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“What’s the best calcium supplement?” That’s a common question we hear from consumers, and we answer with an old adage: “The best calcium supplement is the one you’ll actually take.”

The key is getting your daily recommended amount of calcium, preferably from food sources.

Life stage group

RDA (mg/day)

Do Not Exceed (mg/day)

19-50 years old

1,000

2,500

Men: 51-70 years old

1,000

2,000

Women: 51-70 years old

1,200

2,000

71+ years old

1,200

2,000

Be sure to use supplements only to make up for what you’re not getting in your diet. Thus, the amount of supplement you’ll take may vary from day to day. More is not better when it comes to calcium, particularly if you’re getting more from supplements than you need.

The best calcium supplement is one you’ll take regularly to help you meet your recommended daily intake of this essential nutrient.

Remember to take a vitamin D supplement or a calcium supplement that also contains vitamin D. Vitamin D is the key that unlocks your body’s ability to absorb and use calcium, but it’s difficult to get all you need from your diet alone. Most of us, particularly those who live in northern latitudes, also don’t get enough sunshine year-round to provide the vitamin D we need.

There are a lot of pricey calcium supplements on the market that claim that they’re better than basic or generic products, but the evidence is thin to support the difference in cost. Name-brand supplements can cost as much as $1.50 per day, while generic calcium carbonate with vitamin D costs only about 10 cents a day.

You should avoid supplements that contain strontium. This heavy mineral takes the place of calcium in the bones and can falsely elevate bone density results.

WHAT YOU NEED TO KNOW

The most common types of calcium supplements are calcium carbonate and calcium citrate.

  • Calcium carbonate may be less expensive. It requires the acid in your stomach to break it down, so be sure to take it with food.
  • Calcium citrate is absorbed more easily and can be taken with or without food. It is generally more expensive.
  • Check with your doctor or pharmacist to find out if calcium supplements might interact with other medicines you’re taking, such as antibiotics, bisphosphonates, or high blood pressure medications.

Be sure to read the label to find the amount of calcium per tablet. This will help you determine how many tablets you need to achieve your daily dose. If a food label says “% daily value,” that assumes 100% equals 1,000 mg/day. Many people only need one 500 mg supplement a day. 

TIPS FOR TAKING CALCIUM

  • Avoid constipation when taking calcium supplements by getting plenty of water. A calcium supplement that includes magnesium can help prevent this side effect.
  • Consider chewables that may be more convenient for children and older adults. In fact, many common antacids also contain calcium.
  • Watch for vitamin K contained in some chewable products if you are taking blood thinners.
  • Avoid taking calcium with high-fiber meals or with bulk-forming laxatives. The fiber can bind with the calcium and reduce the amount available for your body to use.
  • Take small amounts of calcium throughout the day, no more than 500-600 mg of elemental calcium at once. This may mean you need to take supplements two or three times during the day.
  • Cut the tablet in two. This will make it easier to swallow and give you half the amount on the label.
  • Avoid taking calcium and iron supplements at the same time because they interfere with each other’s absorption.
  • Avoid taking calcium supplements and thyroid medicine at the same time.

FIND CALCIUM IN YOUR FOODS

Read the labels on your foods, and seek out calcium-rich foods that have 200 mg or more calcium per serving.  Some bottled mineral water products also are high in calcium.

The post Get the Best Out of Your Calcium Supplement appeared first on American Bone Health.

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One weekend morning I was wearing a sleep shirt that came down to the middle of my thighs, and my dad saw me walk by and said, holy ****. He made me get on the scale and saw that I weighed 85 pounds, and he thought my heart was going to stop.

Here is another deeply personal story from a member of American Bone Health’s Board of Directors to illustrate how risk factors, in this case a history of eating disorder, can affect your bones throughout your life. Kathy Sharp suffered from anorexia during her teens and 20s, leaving her with osteoporosis and osteopenia and at high risk of fracture.

Kathy has been able to turn around her bone health thanks to therapy, developing a healthy relationship with food, and weight training. We thank her for her service to American Bone Health and for sharing her experience to help others. 

