to weaken bone. The reduction of estrogen levels in women at menopause is one of the strongest risk factors for developing osteoporosis. 

  • Men have a gradual reduction in testosterone levels as they age. Treatments for prostate cancer that reduce testosterone levels in men and treatments for breast cancer that reduce estrogen levels in women are likely to accelerate bone loss. 

  • Thyroid problems. Too much thyroid hormone can cause bone loss (Hyperthyroidism) This can occur if your thyroid is overactive or if you take too much thyroid hormone medication to treat an underactive thyroid. 

  • Other glands. Osteoporosis has also been associated with overactive parathyroid (Hyperparathyroidism) and adrenal glands (Cushing's Syndrome)  

  • Diabetes Mellitus. Both Type 1 and Type 2 patients are at risk for bone loss and fractures. 

  • Gastrointestinal disorders, including Crohn's disease, Celiac disease, Lactose intolerance and Liver disorders such as primary biliary cirrhosis 

  • Rheumatoid arthritis 

  • Amenorrhea (Absent or infrequent menstrual cycles in women of childbearing age) 

  • Celiac disease 

  • Inflammatory bowel disease 

  • Kidney or liver disease 

  • Cancer 

  • Lupus 

  • Multiple myeloma 

  • Rheumatoid arthritis 

  • Gastrointestinal surgery. Surgery to reduce the size of the stomach or to remove part of the intestine limits the ability of these organs to absorb nutrients, including calcium. 


  • Risk factors that can be changed:  


  • Good nutrition and regular exercise are essential for keeping your bones healthy throughout your life. 


  • Sedentary lifestyle & Lack of physical activity 

  • People who spend a lot of time sitting have a higher risk of osteoporosis than do those who are more active. Any weight-bearing exercise and activities that promote balance and good posture are beneficial for your bones 

  • Regular physical activity is key to preventing osteoporosis and fractures. Lack of exercise accelerates bone loss; whereas, weight-bearing exercises such as walking and resistance training can increase or at least maintain your bone density at any age 

  • Combine strength training exercises with weight-bearing and balance exercises. Strength training helps strengthen muscles and bones in your arms and upper spine. Weight-bearing exercises — such as walking, jogging, running, stair climbing, skipping rope, skiing and impact-producing sports — affect mainly the bones in your legs, hips and lower spine. Balance exercises such as tai chi can reduce your risk of falling especially as you get older. Swimming, cycling and exercising on machines such as elliptical trainers can provide a good cardiovascular workout, but they don't improve bone health.  

  • Low calcium and vitamin D intakes. A lifelong lack of calcium plays an important role in the development of osteoporosis. Low calcium intake contributes to diminished bone density, early bone loss and an increased risk of fractures. Because vitamin D is essential for calcium absorption, chronically low levels can contribute to osteoporosis. Some studies suggest that large portions of the U.S. population may have low levels of vitamin D. But the data is difficult to interpret, because the definition of what constitutes deficiency can vary. Still, it's a good idea to have your vitamin D level checked if are in one of the categories of higher risk of deficiency. 

  • Calcium: Men and women between the ages of 18 and 50 need 1,000 milligrams of calcium a day. This daily amount increases to 1,200 milligrams when women turn 50 and men turn 70. 

  • Good sources of calcium include: 

  • Low-fat dairy products 

  • Dark green leafy vegetables 

  • Canned salmon or sardines with bones 

  • Soy products, such as tofu 

  • Calcium-fortified cereals and orange juice 

  • If you find it difficult to get enough calcium from your diet, consider taking calcium supplements. However, too much calcium has been linked to kidney stones. Although yet unclear, some experts suggest that too much calcium especially in supplements can increase the risk of heart disease. 

  • The Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine (formerly the Institute of Medicine) recommends that total calcium intake, from supplements and diet combined, should be no more than 2,000 milligrams daily for people older than 50. 


Vitamin D


  • Vitamin D improves your body's ability to absorb calcium and improves bone health in other ways. People can get some of their vitamin D from sunlight, but this might not be a good source if you live in a high latitude, if you're housebound, or if you regularly use sunscreen or avoid the sun because of the risk of skin cancer. Your doctor can check a blood test to determine your vitamin D level. If it’s too low, you may need a supplement. 

  • To get enough vitamin D to maintain bone health, it's recommended that adults ages 51 to 70 get 600 international units (IU) and 800 IU a day after age 70 through food or supplements. 

  • People without other sources of vitamin D and especially with limited sun exposure might need a supplement. Most multivitamin products contain between 600 and 800 IU of vitamin D. Up to 4,000 IU of vitamin D a day is safe for most people. 

  • Smoking. smoking is bad for your bones. Smoking interferes with the production of estrogen and testosterone, which are needed to build bone. Smoking also disrupts calcium absorption. Another good reason to quit  

  • Alcohol use. Alcohol delivers a double whammy to your bones, putting a damper on bone building and stimulating the bone loss process. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger.  

  • Protein 

  • Protein is one of the building blocks of bone. However, there's conflicting evidence about the impact of protein intake on bone density. But taking in high amounts of protein every day can cause your body to lose calcium.  

  • Most people get plenty of protein in their diets, but some do not. Vegetarians and vegans can get enough protein in the diet if they intentionally seek suitable sources, such as soy, nuts, legumes, seeds for vegans and vegetarians, and dairy and eggs for vegetarians. 

