Like calcium, an adequate amount of vitamin D is necessary for bone health and to prevent bone loss. Most (80-95%) of our vitamin D is produced by the skin when it is exposed to sunlight; or it is consumed in vitamin D enriched foods. Many women do not get enough vitamin D, especially if they do not get out in the sun regularly, or live in parts of the country with less sunlight. The body's ability to manufacture vitamin D naturally decreases with age and older individuals are more prone to vitamin D deficiency. In addition, sunscreen interferes with vitamin D production and because of this, many dermatologists recommend vitamin D supplements for people who routinely use sunscreen.

Vitamin D deficiency is very common. More than half of older women in the U.S. are vitamin D deficient; and more than a third of younger women are as well. The easiest way to get enough vitamin D is to take a single multivitamin every day. Each multivitamin has 400 units of vitamin D. Women should take 400 to 800 units a day (1 or 2 multivitamins). No one should take 2000 or more units per day since this can be toxic (poisonous).

The effectiveness of calcium for preventing bone thinning has not been well-studied, but is widely believed to help. According to the National Academy of Sciences guidelines, women from ages 19 to menopause should get 1000 mg per day of calcium and, after menopause, 1200 mg per day. In contrast, the Foods Standard Industry guidelines in Britain recommends 700 mg per day. Optimal daily amounts have not been firmly established. The body can only absorb about 600 mg at a time, so calcium supplements should be taken twice a day.

Foods high in calcium are:

• Sardines with bones (4 oz=496 mg)
• nonfat yogurt (8 oz=452 mg)
• collard greens (1 cup=350mg)
• orange juice (1 cup=350mg)
• canned sardines (6 oz=333 mg)
• instant oatmeal (2 packages=326mg)
• 1%-2%-skim-whole milk (1 cup=300 mg)
• cheese (1 oz=250 mg)
• ice cream (1 cup=160 mg)
• almonds (half cup=152 mg)
• okra (1 cup=147 mg)
• vegetarian baked beans (1 cup=128mg)
• cottage cheese (1 cup=125mg)
• broccoli (1 cup=100 mg).

Weight-bearing exercise helps to stop bone loss. Walking briskly, jogging, stair climbing, dancing, and tennis are all examples of weight-bearing exercise which should be done for at least 30 minutes at a time, three or more times a week. Swimming or cycling are NOT weight-bearing. Weight-bearing exercise mostly benefits the lower body.

Lifting weights or using weight machines (weight or "resistance" training) also helps increase strength especially in the upper body, and improves balance (which prevents falls).

Engaging in these activities is not so easy for people who do not like to exercise but is very effective, not just for bone maintenance but for the health of many other body systems (heart, blood vessels, lungs, etc.) as regular exercise has many other benefits.

Even though the mechanism is not understood, smoking has been shown in studies to be an important risk factor for osteoporosis and weak bones.

Excess alcohol use interferes with the body's ability to absorb calcium and form bone. Too much alcohol intake is also a risk factor for falling, which increases the risk of broken bones (fractures) in people with osteoporosis.

Heavy alcohol consumption can also cause bone loss from poor nutrition. Many experts recommend no more than two alcoholic beverages per day.

DEXA (dual energy X-ray absorptiometry) is a test that aims x-rays at a bone to see how much radiation passes through, allowing the calculation of the density or thickness or the bone. This test uses small amount of radiation (less than 1/10th the amount of radiation in a chest X-ray). It can measure the density of the hip, spine and forearm bones. Of all the bone density tests, DEXA is the most accurate. A single energy X-ray absorptiometry test measures the density of the heel and the forearm, and is not as good a predictor of significant fractures as the DEXA scan. An ultrasound can measure the density of the heel bone and is also not as accurate as DEXA. A CT scan (Computerized tomography) provides accurate measurements of the spine bones but involves high doses of radiation, is expensive, and is therefore seldom used.

DEXA results are reported in units called "T-scores" which compares a person's bone density to that of a healthy young adult of the same gender. The results of this test can be confusing: if the score is higher than -1 ("negative 1"), results are considered normal. (For example, "-0.5" and "+1" are both higher than -1; this is because of the negative sign). If the score is between -1 and -2.5, the diagnosis is osteopenia (early thinning of the bones that may lead to osteoporosis); and if below -2.5, osteoporosis is diagnosed. You may also be given a "Z-score", which compares your score to what would normally be expected for someone of your age, sex, weight, and ethinic or racial origin.