For further reading, here is a primer on taking charge of your bone health if you have risk factors: 

And here is a lesson on how to talk to your doctor about bone health:

The post Anorexia in her 20s leaves damage to bones at 50 appeared first on American Bone Health.

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Shelley Powers

American Bone Health Board of Directors member Shelley Powers shares her personal story of living with osteoporosis on the health information website HealthyWomen.org. The essay includes her thoughts on “What I Wish I Had Known When I Was 40” along with advice for younger women to do what they can to strengthen their bones and muscles. 

Younger people should do everything they can to build up their bone bank. For example, high-impact exercise really stimulates bone growth. Strong muscle mass protects your bones. The more muscular you are, the better. Balance is also tied into fall prevention. If you have good balance, the pathways are laid down in your brain from muscle memory. You may be able to recover from a fall if your balance is strong. Be sure to talk to your healthcare provider before starting or changing an exercise regimen.

Shelley actually got involved with American Bone Health soon after her diagnosis. The retired teacher’s experience can be a lesson for all of us to be our own best advocate when it comes to our bone health.

Thanks to Shelley for sharing her story and for being a dedicated volunteer and board member for American Bone Health!

The post Board member shares her story of postmenopausal osteoporosis appeared first on American Bone Health.

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The U.S. Food and Drug administration this past spring approved a drug called Evenity (romosozumab-aqqg) to treat osteoporosis in postmenopausal women at high risk of broken bones. These patients are women who have a history of osteoporotic fractures or multiple risk factors for fractures, as well as those who have failed in treatment with other osteoporosis drugs or are unable to take those drugs.

WHAT WE KNOW

Evenity, developed by Amgen, is a monoclonal antibody that blocks the effects of a protein called scleronin. Scleronin stops bone production and causes bone to break down. Evenity works by increasing bone formation. This makes it different from commonly used osteoporosis drugs called bisphosphonates (such as alendronate, aka Fosamax), which block the osteoclasts that break down bone tissue but don’t cause new bone to form.

WHAT YOU SHOULD KNOW

One dose of Evenity consists of two injections, one immediately following the other, given once a month by a health care professional. The bone-forming effect of Evenity decreases after 12 doses, so the treatment is stopped at the end of a year. To maintain the gains in bone density from Evenity, patients will be prescribed another osteoporosis medicine that redrduces bone breakdown.

Evenity comes with a “black box” warning stating that it may increase the risk of heart attack, stroke and cardiovascular death. Patients who have had a heart attack or stroke in the previous year should not use Evenity; Amgen says the warning does not concern people who have not had something like that in the past year.

NOTE: Amgen is a corporate partner of American Bone Health and provides unrestricted financial support for American Bone Health’s educational programming. Amgen has no input on the content of American Bone Health’s programs and resources. 

The post New osteoporosis drug Evenity approved appeared first on American Bone Health.

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By Risa Kagan, MD, FACOG, CCD, NCMP (Member, Medical and Scientific Advisory Board)

I have been working in the bone world for many years. I know it’s challenging for consumers to keep up with the emerging science and research, so here is a look at where we came from and where we are now.

Advances in medicine over the past several decades have helped us live longer, and because many women previously didn’t live long past menopause, we didn’t know the impact of the loss of estrogen on bone mass.

In the 1980s, bone density testing machines gave us the ability to identify the quantity of bone mass and monitor changes in the trabecular structure of bone. This is when we started using the terms “osteoporosis” and “osteopenia.” The World Health Organization in 1994 established a definition of osteoporosis based on the statistical concept of a normal distribution. A T-score is a standard deviation from the average 30-year-old, and a consensus of scientists determined that more than 2.5 standard deviations below the mean should be defined as “osteoporosis.” “Osteopenia” became the standard term for a T-score between -1.0 and -2.5. Osteopenia is not a disease, but a term created by the World Health Organization (WHO) to describe low bone mass. Anyone with a T-score greater than -1.0 was consider “normal.”

Not perfect, but a start.

One of the main reasons it wasn’t perfect is that because we didn’t do a bone density test on a person when they reached peak bone mass at age 30, we didn’t really know whether a T-score at age 50 was the result of bone loss. Maybe that’s the peak bone mass/ density they ever achieved.