  • Older adults might eat less protein for various reasons. If you think you're not getting enough protein, ask your doctor if supplementation is an option. 

  • Caffeine: 

  • Caffeine in large amounts may also make it hard for your body to retain calcium.  

  • Body weight 

  • Being underweight increases the chance of bone loss and fractures. Excess weight is now known to increase the risk of fractures in your arm and wrist. As such, maintaining an appropriate body weight is good for bones just as it is for health in general. 

  • Eating disorders 

  • Severely restricting food intake and being underweight can weaken bone. 


FAQ's (Bone Health) 

How do I know if I have Osteoporosis? 

Osteoporosis does not cause symptoms until you break a bone. But your doctor or nurse can have you tested for it. The best test is a bone density test called the "DXA test." It is a special kind of X-ray. 

Experts recommend bone density testing for women older than 65. That is because women in this age group have the highest risk of osteoporosis. Still, other people should sometimes be tested, too. Ask your doctor or nurse if you should be tested. 

Some people learn that they have osteoporosis because they break a bone during a fall or a mild impact. This is called a "fragility fracture," because people with healthy bones should not break a bone that easily. People who have fragility fractures are at high risk of having other bones break. 

Who and when should we get Bone Density test? 

If someone has gone through menopause (even if you have been taking hormone therapy for a long time), have had a fracture (bone break), or are considering treatment for osteoporosis, a bone density test (DXA scan) can help determine your risk of fracture. 

 Women over 65 

Men over 70 (even if no history of fractures or other risk factors) 

Who is at risk for osteoporosis? 

  • Women make up 80 percent of cases. Certain risk factors make it more likely that you will develop osteoporosis. 

  • Risk Factors for osteoporosis include: 

  • Hormonal conditions (such as Hyperparathyroidism, Hyperthyroidism, Diabetes, Hypercortisolism, or Hyperprolactinemia) 

  • Anorexia Nervosa (a condition associated with very poor nutrition and abnormal ovarian function) 

  • Too much exercise or stress that leads to loss of menstrual periods 

  • Family history of fractures  

  • Postmenopausal 

  • Premenopausal with irregular or no menstrual periods (amenorrhea)  

  • Thin or small frame 

  • Caucasian or Asian 

  • Diet low in Calcium & Vitamin D 

  • Little or no exercise 

  • Cigarette smoking 

  • Drinking too much alcohol 

  • Therapy with a steroid (such as prednisone) for any significant length of time 

  • Personal History of Rheumatoid Arthritis 

  • You might want to talk to your doctor about osteoporosis if you went through early menopause or took corticosteroids for several months at a time, or if either of your parents had hip fractures. 

Are there any symptoms of Osteoporosis?  

There typically are no symptoms in the early stages of bone loss. But once your bones have been weakened by osteoporosis, you might have signs and symptoms that include: 

Back pain, caused by a fractured or collapsed vertebra 

Loss of height over time 

A stooped posture 

A bone that breaks much more easily than expected 

How is osteoporosis prevented ? 

There are certain steps that could be taken to prevent bone loss: 

Get enough calcium and vitamin D, either through diet or supplements (at least 1,000–1,200 mg of calcium; at least 400–800 IU of vitamin D daily under age 50 or 800–1,000 IU after age 50) 

Do weight-bearing exercises and stay physically fit. Be active for at least 30 minutes, most days of the week 

Avoid smoking 

Don’t drink too much alcohol (Limit the amount of alcohol to 1 to 2 drinks a day) 


What are the dietary sources of Calcium and Vitamin D? 


Foods rich in calcium include ice cream, soy milk, breads, kale, broccoli, milk, cheese, cottage cheese, almonds, yogurt, ready-to-eat cereals, beans, and tofu. Foods rich in vitamin D include milk, canned tuna fish, cod liver oil, yogurt, ready-to-eat-cereals, cooked salmon, canned sardines, mackerel, and eggs. Some of these foods are rich in both. 


Foods and drinks with calcium 


Calcium in milligrams 

Milk (skim, 2%, or whole; 8 oz [240 mL]) 


Yogurt (6 oz [168 g]) 


Orange juice (with calcium; 8 oz [240 mL]) 


Tofu with calcium (0.5 cup [113 g]) 


Cheese (1 oz [28 g]) 

195 to 335 (hard cheese = higher calcium) 

Cottage cheese (0.5 cup [113 g]) 


Ice cream or frozen yogurt (0.5 cup [113 g]) 


Soy milk (8 oz [240 mL]) 


Beans (0.5 cup cooked [113 g]) 

60 to 80 

Dark, leafy green vegetables (0.5 cup cooked [113 g]) 

50 to 135 

Almonds (24 whole) 


Orange (1 medium) 



What are the most common type of fractures seen in patients with Osteoporosis? 

  • Bones in the hip, spine, and wrist are especially prone to fragility fractures—fractures that would not have occurred in a younger person with stronger bones. Spine and hip fractures are the most serious complications of osteoporosis. Hip fractures often are caused by a fall and can result in disability and even an increased risk of death within the first year after the injury. In some cases, spinal fractures can occur even if you haven't fallen. The bones that make up your spine (vertebrae) can weaken to the point of crumpling, which can result in back pain, lost height and a hunched forward posture. 


  • How is Osteoporosis treated ? 