Guidelines vary somewhat about who should have a BMD test. Most guidelines recommend that women over the age of 65 be tested. They also tend to recommend that women younger than age 65 be tested if they have particular risk factors or have had a fracture that could be related to osteoporosis. Specific guidelines are as follows:

US Preventive Services Task Force:

• Women over 65
• Women between 60 to 64 who weigh less than 154 pounds and are not using estrogen

• Women over 65
• Women over 40 who have had a fracture
• Women with risk factors for fracture who would consider treatment with medications
• Women with x-rays that suggest osteoporosis
• Women who are taking steroids or other medications that can cause significant bone loss
• Women with diseases or nutritional conditions associated with bone loss such as symptomatic "hyperparathyroidism"

• Women over 65
• Women who have a medical condition that can cause bone loss
• Postmenopausal women below age 65 with one of the following risk factors: a fracture after menopause (other than of the spine); body weight less than 127 pounds; or a history of a first-degree relative (mother, sister, daughter, etc) who has had a hip or spine fracture
• Premenopausal women who experience a low-trauma fracture (broken bone that results from a minor or low-impact injury) or who have a condition that is known to cause osteoporosis

• Women over 65
• All postmenopausal women with fractures
• Possibly recommended for women with one or more risk factor for osteoporosis

Several large studies have been performed to evaluate the effectiveness of osteoporosis drugs. However, there have been no good studies that directly compare the different drugs to each other. Therefore, no one is certain which of the various medication options are most effective, but experts have formed certain opinions based on studies of individual drugs and on clinical experience with the medications.

Bisphosphonates (Fosamax, Actonel, Boniva, Reclast) appear to be the most effective medications available for decreasing the chance of fracturing either the spine, hip, or other bones. Several large studies have found that Fosamax (alendronate) increases bone density (the thickness of bones). The drug also decreases the risk of breaking the bones of the spine and hip by about around 50 percent. This translates into prevention of approximately 3 hip fractures a year for every 1,000 people who are taking the drug.

Studies suggest that Actonel (risedronate), another bisphosphonate, is also effective for decreasing broken bones. Boniva (ibandronate), the newest bisphosphonate, also increases bone density and decreases fractures. One large study suggests that Boniva may be effective if given once a month instead of daily or once a week. A powerful new bisphosphonate, Reclast (zoledronic acid), in one study decreased spine fractures by 70% and hip fractures by 41%. This drug, however,has to be given through an IV (intravenous needle) and is not used to prevent osteoporosis; only to treat it once it occurs.

An individual on a bisphosphonate probably needs to stay on the medication indefinately since the effect of is drug may wear off slowly over time. But since this takes a while to happen, some experts think that it may be possible to stop the drug for a while ("drug holiday") and then start again on a cycle of some sort; however, this hasn't been studied yet.

Alendronate (Fosamax) is available in daily and weekly doses; risedronate (Actonel) is available in daily, weekly and twice monthly doses; ibandronate (Boniva) is available as a monthly dose and as an intravenous injection once every three months; zoledronic acid (Reclast) is given once a year as an intravenous injection.

The pill-form of bisphosphonates are not absorbed well, which is why the stomach has to be empty and stay empty for a while after taking a dose. Pills must be taken on an empty stomach without eating or drinking anything else including other pills for 30 minutes. The pills can also cause significant irritation of the swallowing tube (esophagus) and must be taken with 8 oz of water with the individual remaining upright or sitting for 30 minutes afterwards. The intravenous form of the drug may be recommended for people who have side effects with pills.

Side effects with the pills include digestive tract problems that can be severe such as trouble swallowing, inflammation of the esophagus (swallowing tube that connects the mouth to the stomach), and esophagus and stomach ulcers. There have also been rare instances of vision problems and damage to the jaw bone (typically after trauma from a tooth extraction or cancer treatment, for example). Because of this, experts recommend informing dentists that you are taking a bisphosphonate before a tooth extraction. Intravenous injections have been reported to cause flu-like symptoms such as fever, muscle and joint aches and headache that typically last for a few days.

People with a history of problems with the swallowing tube (esophagus) should not take bisphosphonates.

Raloxifene/Evista (an estrogen-like drug) is related to tamoxifen that is used to treat breast cancer in older women. This type of drug may have the advantage of estrogen and "hormone replacement therapy" in decreasing bone thinning and the risk of fractures, but without increasing the risk of breast cancer. In one study, raloxifene decreased the number of repeat spine fractures by 30 percent in postmenopausal women who had already had a fracture; and by about half in women who had never had one. However, in contrast to estrogen, raloxifen is not effective for hot flashes or urinary symptoms that are often a part of menopause.

The biggest risk in taking raloxifene is of developing blood clots (just like with estrogen), and it should not be used in women who have had blood clots previously. The medication can cause hot flashes and leg cramps.

This drug mimics the effects of female hormones and is not approved for use in men with osteoporosis.

Several large studies have been performed to evaluate the effectiveness of osteoporosis drugs. However, there have been no good studies that directly compare the different drugs to each other. Therefore, no one is certain which of the various medication options are most effective, but experts have formed certain opinions based on clinical experience with the medications.

Calcitonin seems to work on bones of the spine but may not work as well for hip bones. Since hip fractures are a common problem for women with osteoporosis, calcitonin may not be as useful as the bisphosphonates. One study showed that spine fractures were decreased by 33 percent after two years of taking the medicine.