As the science has improved, we have learned that we need to focus on bone quality as well as bone density. The quality of the bone is important in understanding fracture risk. Just like high cholesterol is a risk factor for heart attacks and high blood pressure is a risk factor for stroke, osteoporosis on a bone density test is a risk factor for fracture. We can think of fractures as “bone attacks.” We are now thinking about treatment and prevention strategies to focus on fracture prevention, rather than just bone density. As a result, we realized that not all patients were candidates for osteoporosis medicines, especially women and men who are relatively young, without any risk factors for breaking a bone.

Having a better understanding of bone quality is encouraging us to engage in more conversations with patients about fracture risk. We use calculators to understand patients’ risk profile and their chances of breaking a bone. This helps us focus on a bone health plan that is appropriate for an individual.

As a consumer, you have an important role to play in this discussion. Knowing your risks and taking action with your doctor to prevent bone loss can help you avoid a “bone attack.”

Not all people will have the luxury of prevention strategies alone. Whether it’s a medical condition, a medicine that you take, or a family history of bone loss and fractures, you could be one of the patients who would benefit from a medication to reduce the risk of a “bone attack.”

Patients should not be afraid of the medications that are available. All the medications used for the prevention and treatment of osteoporosis have good safety data, and they reduce the risk of fractures, especially spine and hip fractures. We know that 25% of hip fracture patients die within a year and the majority of the rest are not able to live with mobility without assistance. We know now how to determine who is a good candidate for treatment based on fracture risk and what medicine would be best.

In December 2017, a study that reviewed the Medicare database found that the decline in hip fractures had leveled off. The researchers estimated that 11,464 additional hip fractures (costing $459 million) occurred from 2013-2015 due in part to a decline in screening and treatment and an increase in other chronic conditions, like diabetes. We are now facing a public health crisis in our older population.

Let’s remember that knowing our risk factors and our bone density scores is just the start. Doctors and patients need to work together to take action and prevent bone loss and fractures.

About Dr. Kagan

Dr. Kagan is a board certified obstetrician-gynecologist and Clinical Professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco.  She serves on the Medical and Scientific Advisory Board of American Bone Health (FORE) and is the principal investigator on numerous women’s health clinical research studies. Dr. Kagan is well known as a communicator and teacher and is often approached by media and public forums for her expertise and frequently is an invited speaker at national and international scientific meetings.

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By Wendy Kohrt, PhD (Member, Medical and Scientific Advisory Board)

We often hear that weight-bearing activity is critical for bone health, but many people don’t know what that means or how to achieve it. If you watch children play, they’ve got it right! Running, jumping and cartwheeling are the kinds of activities that help them build bone.

Weight bearing, or loading, adds a stress to the bones that stimulates bone building. The load slightly compresses the bone matrix and triggers the cells to take in more calcium and other minerals, and ultimately to increase bone density. The amount of weight that causes this response from the bone is called “osteogenic loading” because it takes a certain “load” to stimulate the bone-building cells. In contrast, “unloading” the bones — prolonged bed rest or space travel, for example — can result in loss of bone mineral density. While normal daily activities are sufficient to prevent the harmful effects of unloading, significant “loading” appears to be required to increase bone density.

We measure activity by how many multiples of body weight are loaded onto the skeleton. Scientists in the United Kingdom, using accelerometers, did a cross-sectional study in children that found the amount of loading required to stimulate the bone-building process equals 4.2 times body weight.

As with all exercise studies, it is difficult to control for all of the variables associated with the participants, so we must be careful in generalizing the results to other populations.

When we stand, gravity applies a load to our bones that equals our body weight. Walking briskly increases load, and running or jogging adds even more load, but we need higher-impact activities like jumping or strength training to add four or more times our body weight.

Always begin loading activities at a level that is right for you. As you train to walk in the Susan G. Komen 3-Day, work to increase your walking stride. If you are running, consider adding higher-impact activities. Weight or resistance training is beneficial to muscle, and with enough load, it can stimulate bone building as well. Avoid excessive loading to prevent injury.