  • Even with a healthy lifestyle, however, some people who are at moderate to high risk for fractures, may still need additional therapy to protect against bone loss and fractures.  

  • You may need to be prescribed medications such as: 

  • Bisphosphonates - Oral: Alendronate (Fosamax) Risedronate (Actonel) or Ibandronate (Boniva) Injectable: Zoledronic acid Infusion once a year (Reclast) 

  • Raloxifene (Evista) Oral Therapy 

  • Teriparatide (Forteo) Daily Injections for 2 years 

  • Denausomab (Prolia) Subcutaneous injections every 6 months 

  • Estrogen (when also prescribed for the relief of menopausal symptoms) 

  • Calcitonin 

  • All of these treatment options are effective, but may have side effects. Talk with your doctor to determine whether you need treatment, and which option is best for you. 



How osteoporosis is diagnosed? 

  • A bone density test can help you determine if you have osteoporosis or are at risk. Since the bone loss typically happens gradually and painlessly, the first sign of osteoporosis can be breaking a bone, often more easily than you'd expect. But it is possible to determine if you have osteoporosis, even before a bone is broken, by getting a bone density test. The test can also detect if your bone density is lower than normal for a person of your age and sex. Bone loss that has not reached the stage of an Osteoporosis diagnosis is called Osteopenia. A bone density test is the best way to predict fracture risk. 

  • A bone density test uses a low dose of X-rays in a quick, noninvasive way to measure the amount of calcium and other minerals in a segment of bone, usually the hips and spine. By identifying decreases in bone mineral density, your health care provider can determine your risk of fractures, and diagnose and monitor Osteoporosis progression.  

  • Bone density testing uses a device called a bone densitometer. 


There are 2 type of densitometers 


  • Central  

  • Peripheral 

  • Central Densitometers : These machines are used to measure the density of the central, stabilizing parts of the skeleton, such as the spine and hip. This type of densitometer provides the most accurate bone density testing and can predict your potential risk of fracture. If you're taking medication for osteopenia or osteoporosis, central densitometry of your spine is best for monitoring your treatment. 

  • Dual energy X-ray absorptiometry (DXA). A DXA machine uses two different X-ray beams to increase the precision of what it's measuring. DXA is most often performed on the narrow neck of the upper leg bone (Femur), just below the hip joint, as well as the Lumbar vertebrae, which form the lower part of the spine. Sometimes forearm is checked as well. DXA testing is painless and takes only a few minutes. 

  • Quantitative computerized tomography (QCT). This instrument measures bone density using computerized tomography (CT). QCT is most often used to measure density in the vertebrae and the part of the femur below the hip. 

  • Peripheral densitometers: Smaller devices are used to measure bone density on the periphery of the skeleton, such as in the wrist and heel bone. Although they are more portable, these densitometers are less accurate at predicting fracture risk. If your test on a peripheral device is positive for osteopenia or osteoporosis, then your doctor might recommend a follow-up scan of your spine or hip to confirm the diagnosis. 

  • Quantitative ultrasound (QUS). This procedure is often called heel ultrasound because it typically measures bone density in the heel bone. Peripheral dual energy X-ray absorptiometry (pDXA). This device is a compact, portable DXA scanner. Using X-rays, pDXA measures bone density in the wrist or heel. Although it's quick and accurate, this testing can be expensive. 

  • Peripheral quantitative computerized tomography (pQCT). This portable version of QCT measures the bone density of the wrist or hand. This test is also expensive, and it produces a higher radiation exposure than do other tests. 

  • How is Bone Density results reported?  


Bone density test results are reported in a measurement known as a “T-score.” This is bone density compared with what is normally expected in a healthy young adult of the same sex. The T-score is the number of units called standard deviations that an individual's bone density is above or below the average. Z-score. This is the number of standard deviations above or below what's normally expected for a person's age, sex, weight, and ethnic or racial origin. A Z-score of -2 or lower in a premenopausal woman is considered to be low bone density. 

For older women, bone density test results are most commonly reported as a number called a T-score. Another number, the Z-score, is more appropriate for younger individuals. 

A T-score of minus 1 or higher is normal. A score of minus 2.5 or lower is osteoporosis. The range between normal and osteoporosis is considered osteopenia, a condition where bone density is below the normal range and puts a person at higher risk for developing osteoporosis. Osteopenia also raises the risk for breaking a bone. 


What it means 

-1 and above 

Normal bone density 

-1 to -2.5 

Low bone mass (Osteopenia): Bone density is below normal and can lead to osteoporosis 

-2.5 and below 



Who should get a bone density testing? 


  • Most young, healthy people do not need a bone density test. But as you age, your risk for osteoporosis increases because bone density tends to decrease as people grow older. That is especially true in women. If you’re a woman


  • 65 or older, a bone density test is recommended. Even if testing reveals your bone health is good, this test can be a baseline measurement for future testing. 

  • For men without fractures, the answer isn’t quite as clear. The U.S. Preventive Services Task Force doesn’t recommend routine bone density testing for men. Because men have a higher bone mass and lose bone more slowly than women, they’re at a lower risk of fracture. There’s also no conclusive evidence that osteoporosis medications can prevent fractures in men. However, up to 1 in 4 men over 50 will break a bone due to osteoporosis. Groups such as the National Osteoporosis Foundation still recommend testing for men 70 and older. 