Calcitonin is sprayed into the nose. Each spray gives 200 Units of the drug; the usual dose is one spray per day (one day in one nostril, and the next day in the other). Up to 400 Units per day can be given for severe osteoporosis which would be one spray in each nostril every day. Calcitonin is also available as an injection.

Calcitonin prevents bone thinning by slowing down the cells that naturally destroy/recycle bone.

Several large studies have been performed to evaluate the effectiveness of osteoporosis drugs. However, there have been no good studies that directly compare the different drugs to each other. Therefore, no one is certain which of the various medication options are most effective, but experts have formed certain opinions based on clinical experience with the medications.

Calcitonin is usually used in women who have had menopause for at least five years and have osteoporosis that has not improved with other medications.

Calcitonin is not available as a pill but is used as a nasal spray or can be injected. It may have an added benefit of reducing the pain of a new fracture which may be especially helpful for people with a new spine fracture. It can cause stuffiness of the nose and upset of the stomach and bowels.

Estrogen (hormone replacement therapy) used to be the primary treatment for osteoporosis prevention but is no longer the drug of choice because of safety concerns (blood clots, stroke, breast cancer) and because of the availability of alternative medications that are considered safer.

Studies have shown that estrogen is effective in increasing bone density (bone thickness) and in decreasing fractures in both the spine and hip. Estrogen hormone acts directly on bone to decrease thinning.

Estrogen-containing hormone replacement therapy is most often used currently to treat severe symptoms of menopause that are not alleviated with other measures.

Teriparatide works by stimulating new bone formation rather than decreasing bone loss, which makes it different from the other drugs used for osteoporosis. This drug is available as a once-a-day injection given under the skin. It is usually only used for postmenopausal women who have a high risk for fractures, and is also approved for men with osteoporosis.

The drug causes bone cancer (osteosarcomas) in animals and should NOT be used in children or adolescents. It also should not be used in individuals with high calcium in the blood since it can further increase calcium levels.

Studies in postmenopausal women and men with osteoporosis treated for about a year with teriparatide along with calcium and vitamin D supplements showed increases in bone density in the spine and hip. The drug cannot be given all of the time, without a break, or it can cause bone loss. When given at regular intervals (in pulses) teriparatide increased bone density by 15% over 3 years, compared to a 6 to 8% increase for alendronate (Fosamax). In these studies, the drug decreased spine fractures as well as other fractures.

Side effects can include nausea, dizziness and leg cramps. Because long-term effects and safety have not yet been studied, teriparatide has only been approved for use by the US FDA (Food and Drug Administration) for up to 24 months.

Many people have medical conditions such as rheumatoid arthritis, ulcerative colitis, lupus, asthma and other lung disease, etc. that require long-term use of "steroid" medications (prednisone, dexamethasone, etc). While these medicines are often life-saving, one of their side effects is thinning of the bones. The risk of fractures is 30% greater if taking steroids.

Preventing this bone thinning is best accomplished with weight-bearing exercise and supplements of calcium and vitamin D. Many people will need osteoporosis medications as well. Bisphosphonates are most commonly used, but special situations may require other osteoporosis medications such as calcitonin, female hormone replacement therapy, or Raloxifene, based on the particular situation.

Most experts feel that a baseline study of bone density (BMD test) should be performed when starting a long-term (more than 6 weeks) course of steroids, and then should be repeated every two years.

Early treatment is essential to prevent fractures. It is best to optimize calcium and vitamin D intake, exercise regularly if possible, quit smoking, and eat nutritiously. Many people will need supplemental treatment with oral or intravenous bisphosphonates, Raloxifene or female hormone replacement therapy, depending on their primary condition.

Soy foods contain an estrogen/female hormone-like substance called "phytoestrogen" and have been used as home remedies for menopause symptoms. There is no evidence, however, that soy-containg foods prevent osteoporosis, or decrease the risk of bone fracture.

The North American Menopause Society (NAMS) guidelines consider soy-containing products/foods to be not harmful, except for certain women (who should also not receive supplemental female hormones/estrogen) including women who have a personal or strong family history of:

• breast, uterine, or ovarian cancer;
• blood clots;
• endometriosis;
• or uterine fibroids.

One study suggested that low doses of estrogen (either with or without progestin) may be effective for osteoporosis prevention but data is still inconclusive and more study is necessary. In this study, doses that were approximately half (0.3-0.45 mg per day) of that normally prescribed reduced bone loss in women who had recently gone through menopause. Further evaluation is necessary to determine if these finding are reproducible and therefore reliable.

In addition, experts hope that lower dose estrogen does not present the same safety problems as the higher doses (increased risk of stroke, blood clots, and breast cancer) but this question has not been adequately addressed and for now, it is safer to assume that the risks do not differ until proven otherwise.