If you have low bone density or osteoporosis, work with a professional on any activity that will add load to your bones. You want to use proper form and body mechanics to protect your spine.

The 2018 Physical Activity Guidelines recommend 150 minutes of moderate physical activity every week, and more importantly, for bone health they advise strength training for all major muscle groups at least two times a week. Doing many repetitions with light weights is not the way to go. To add sufficient load on the bones, the muscle you are working should fatigue within 12 to 15 repetitions or fewer.

Be safe and smart with your training, and remember: Loading up your workouts will keep your bones going strong for the 3-Day and beyond!

About Dr. Kohrt

Dr. Kohrt is a Professor of Medicine in the Division of Geriatric Medicine at the University of Colorado Anschutz Medical Campus and the Nancy Anschutz Endowed Chair In Women’s Health Research.

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What we know

There are 750,000 spine (vertebral) fractures, also called compression fractures or fragility fractures, each year in the United States. They are highly prevalent in patients with osteoporosis. One-third of patients with spine fractures have chronic or severe back pain, causing an inability to manage daily life activities. The traditional treatment for spine fractures is also called nonsurgical management. Doctors may prescribe pain medication, bed rest, and use of a back brace to help stabilize the fracture.

A more aggressive management is surgical and called vertebral augmentation. Vertebroplasty and kyphoplasty are the most common surgical procedures. In vertebroplasty, a bone cement is injected directly into the fractured area of the spine bone to form an internal “cast”. In kyphoplasty, a balloon is inserted into the fractured area and inflated to create a cavity and bring back the height of the bone.  Then bone cement is injected.

There has been a lack of consensus about the best approach to managing painful spine fractures. Both types of vertebral augmentation relieve pain, but it is not clear that they are superior to more conservative nonsurgical management.

New findings question long-term effectiveness of spine fracture management

The American Society for Bone and Mineral Research published a report looking to answer questions about the effectiveness of the two surgical procedures compared to nonsurgical management. They reviewed five randomized trials and concluded that the surgical procedures provided no notable benefit over nonsurgical management in relieving pain or improving the physical function. Additionally, at least one prospective trial has shown that vertebroplasty is associated with an increased risk of vertebral fractures at vertebral bodies adjacent to the ones where the procedure was performed (Blasco, et al. Journal of Bone and Mineral Research, Vol. 27, No. 5, May 2012, pp 1159–1166.)  The studies completed at this time cannot confirm either the effectiveness or the risk of these procedures.

In addition to the surgical procedures, the researchers were not able to determine if the use of a brace can improve physical function, disability or quality of life.

The authors stressed that we need more research and better data to improve outcomes in managing osteoporosis-related spine fractures. They recommended larger sample sizes in future trials, use of a placebo group in further trials of balloon kyphoplasty, and more research on nonsurgical interventions in general. The studies completed at this time cannot confirm either the effectiveness or the risk of these procedures.

Aggressive spine fracture management is not for everyone

Another panel of physicians including pain specialists, surgeons and radiologists published a study in November 2018 in The Spine Journal to try to clear up when vertebral augmentation procedures should be used. The panel recommended these procedures in cases where an MRI or CT scan tests positive for a fracture, and where symptoms such as pain, limited activity or loss of height got worse more than a week after the injury. If pain and activity level are stable or improve, or if an MRI comes back negative for bone edema, nonsurgical management is likely the better option.   

The panel’s study was different from some previous recommendations in that it found that many spinal fractures should be treated early with vertebral augmentation, rather than only after six weeks of no improvement. Authors said that in these cases, particularly where symptoms worsen, getting patients back on their feet as quickly as possible might be better than having them inactive and in pain.

What can you do if you have a spine fracture?

Any fracture, including those in the spine, can take 6-8 weeks to fully heal, and there is pain during the healing process, especially in the beginning. Since there is no cast to help stabilize the bone, rest and pain medicines can help. Calcium and vitamin D are also important for fracture healing.

You may benefit from a surgical procedure or bracing if:

  1. An MRI or CT scan tests positive for an acute (very recent) fracture, and
  2. Pain, limited activity or loss of height get worse more than a week after the injury.