  • Men 50–69 and women under 65 also may want to have bone density testing if they have risk factors for osteoporosis, including a family history of the disease or a history of fractures. Another risk factor is taking certain kinds of drugs that can interfere with the body’s process of rebuilding bone. Examples of these drugs include steroid medications, such as prednisone, and immunosuppressant medications, such as those taken after an organ transplant or bone marrow transplant. 

  • People over 50 who have broken a bone and people who have lost 1.5 inches of height or more also may need a bone density test to screen for osteoporosis. 



Which medications are commonly used for osteoporosis treatment? 

Bisphosphonates are the most common medications prescribed for osteoporosis treatment. These include: 

  • Alendronate (Fosamax) 

  • Risedronate (Actonel) 

  • Ibandronate (Boniva) 

  • Zoledronic acid (Reclast)

Hormones, such as estrogen, can play a role in osteoporosis prevention and treatment. However, there has been some concern about potential side effects tied to the use of hormone therapy. Current recommendations say to use the lowest dose of hormones for the shortest period of time. 

Still, women who have reasons — such as menopausal symptoms — to consider using hormones can weigh the benefit of improved bone health into their decision. 

Some hormonelike medications also are approved for preventing and treating osteoporosis, such as raloxifene (Evista). 

Denosumab (Prolia, Xgeva) is a newer medication shown to reduce the risk of osteoporotic fracture in women and men. Unrelated to bisphosphonates, denosumab might be used in people who can't take a bisphosphonate, such as some people with reduced kidney function. 

Teriparatide (Forteo) is typically reserved for men and postmenopausal women who have very low bone density, who have had fractures or whose osteoporosis is caused by steroid medication. Teriparatide has the potential to rebuild bone. 

Abaloparatide (Tymlos) is the newest osteoporosis medication. Like teriparatide, it has the potential to rebuild bone. In a research trial comparing these two treatments, Abaloparatide appeared to be as effective as teriparatide but was less likely to cause an excess of calcium. 

How do most osteoporosis medications work? 

With the exception of teriparatide, osteoporosis medications slow bone breakdown. Healthy bones continuously break down and rebuild. 

As you age — especially after menopause — bones break down faster. Because bone rebuilding cannot keep pace, bones deteriorate and become weaker. 

Osteoporosis medications basically put a brake on the process. These drugs effectively maintain bone density and decrease the risk of breaking a bone as a result of osteoporosis. 

How do you know if you're taking the right bisphosphonate? 

Drugs in the bisphosphonate class are more alike than they are different. They all help maintain bone density. And, all bisphosphonates have been shown to reduce the chance of a fracture. 

The decision to take one drug over another often is based on: 

  • Preference 

  • Convenience 

  • Adherence to the dosing schedule 

  • Cost, including whether or not the drug is a "preferred" option on your insurance company's list of acceptable medications (formulary) 

Your doctor might recommend a monthly dose of medication if it's going to be better tolerated or better accepted. But if you're likely to forget to take your medicine on a monthly schedule, you might do better taking medication once a week. 

When might other osteoporosis medications be used? 

Drugs such as denosumab, teriparatide and abaloparatide can be used by anyone with osteoporosis, but are more likely to be recommended for people with unique circumstances, including severe osteoporosis with very low bone density, multiple fractures, steroid use and young age. 

These drugs, which are injected, might also be given to people who can't tolerate an oral bisphosphonate. Intravenous (IV) forms of zoledronic acid and ibandronate also can be an option for people who can't tolerate an oral bisphosphonate. 


What are common side effects of bisphosphonate pills? 

Bisphosphonate pills aren't absorbed well in the stomach. The main side effects of bisphosphonate pills are stomach upset and heartburn. Generic forms of these drugs may be more likely to cause these side effects. 

To ease these potential side effects, take the medication with a tall glass of water on an empty stomach. Don't lie down or bend over or eat for 30 to 60 minutes to avoid the medicine washing back up into the esophagus. When the recommended wait time is over, eat to neutralize the remaining medication. 

Most people who follow these tips don't have these side effects. But it's possible to take the medicine correctly and still have stomach upset or heartburn. 

Do intravenous bisphosphonates have advantages over the pill form? 

Infused forms of bisphosphonates don't cause stomach upset. And it may be easier for some women to schedule a quarterly or yearly infusion than to remember to take a weekly or monthly pill. 

But, these drugs can cause mild flu-like symptoms in some people. You can lessen the effect by taking acetaminophen (Tylenol, others) before and after the infusion. 

Two infusion medications — those that are injected directly into your vein — have been approved for osteoporosis treatment: 

  • Ibandronate (Boniva), infused once every three months 

  • Zoledronic acid (Reclast), infused once a year 


Can bisphosphonates hurt your bones? 

Long-term bisphosphonate therapy has been linked to a rare problem in which the upper thighbone cracks and may break. This injury, known as atypical femoral fracture, can cause pain in the thigh or groin that begins subtly and may gradually worsen. 

Bisphosphonates can also cause osteonecrosis of the jaw, a rare condition in which a section of jawbone is slow to heal or fails to heal, typically after a tooth is pulled. This occurs more commonly in people with cancer that involves the bone — who take much larger doses of a bisphosphonate than typically are used for osteoporosis. 

How long should you take a bisphosphonate for osteoporosis treatment? 

There's some uncertainty about how long to take bisphosphonates because of a lack of long-term studies. Bisphosphonates have been shown to be safe and effective for up to 10 years of treatment, depending on the medication. 

However, even if you stop taking the medication, its positive effects can persist. That's because after taking a bisphosphonate for a period of time, the medicine remains in your bone. 

Because of this lingering effect, most experts believe it's reasonable for people who are doing well during treatment — those who have not broken any bones and are maintaining bone density — to consider taking a holiday from their bisphosphonate after taking it for five years. But if you're at very high risk of fractures or you have very low hipbone density, taking a break from your osteoporosis medication may not be a good idea. 


What happens if you break a bone while taking an osteoporosis medication? 

Osteoporosis medications lower the chance of fracture, but they don't eliminate all risk of breaking a bone. If you have a fracture while on treatment, your doctor will reassess you to check for other problems that may have contributed to the broken bone. 

Depending on the outcome of that assessment, you may be a candidate to switch to a more aggressive bone-building therapy such as teriparatide. Another option might be to switch to a newer type of osteoporosis drug called denosumab. 


What is Vitamin D? 


Vitamin D is a hormone, although most commonly known as a fat-soluble vitamin, which means it is stored in the body’s fatty tissue. Vitamin D is necessary for building and maintaining healthy bones. That's because calcium, the primary component of bone, can only be absorbed by your body when vitamin D is present. Your body makes vitamin D when direct sunlight converts a chemical in your skin into an active form of the vitamin (calciferol). 

Without vitamin D your bones can become soft, thin and brittle. Insufficient vitamin D is also connected to osteoporosis and some types of cancer. If you don't get enough vitamin D through sunlight or dietary sources, you might need vitamin D supplements. 

Vitamin D isn't found in many foods, but you can get it from fortified milk, fortified cereal, and fatty fish such as salmon, mackerel and sardines. 

The amount of vitamin D your skin makes depends on many factors, including the time of day, season, latitude and your skin pigmentation. Depending on where you live and your lifestyle, vitamin D production might decrease or be completely absent during the winter months. Sunscreen, while important, also can decrease vitamin D production. 

Many older adults don't get regular exposure to sunlight and have trouble absorbing vitamin D, so taking a multivitamin with vitamin D will likely help improve bone health. The recommended daily amount of vitamin D is 400 international units (IU) for children up to age 12 months, 600 IU for ages 1 to 70 years, and 800 IU for people over 70 years. Vitamin D is also available in nutritional supplements. Vitamin D is the only vitamin made by your own body. Other vitamins, like A, B, and C only come from food and supplements.   

Taken in appropriate doses, vitamin D is generally considered safe. 

However, taking too much vitamin D can be harmful and can cause very high Calcium levels. Children age 9 years and older, adults, and pregnant and breast-feeding women who take more than 4,000 IU a day of vitamin D might experience: 

  • Nausea 

  • Vomiting 

  • Poor appetite 

  • Constipation 

  • Weakness 

  • Weight loss 

  • Confusion 

  • Disorientation 

  • Heart rhythm problems 

  • Kidney damage 


Calcium and calcium supplements: Achieving the right balance 

Calcium is important for bone health. See how much calcium you need and how to get it. 

Calcium is important for optimal bone health throughout your life. Although diet is the best way to get calcium, calcium supplements may be an option if your diet falls short. 

Before you consider calcium supplements, be sure you understand how much calcium you need, the pros and cons of calcium supplements, and which type of supplement to choose. 


The benefits of calcium 

Your body needs calcium to build and maintain strong bones. Your heart, muscles and nerves also need calcium to function properly. 

Some studies suggest that calcium, along with vitamin D, may have benefits beyond bone health: perhaps protecting against cancer, diabetes and high blood pressure. But evidence about such health benefits is not definitive. 


The risks of too little calcium 

If you don't get enough calcium, you could face health problems related to weak bones: 

  • Children may not reach their full potential adult height. 

  • Adults may have low bone mass, which is a risk factor for osteoporosis. 

Many Americans don't get enough calcium in their diets. Children and adolescents are at risk, but so are adults age 50 and older. 

Calcium requirements 


How much calcium you need depends on your age and sex. Note that the upper limit in the chart represents the safe boundary — it's not how much you should aim to get. If you exceed the upper limit, you may increase your risk of health problems related to excessive calcium. 

Calcium: Recommended Dietary Allowance (RDA) for adults 


Daily RDA 

Daily upper limit 

19-50 years 

1,000 mg 

2,500 mg 

51-70 years 

1,000 mg 

2,000 mg 

71 and older 

1,200 mg 

2,000 mg 


Daily RDA 

Daily upper limit 

19-50 years 

1,000 mg 

2,500 mg 

51 and older 

1,200 mg 

2,000 mg 

Calcium and diet 

Your body doesn't produce calcium, so you must get it through other sources. Calcium can be found in a variety of foods, including:  

  • Dairy products, such as cheese, milk and yogurt 

  • Dark green leafy vegetables, such as broccoli and kale 

  • Fish with edible soft bones, such as sardines and canned salmon 

  • Calcium-fortified foods and beverages, such as soy products, cereal and fruit juices, and milk substitutes 

To absorb calcium, your body also needs vitamin D. A few foods naturally contain small amounts of vitamin D, such as canned salmon with bones and egg yolks. You can also get vitamin D from fortified foods and sun exposure. The RDA for vitamin D is 600 international units (15 micrograms) a day for most adults. 