Most importantly: Get treatment. When the fracture has healed, exercise may improve your ability to get around, but the most important step to take is to get on a medicine to strengthen your bones. One in five women with a vertebral fracture will suffer another fracture within a year, according to the International Osteoporosis Foundation. Having had a vertebral fracture also doubles your risk of having another fracture of any kind. Medication to treat osteoporosis can reduce the risk of additional fractures by 40 percent to 70 percent.

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Patients who take medicine to treat an underactive thyroid need to be cautious that they don’t take too much. Most patients on thyroid medicine have Hashimoto’s thyroiditis and a smaller number take thyroid medicine because of thyroid cancer or Graves disease. Too much thyroid medicine increases the activity of the osteoclasts (the bones that break down bone) and put you at an increased risk for breaking a bone. To find the correct dose, your health care provider will get a thyroid-stimulating hormone (TSH) blood test and once you are on the correct dose, monitor your levels at least once a year.

Thyroid hormone requirements decline with age, so a dose that was good for a patient at age 20 or 30, may be too high when they are in their 60s, 70s, 80s or 90s. Younger patients should target a level of TSH in the lower half of the normal range (especially those diagnosed because of weight gain), while patients in their mid-50s should target a TSH level in the upper half of the normal range. For older patients, studies have shown that a lower TSH level was associated with an increased risk of heart disease.

Thyroid Stimulating Hormone (TSH)   Typical normal range
Normal Range .35 – 5.0
Target for younger patients .35 – 2.5
Target for older patients 2.5 – 5.0
What to know about taking thyroid medicine
  • Take thyroid medicine at the same time every day to avoid fluctuations in TSH
  • Take thyroid medicine at bedtime for best effect at regulating thyroid levels.
  • Do not take your thyroid medicine with iron or calcium supplements or food because it can affect the absorption of the medicine.
Steps your health care provider may take when you are taking thyroid medicines. 
  • Know your bone density which can help inform you about your risk of breaking a bone and may be useful to monitor any potential bone loss.
  • If you are at high risk for breaking a bone, your health care provider may suggest an osteoporosis medication to reduce the harmful effects on your skeleton.
  • Take as low a dose as possible, for as short a time as possible — but talk with your healthcare provider before you make any changes.
  • Make sure that you get 3-4 servings of a calcium-rich food every day. If you cannot eat dairy or calcium-fortified food, you may need a calcium supplement.
  • Be sure that you have an optimal vitamin D level (≥ 30 ng/mL or ≥74.9 nmol/L). People with breast cancer and prostate cancer may need higher blood levels of vitamin D.
  • Practice great posture and use good body mechanics to prevent spine fractures.
  • Strengthen your legs and do balance exercises to prevent falls and fractures.
  • Remove trip hazards from your home.
Common thyroid medicines that affect the skeleton
  • Levothyroxine LT4 (Levoxyl®, Synthroid®, Unithroid®)
  • Armour Thyroid

Download the BONESENSE PDF

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If you take a moment to read the tiny contents of the package insert that comes with your prescription drugs, you will see in the section on side effects that there are many that can harm your bones. Some drugs can cause bone loss and some may increase the chance of breaking a bone. If you have certain diseases, you may not have a choice but to take one of these medications. If you do, it is very important to take steps to protect your bones.

Download the BONESENSE Overview

Download the chart

The most common medications that can harm your bones include:

If you are taking any medications that can harm your bones, these are some general rules to reduce the harm:

  • Know your bone density which can help inform you about your risk of breaking a bone and may be useful to monitor any potential bone loss.
  • If you are at high risk for breaking a bone, your health care provider may suggest an osteoporosis medication to reduce the harmful effects on your skeleton.
  • Take as low a dose as possible, for as short a time as possible — but talk with your healthcare provider before you make any changes.
  • Make sure that you get 3–4 servings of a calcium-rich food every day. If you cannot eat dairy or calcium-fortified food, you may need a calcium supplement.
  • Be sure that you have an optimal vitamin D level (≥ 30 ng/mL or ≥74.9 nmol/L). People with breast cancer and prostate cancer may need higher blood levels of vitamin D.
  • Practice great posture and use good body mechanics to prevent spine fractures.
  • Strengthen your legs and do balance exercises to prevent falls and fractures.
  • Remove trip hazards from your home.
If you are taking high doses of steroid-like pills such as prednisone

Steroids are often used to help reduce inflammation and pain for people who have rheumatoid arthritis, lupus, Crohn’s disease and asthma. Because these diseases are chronic, people often take them for long periods of time. Daily doses of over 5 mg are the most harmful to the bones.