Who should consider calcium supplements? 

Even if you eat a healthy, balanced diet, you may find it difficult to get enough calcium if you: 

  • Follow a vegan diet 

  • Have lactose intolerance and limit dairy products 

  • Consume large amounts of protein or sodium, which can cause your body to excrete more calcium 

  • Have osteoporosis 

  • Are receiving long-term treatment with corticosteroids 

  • Have certain bowel or digestive diseases that decrease your ability to absorb calcium, such as inflammatory bowel disease or celiac disease 

In these situations, calcium supplements may help you meet your calcium requirements. Talk to your doctor or dietitian to determine if calcium supplements are right for you. 

Do calcium supplements have risks? 

Calcium supplements aren't for everyone. For instance, if you have a health condition that causes excess calcium in your bloodstream (hypercalcemia), you should avoid calcium supplements. 

It's not definitive, but there may be a link between calcium supplements and heart disease. The evidence is mixed and more research is needed before doctors know the effect calcium supplements may have on heart attack risk. 

A similar controversy surrounds calcium and prostate cancer. Some studies have shown that high calcium intake from dairy products and supplements may increase risk, whereas another more recent study showed no increased risk of prostate cancer associated with total calcium, dietary calcium or supplemental calcium intakes. 

Until more is known about these possible risks, it's important to be careful to avoid excessive amounts of calcium. As with any health issue, it's important to talk to your doctor to determine what's right for you. 

Types of calcium supplements 

Several different kinds of calcium compounds are used in calcium supplements. Each compound contains varying amounts of the mineral calcium — referred to as elemental calcium. Common calcium supplements may be labeled as: 

  • Calcium carbonate (40 percent elemental calcium) 

  • Calcium citrate (21 percent elemental calcium) 

  • Calcium gluconate (9 percent elemental calcium) 

  • Calcium lactate (13 percent elemental calcium) 

The two main forms of calcium supplements are carbonate and citrate. Calcium carbonate is cheapest and therefore often a good first choice. Other forms of calcium in supplements include gluconate and lactate. 

In addition, some calcium supplements are combined with vitamins and other minerals. For instance, some calcium supplements may also contain vitamin D or magnesium. Check the ingredient list to see which form of calcium your calcium supplement is and what other nutrients it may contain. This information is important if you have any health or dietary concerns. 

Choosing calcium supplements 

When looking at calcium supplements, consider these factors: 

Amount of calcium 

Elemental calcium is key because it's the actual amount of calcium in the supplement. It's what your body absorbs for bone growth and other health benefits. The Supplement Facts label on calcium supplements is helpful in determining how much calcium is in one serving. As an example, calcium carbonate is 40 percent elemental calcium, so 1,250 milligrams (mg) of calcium carbonate contains 500 mg of elemental calcium. Be sure to note the serving size (number of tablets) when determining how much calcium is in one serving. 


Calcium supplements cause few, if any, side effects. But side effects can sometimes occur, including gas, constipation and bloating. In general, calcium carbonate is the most constipating. You may need to try a few different brands or types of calcium supplements to find one that you tolerate the best. 

What prescriptions you take 

Calcium supplements can interact with many different prescription medications, including blood pressure medications, synthetic thyroid hormones, bisphosphonates, antibiotics and calcium channel blockers. Depending on your medications, you may need to take the supplement with your meals or between meals. Ask your doctor or pharmacist about possible interactions and which type of calcium supplement would work for you. 

Quality and cost 

Manufacturers are responsible for ensuring that supplements are safe and claims are truthful. Some companies have their products independently tested by U.S. Pharmacopeial Convention (USP), (CL) or NSF International (NSF). Supplements that bear the USP, CL or NSF abbreviation meet voluntary industry standards for quality, purity, potency, and tablet disintegration or dissolution. Different types of calcium supplements have different costs. Comparison shop if cost is a factor for you. 

Supplement form 

Calcium supplements are available in a variety of forms, including tablets, capsules, chews, liquids and powders. If you have trouble swallowing pills, you may want a chewable or liquid calcium supplement. 


Your body must be able to absorb the calcium for it to be effective. All varieties of calcium supplements are better absorbed when taken in small doses (500 mg or less) at mealtimes. Calcium citrate is absorbed equally well when taken with or without food and is a form recommended for individuals with low stomach acid (more common in people over 50 or taking acid blockers), inflammatory bowel disease or absorption disorders. 


Why are vitamin D and calcium important to bone health? 

Vitamin D allows your body to absorb calcium. Calcium is necessary for building strong, healthy bones. Without enough vitamin D and calcium, bones may not form properly in childhood and can lose mass, become weak, and break easily in adulthood. Even if you get enough calcium in your diet, your body will not absorb that calcium if you don’t get enough vitamin D. 


What are some of the dietary sources of Calcium and Vitamin D? 

Foods rich in calcium include ice cream, soy milk, breads, kale, broccoli, milk, cheese, cottage cheese, almonds, yogurt, ready-to-eat cereals, beans, and tofu. Foods rich in vitamin D include milk, canned tuna fish, cod liver oil, yogurt, ready-to-eat-cereals, cooked salmon, canned sardines, mackerel, and eggs. Some of these foods are rich in both. 