The impact of systemic (oral or IV/IM) steroids on the skeleton happens rapidly, often within three months of starting the drug. Systemic steroids affect the bone remodeling process by decreasing the activity of the bone-building cells (osteoblasts) and increasing the activity of the cells that break down bone (osteoclasts). The combination of these actions causes bone loss quickly.

To lessen the harm to the bones from steroid medications: Stay on as low a dose of the steroid as possible to manage inflammation and pain try for 5 milligrams or less per day.

Steps your health care provider may take when you start steroid treatment. 

List of common steroid medications that affect the skeleton
  • Prednisone: Deltasone®, Rayos®, Prednisone Intensol®, etc.
  • Prednisolone: Omnipred®, Pediapred®, Pred Mild®, etc.
  • Methyprednisolone: Medrol®, Solu-Medrol®, Depo-Medrol®, ReadySharp®,
    P-Care D40®, P-Care D80®, etc.
  • Dexamethasone: Decadron®, Ozurdex®, DexPak 6 Day®, DexPak 13 Day®, Dexamethasone Intensol®, DexPak 10 day®, Maxidex®, LoCort®, etc.
  • Cortisone: Cortison, Cortisone, Cortisone Acetate, Cortone, Cortistab, Cortisyl, Adreson, etc.
  • Triamcinolone: Aristocort®, Aristocirt Forte®, Aristospan®, Clinacort®, Kenalog-10®, Kenalog-40®, Triamcot®, Triam-Forte®, Triesense®, etc 
If you are taking high doses of thyroid medicines

Patients who take medicine to treat an underactive thyroid need to be cautious that they don’t take too much. Most patients on thyroid medicine have Hashimoto’s thyroiditis and a smaller number take thyroid medicine because of thyroid cancer or Graves disease. Too much thyroid medicine increases the activity of the osteoclasts (the bone cells that break down bone) and put you at an increased risk for fracture. To find the correct dose, your health care provider will get a thyroid-stimulating hormone (TSH) blood test and once you are on the correct dose, monitor your levels at least once a year.                      

Thyroid hormone requirements decline with age, so a dose that was good for a patient at age 20 or 30, may be too high when they are in their 60s, 70s, 80s or 90s.  Younger patients should target a level of TSH in the lower half of the normal range (especially those diagnosed because of weight gain), while patients in their mid-50s should target a TSH level in the upper half of the normal range. For older patients, studies have shown that a lower TSH level was associated with an increased risk of heart disease.

If you are taking a thyroid medicine, it is important to take thyroid medicine at the same time every day to avoid fluctuations in TSH, and some studies suggest taking it at bedtime works best. Finally, do not take your thyroid medicine with iron or calcium supplements or food because it can affect the absorption of the medicine.  

Steps your health care provider may take when you are taking thyroid medicines. 

List of common thyroid medicines that affect the skeleton If you are taking drugs that can reduce your estrogen or androgen level

Estrogens and androgens, such as testosterone, are hormones that can worsen some medical conditions such as breast cancer, uterine cancer, prostate cancer, endometriosis and uterine fibroids. The medications used to treat these conditions often reduce the level of estrogen or androgens in your body. This reduction in hormones causes an increase in the activity of the osteoclasts, followed by an increase in bone loss.

Steps your health care provider may take when you start a hormone blocker.

List of common hormone blockers that affect the skeleton
  • Aromatase inhibitors (Arimidex®, anastrozole, Aromasin®, exemestane, Femara®, letrazole, etc.)
  • Androgen/estrogen deprivation therapy/gonadotrophin agonists/antagonists (Lupron®, Lupron Depot®, leuprorelin, Eligard®, leuprolide, Zoladex®, goserelin, Suprefact®, buserelin, Eulexin®, flutaminde, Trelstar®, triptorelin, Vantas®, histrelin, Firmagon®, degarelix, long-term treatment with Cetrotide®, cetrorelix or Antogon®, ganirelix, etc.)
  • Depomedroxyprogesterone acetate injections. (Depo-Provera®, Depo-Ralovera®, etc.) 
If you are taking a drug for diabetes

Some medications used for people with diabetes increase the risk of fractures. TZD drugs cause an increase in the number of fat cells in the bone marrow at the expense of bone-forming osteoblasts. SGLT-2 inhibitors may reduce the bone density at the hip and increase fracture risk, although some data are conflicting. Both type 1 and type 2 diabetes are associated with increased risk of breaking a bone, although bone density is usually lower than average in people with type 1 diabetes and higher than average in people with type 2 diabetes. You should talk with your diabetes doctor before stopping or changing any of your medications.

To lessen the harm to the bones from diabetes medications:

  • If you are at increased risk of breaking a bone, try to avoid the use of a TZD.
  • If you are at increased risk of falls, try to avoid the use of a SGLT-2 inhibitor

Additional steps your health care provider may take when you are taking a drug for diabetes. 

List of common diabetes medications that affect the skeleton
  • Thiazolidinediones or TZDs, (Actos® or pioglitazone, Avandia® or rosiglitazone)
  • SGLT-2 Inhibitors (Invokana® or canagliflozin, Forxiga® or dapagliflozin, Jardiance® or empagliflozin, etc.)
If you are taking an antacid

People who have acid reflux, stress gastritis, or peptic ulcers may take a variety of antacids, both prescription and over the counter, that reduce acid and heartburn or abdominal pain. However, the long-term, daily use of aluminum-containing antacids or proton pump inhibitors (PPI) may affect the absorption of calcium and appears to increase the risk of fracture.

To lessen the harm to the bones from antacids:

  • Consider an H2-blocker such as Zantac® (ranitidine) 75 to 150 mg twice daily instead of a PPI.
  • Consider changes to your diet to reduce acid production.

Additional steps your health care provider may take if you are taking an antacid.

List of common acid-reducing medications that affect the skeleton
  • Antacids with aluminum (Maalox®, Mylanta®, Riopan®)
  • Proton Pump Inhibitors (Prilosec® or omeprazole, Nexium® or esomeprazole, Prevacid® or lansoprazole, Protonix or pantoprozole, Aciphex® or rabeprazole, Dexilent or dexlansoprazole)
If you are taking antidepressants

A common medication for depression is a selective serotonin receptor uptake inhibitor or SSRI. This particular antidepressant medication increases fracture risk and bone loss in older women and is associated with lower bone density in children and men.

To lessen the harm to the bones from antidepressants:

  • Consider a SNRI (serotonin and norepinephrine reuptake inhibitor) instead of an SSRI
  • Avoid SSRIs if you have other factors that increase your risk of breaking a bone

Additional steps your health care provider may take when you start an antidepressant. 

List of common antidepressants that affect the skeleton
  • SSRIs (Prozac®, Paxil®, Zoloft®) 
If you are taking blood thinners and anticoagulants

Patients who are at risk for stroke or blood clots are often prescribed a blood thinner or a medication that reduces the chance of blood clots. These medications prevent the absorption of calcium and affect the bone-building cells leading to bone loss and increased risk of breaking a bone. WarfarinÒ, in particular, may also affect vitamin K metabolism. Newer anticoagulants that don’t inhibit vitamin K such as Pradaxa® (dabigratan), Xarelto® (rivaroxaban), Eliquis® (apixaben) and Arixta appear to be safer for the skeleton than Warfarin or heparin.

Steps your health care provider may take when you are taking blood thinners and anticoagulants. 