Foods and drinks with calcium 


Calcium in milligrams 

Milk (skim, 2%, or whole; 8 oz [240 mL]) 


Yogurt (6 oz [168 g]) 


Orange juice (with calcium; 8 oz [240 mL]) 


Tofu with calcium (0.5 cup [113 g]) 


Cheese (1 oz [28 g]) 

195 to 335 (hard cheese = higher calcium) 

Cottage cheese (0.5 cup [113 g]) 


Ice cream or frozen yogurt (0.5 cup [113 g]) 


Soy milk (8 oz [240 mL]) 


Beans (0.5 cup cooked [113 g]) 

60 to 80 

Dark, leafy green vegetables (0.5 cup cooked [113 g]) 

50 to 135 

Almonds (24 whole) 


Orange (1 medium) 



Does Calcium and Vitamin D prevent falls and fractures? 


  • Falls are often the cause of fractures, especially of the wrist and hip. Exercise is one of the few interventions that has been shown to reduce the number of people who fall and get injured with falls. Although vitamin D and calcium can benefit bone health, especially in those who do not get an adequate amount of calcium in their diet or have low levels of vitamin D, neither has been clearly shown to reduce falls. In fact, very high doses of vitamin D appear to increase the risk of falls. 

  • The best way to take good care of your bones would be to make sure you get enough calcium in your diet, exercise, a combination of aerobic walking type of exercise where you’re bearing your weight, where you’re putting weight on your heels. 

Osteopenia is a more moderate decline in bone mass than occurs in osteoporosis. If you have been diagnosed with osteopenia, or even osteoporosis, you can take steps to prevent further bone loss. 


Certain treatments for breast cancer can lead to bone loss because they decrease estrogen, the main female hormone.  

What is the link between breast cancer and bone loss? 

Certain treatments for breast cancer can lead to bone loss because they decrease estrogen, the main female hormone. In addition to its role in female development and reproduction, estrogen increases bone density (size and strength), prevents bone loss, and lowers the risk of fractures. With less estrogen, your bones are more likely to become weak and break easily. 

Treatments that can decrease estrogen include: 

Some types of hormonal therapy, which affect estrogen levels 

Chemotherapy, which can damage the ovaries and cause early menopause 

Surgical removal of the ovaries, where most estrogen is made 


How is estrogen related to breast cancer? 

Many types of breast cancer tumors are sensitive to estrogen, meaning that tumors can grow and spread when estrogen is present. These types of tumors are called estrogen receptor (ER)-positive tumors. An estrogen receptor is the part of the cell where estrogen attaches. A laboratory test shows whether a tumor has estrogen receptors. If a tumor is ER-positive, then treatment to block the estrogen receptors or stop the body from making estrogen can help prevent the return of the cancer or slow down tumor growth. 

How is breast cancer treated?


The choice of treatment is based on the type of breast cancer and other factors. Surgery is used to remove cancerous tissue in the breast or in other parts of the body. Sometimes one or both ovaries are removed to eliminate the main source of estrogen. Radiation and chemotherapy drugs can destroy cancer cells or stop their growth. Hormonal therapy stops the growth of ER-positive breast cancer cells by stopping the production of hormones or blocking their action. Medicines used for hormonal therapy include: 

AIs (aromatase inhibitors), such as anastrozole, exemestane, and letrozole, which prevent estradiol from being made.  

Estrogen receptor antagonists, such as fulvestrant, which block estradiol action.  

LHRH (luteinizing hormone-releasing hormone) analogs, such as goserelin and leuprolide, which induce a medical menopause.  

SERMs (selective estrogen receptor modulators), such as tamoxifen, which block estradiol action  

For many people, these anti-estrogen hormonal therapies speed up bone loss. However, for postmenopausal women, Al therapy is very useful for treating ER-positive breast cancer, but can be especially damaging to bones.  


Why worry about bone loss? 

Bone loss can lead to fragile bones, a condition called osteoporosis. When someone has osteoporosis, the risk of bone fractures goes up. Hormonal therapy for breast cancer can lead to high rates of fracture - up to 10 to 20 percent after 5 years of use, especially in post-menopausal women. Broken bones can lead to pain and disability. For example, many older people who break a hip lose their ability to function independently. 

An X-ray scan (bone mineral density test) checks the strength of bones by assessing bone mineral density. The test can show early bone loss before the more serious condition of osteoporosis develops. 


What can breast cancer survivors do to prevent bone loss?


The choice of treatments for bone loss is based on whether a patient is at risk for fractures. Aside from cancer treatment, other factors that increase risk include a personal or family history of bone fractures after age 65, being thin, smoking, having four or more alcoholic drinks a day, certain diseases such as rheumatoid arthritis, taking corticosteroids for more than 6 months, and a low bone mineral density. 


Consider the following steps to prevent bone loss and avoid fractures. 

Take medicines as needed. Osteoporosis can’t be cured. But some medicines can prevent or treat osteoporosis. One class of medications, called bisphosphonates, can be taken as a pill every week or month or can be given intravenously (through a vein) in a doctor’s office or hospital as seldom as once a year. These medicines keep bones strong by preventing bone breakdown and helping them retain calcium. New studies also suggest that these medications may help prevent cancer spread (metastases) in women with a high risk of recurrence, especially in post-menopausal women.  

Get enough calcium and vitamin D. You should get 1,000 to 1,500 mg of calcium and 1,000 to 2,000 IU of vitamin D each day. Good sources of calcium include milk, yogurt, cheese, collard greens, and foods with added calcium. Vitamin D, which helps the body absorb calcium, is made in the skin when people spend time in the sun. It’s also found in salmon, shrimp, and milk with added vitamin D. In addition to choosing foods with calcium and vitamin D, many people need dietary supplements to get enough of these nutrients. 

Exercise regularly. Weight-bearing exercise, such as walking, running, dancing, and climbing stairs, helps keep bones strong. So do exercises that strengthen muscles. 

Take other steps to live a healthy lifestyle. Maintain a healthy weight, avoid smoking and limit alcohol to no more than one drink a day.  





Prednisone is a corticosteroid, a type of medication that's very effective in managing inflammation in rheumatoid arthritis and many other conditions. Unfortunately, corticosteroids also can dramatically weaken bones and lead to osteoporosis. If you'll be taking prednisone for more than a few months and you have other risk factors for bone loss, your doctor may prescribe medications specifically designed to treat and prevent osteoporosis. 

What is glucocorticoid-induced osteoporosis? 

Glucocorticoid-induced osteoporosis (GIO) is a condition in which people who take medicines called glucocorticoids develop osteoporosis—weakening of the bones. Osteoporosis increases the risk of broken bones (fractures). 

Glucocorticoids are synthetic (manufactured) hormones also known as steroids. They include medicines such as prednisone, cortisone, hydrocortisone, and dexamethasone. 

Common conditions treated with glucocorticoids include: 

  • Rheumatoid arthritis, lupus, or other inflammatory joint disease 

  • Asthma or chronic obstructive pulmonary disease (COPD) 

  • Inflammatory bowel disease 

  • Psoriasis or other skin diseases 

  • Organ transplant (to reduce the risk of rejection) 

Glucocorticoids can be taken as a pill (by mouth), an injection under the skin or in a vein, a nasal spray or inhaler, or even as a skin ointment or cream. Glucocorticoids given by mouth, by vein, or by skin injection are most likely to cause osteoporosis. 



What causes GIO? 

Normally, your body continuously removes old bone and replaces it with new bone. However, glucocorticoids can increase the breakdown of bone and decrease the formation of new bone. This can cause your bones to weaken. Weak bones can break easily when you have a minor fall (called a fragility fracture). Some people break bones for no reason at all. Bone fractures can be serious and painful. They can affect your ability to move, walk, and care for yourself. 

Glucocorticoids start to weaken your bones during the first 3 months of use. The rate of bone loss is greatest within the first 6 months of treatment but continues as long as you take glucocorticoids. The higher your dose, the greater your risk of GIO. But even low doses can cause GIO over time. Therefore, experts recommend that doctors prescribe the smallest possible dose for the shortest period of time. 

Who is most at risk for GIO? 

Some people who take glucocorticoids are at greater risk for GIO: 

  • Women who have gone through menopause 

  • Men age 50 or older 

  • Those who have had previous fractures 

People who have other risk factors for osteoporosis, including those who: 

  • Don’t get enough calcium and vitamin D 

  • Smoke cigarettes 

  • Drink three or more alcoholic beverages per day 

  • Have a family history of osteoporosis 

How will you know whether your bones are weak? 

A bone mineral density test (also called a DXA test) measures the strength of your bones. This simple, painless test uses low-dose x-rays to help predict your chances of having a fracture. Your doctor also may check your spine for fractures using x-rays or an MRI (magnetic resonance imaging) test. 

How can you reduce your risk of GIO? 

If you’ll be taking glucocorticoids for 3 months or longer, you can lower your risk of GIO by following these steps: 

  • Do weight-bearing exercise such as walking, running, or dancing 

  • Quit smoking if you smoke 

  • Limit yourself to no more than two alcoholic beverages each day 

  • Experts also suggest taking calcium (1000-1200 mgs daily) and vitamin D (1000-2000 IU daily) supplements, even if you’re taking glucocorticoids for less than 3 months. Your doctor can tell you how much to take. Your doctor also may check your risk of falling and provide advice about how to prevent falls. People who are especially at risk for osteoporosis will need medicine. 



Who will need medicine to protect their bones? 

Your doctor will review your medical history, current condition, and glucocorticoid dose to determine your risk. Experts recommend bone-protective medicine for certain groups who are taking glucocorticoids for at least 3 months: Women who have gone through menopause and men age 50 or older 

The following groups also might need medicine to protect their bones: 

Men and women at high risk for osteoporosis, even if they are taking glucocorticoids for less than 3 months 

Premenopausal women and men under the age of 50 who have had fragility fractures in the past 



Which types of medicines help protect bones? 

Three types of medicines are available. Your doctor will prescribe the type of medicine that’s best for you. 

  • Bisphosphonates keep bones strong by slowing the breakdown of bone. They lower the risk of fractures of the hips and spine. 

  • Teriparatide helps the body build new bone and makes bones stronger. It also lowers the risk of fractures. 

  • Denosumab slows done bone breakdown and often increases bone mass  

Ask your doctor if you need a DXA test and how much calcium and vitamin D you should take. If you need medicine to protect your bones, talk with your doctor about how long you should take it, what side effects you might have, and any other questions that concern you. 

Osteoporosis in Men

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