List of common blood thinners and anti-coagulants that affect the skeleton
  • Heparin, Lovenox® (low molecular weight heparin), Warfarin® or Jantoven® (coumadin) 
If you are taking loop diuretics

People with high blood pressure, congestive heart disease, kidney disease and liver disease are often prescribed loop diuretics to reduce swelling, water retention or edema. The loop diuretics such as furosemide (LasixÒ) increase the production of urine by the kidneys and removes calcium, potassium and magnesium salts from the body. The loss of calcium in the urine increases bone loss and fracture risk. In contrast, thiazide diuretics cause the kidney to hold on to calcium, and tend to increase bone density. There is also research that connects the use of some loop diuretics with falls and increases the risk of spine fractures.

To lessen the harm to the bones from loop diuretics:

  • Consider changing to a thiazide diuretic.

Additional steps your health care provider may take when you are taking a loop diuretic.

List of common loop diuretics that affect the skeleton
  • Lasix® (furosemide), Edecrin® (ethacrynic acid), Bumex® (bumetanide) and Demadex® (torsemide), Aldactone, Dyazide, Diamox 
If you are taking anti-convulsive medications

Anti-convulsive medications are used for people who have seizures or epilepsy. Some of the medications increase vitamin D metabolism in the liver and lower vitamin D levels. Since vitamin D is necessary for calcium absorption, the use of these medications increases bone loss and fracture risk. 

To lessen the harm to the bones from an anti-convulsive medication:

  • Take enough vitamin D to raise your blood level to 30–50 ng/mL

Additional steps your health care provider may take when you are taking an anti-convulsive medication. 

List of common anti-convulsive medications that affect the skeleton
  • Dilantin
  • Phenobarbital
  • Depakote

Reviewed: 3/19/19

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Weight-bearing exercise is one of the three primary pillars of bone health along with a calcium-rich diet and vitamin D. Walking is a good option for weight-bearing exercise that offers benefits such as improved muscle strength and balance as well as decreased rate of bone loss.

Maybe you already walk for exercise, but have you ever walked 20 miles in one day? If so, have you walked 20 miles for three days in a row? That’s the grueling challenge that participants face in the Susan G. Komen 3-Day series.

Getting ready for the 3-Day series, which brings together thousands of participants in seven cities to raise funds and awareness in the fight against breast cancer, will require not only improving how you walk but also incorporating other exercises beyond walking. Let’s talk about how you can prepare to meet the challenge and walk the walk for 60 miles at your 3-Day event.

What We Know

Walking is considered a low-impact type of weight-bearing exercise, but to train for the 3-Day, you’ll also want to practice high-impact activities. Examples include running, jumping rope and resistance training (weight lifting and calisthenics). These exercises help bones become stronger.

Putting a load on your bones via weight-bearing exercise triggers a response that stimulates the bone cells to build more bone, leading to increased bone strength. Higher-impact activities such as running and jumping provide the necessary load.

Bicycling and swimming are low-impact activities that provide cardiovascular benefits. Because they partially “unload” the bones, they are not the best for building bone strength.

What You Can Do

Getting the most out of your walk involves increasing your endurance and strength to complete the event. Walking requires coordinated effort from your hips down to your knees, ankles and feet. You’ll want to train each of these parts individually for optimal performance.

Besides walking, incorporating other exercises will improve your overall performance. Cross-training will build muscle strength and cardiovascular endurance while helping protect against overuse injuries. Any activity that increases your heart rate and utilizes different muscles from walking qualifies as cross-training: bicycling, elliptical, swimming, inline skating, Pilates, yoga and dance are all examples. The key here is duration of activity, not intensity or type.

How You Can Be Sure

As you practice walking, be sure to maintain proper body alignment and posture. One way to support your walk is by having a strong core (abdominal and back muscles).

Listen to your body: Too much training too soon can lead to injuries that can derail your training program. Monitoring your loading and not increasing excessively is key to training and avoiding injury.

Whatever exercise you’re working on, start a level that is right for you, and then work up from there. If you’re walking, increase your pace. If you’re running, consider adding higher-impact activities.

You can find more helpful resource at americanbonehealth.org. We are here to help you during your training and on every step along your 60-mile journey. Be strong, and be safe!

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