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Got Milk? – Preventing Osteoporosis

May is National Osteoporosis Awareness and Prevention Month! This is a great time to pause and think about the health of one body system we sometimes take for granted: the skeleton!

The human body has 206 bones, and they are made up of active, living tissue. The health and wellbeing of your skeletal system is critical for getting you around to live your life, but we often don’t think about it until a bone breaks. Children and adolescents tend to have stronger bones made of cells that regenerate at much higher rates. By about age 30, our bone mass peaks and slowly decreases for the rest of our lives.

In addition to this bone mass loss that is a normal part of aging, some adults may develop a disease called osteoporosis. The disease results in excessive loss of bone density, causing the bones to become weak and brittle. It is sometimes called “the silent disease” because there are often no symptoms until a bone fractures. It is different from osteoarthritis, which is a painful joint disease. At least one in two women and one in four men over age 50 will break a bone at some point due to osteoporosis. This disease can cause pain, suffering, and loss of mobility if it progresses too far. Luckily, osteoporosis can be treated and even prevented!

Preventing osteoporosis is a topic near and dear to my heart – not just because as an OB/GYN PA I am keenly aware of how it disproportionately affects women, but also because my own grandmother suffered from osteoporosis. I watched her lose several inches of height as the disease caused her posture to become more and more stooped over time. Luckily, my grandma never broke any bones, but we were always worried about the potential of a life-altering injury if she had a fall. Because of my grandma’s experience with osteoporosis, my mom is keeping a careful eye on her bone health, and I am too. The best ways to prevent osteoporosis are to make healthy lifestyle changes and talk with your healthcare provider about appropriate screenings.

Everyone knows that we should eat a healthy diet and get regular exercise, but you may not know that these good habits can make you less likely to have bone problems when you are older. Since I am getting closer to the age where my bones will stop replacing themselves as well, I make sure to get plenty of calcium and vitamin D in my diet. These are the nutrients your body needs to build bone. You can get calcium through milk and dairy products, but also from things like leafy green vegetables, fortified breads and cereals, and supplements if necessary. For more information about how much calcium and vitamin D you need and how to get it, see the FDA website on recommended daily intake or talk to your healthcare provider.

My mom watches her diet, goes on daily walks, and plans to get a DEXA scan when she turns 65. A DEXA scan is a type of X-ray where we can measure how dense your bones are. If this testing shows that you are at increased risk for fractures, there are medications we can use to help build up your bones. All women 65 and older should have a DEXA scan, as well as anyone at increased risk of low bone density, which may include people with a history of long-term steroid use or a family history of osteoporosis.

No matter what stage of life you are in, you can make changes to improve your bone health. It’s so important I’ll say it one more time: make sure you are getting enough calcium! And don’t forget vitamin D. Live an active life and do some kind of weight-bearing exercise (like walking, running, aerobics, or resistance training) regularly to help keep your bones strong. Avoiding smoking and minimizing alcohol intake can also decrease your risk of developing osteoporosis. Stay up to date on regular health screenings including your DEXA scan if applicable. If you have been diagnosed with osteoporosis, make sure you have a plan for preventing falls. And as always, personalized medical advice is the best kind of advice, so talk to your healthcare provider about how to keep your skeleton healthy. 

For more information, please see: 

Blogs from Kristen Wright, FNP –

National Osteoporosis Foundation –


Photoshop can’t “fix” bones (bone health part II)

With the right software program, a couple of minutes, and a little skill, we can transform the girl in the picture on the left to the girl on the right.

That’s right! Photoshop can fix or manipulate many things within just a matter of minutes, making the enhanced version appear even better than the original!

Unfortunately, even with the right equipment and ample skill, a fractured hip can’t be repaired as quickly or as easily. Broken bones are painful at any age and weak bones can be deadly for the older population. Statistics clearly show that hip fractures are associated with loss of independence, decreased quality of life, financial burden and frequently death. In fact, it is estimated that 14 to 58% of people will die within a year following a hip fracture.

If the prime time for calcium deposition has passed (if you are older than age 30), you can still decrease the risk of a fragility fracture by…

#1. Being aware of your bone health
#2. Evaluating your risk for fracture
#3. Discussing treatment options
#4. Evaluating what is the best treatment for you

This article discusses bone health, risk factors associated with osteoporosis and subsequent fracture, and treatment options.

Bone Mineral Density (BMD) is a test that uses

X-ray technology to measure the number of minerals (specifically calcium) in the bone that reflects the strength of the bone.  A normal BMD is defined as a T-score greater than -1.0.  Osteopenia or mild bone loss is reflected via a T-score between -1.0 to -2.5 and individuals diagnosed with osteoporosis have a T-score of -2.5 or lower.  The majority of fragility fractures occur in patients with bone mineral density in the osteopenic range.

Bone Mineral DensityT-score
Normal-1.0 and above
Osteopenia (low bone density)-1.0 to -2.5
OsteoporosisLess than -2.5

Measuring the BMD is typically evaluated through a medical test called a dual-energy x-ray absorptiometry, otherwise known as a DEXA scan.  It is a simple, painless test that takes about 5 to 10 minutes to perform.  Typically, a DEXA scan should be done at age 65 for healthy women who are not at particular risk for osteoporosis. Depending on risk factors, it may need to be done earlier or be repeated every two to five years after the initial evaluation.


There are several known risk factors that can increase the risk of fracture.  These are:

  • significant weight loss or lower body weight (women < 127 pounds)
  • smoking
  • family history of fractures
  • decreased physical activity
  • alcohol or caffeine use
  • low calcium and vitamin D intake (especially vegans, those with lactose intolerance, disease of the digestive system causing absorption issues or those who consume large amounts of protein or sodium causing excess secretion of calcium through the urine)
  • long-term corticosteroid use

The Fracture Risk Assessment Tool (FRAX) was developed in 2008 by lead researchers involved with bone health in a combined effort with the World Health Organization (WHO) to improve the predictability of assessing patients with low bone density and risk for fracture.  Although the FRAX calculator has not been proven in randomized controlled trials to be beneficial, it is a widely used tool in the treatment decision-making process throughout the world.

Advancing age is the most important risk factor in developing a low BMD. 

The FRAX is a helpful tool in assisting the decision making process regarding pharmaceutical treatment.

The American College of Obstetricians and Gynecologists (ACOG) and the American College of Physicians (ACP) recommend that women who have known osteoporosis should be treated with prescription medication.  If a woman falls into the low bone mass category (T-score between -1 and -2.5) the FRAX tool can assist the woman and provider in making a treatment decision.  Generally, if a woman is at increased risk of experiencing a hip fracture or other major fractures in the upcoming 10 years, treatment with medication is recommended.

Prescription medication is recommended when the FRAX calculator predicts a ten-year risk of:

a hip fracture of 3% or more
a major fracture of 20% or greater


All women should be getting adequate amounts of calcium, vitamin D and participating in a weight-bearing activity on a regular basis.  Ideally, this is done through a healthy diet.  However, over-the-counter supplements may be necessary for many individuals.

menopausal women – 1,200 mg/d ≈4 cups of milk or calcium equivalents

women with low bone density (osteopenia) – 1,500 mg/d

women at risk for fracture (osteoporosis) – 1,500 mg/d

All need vitamin D – 1,000 to 2,000 IU/d

All need regular weight-bearing and bone-strengthening exercise
(ie: walking, jumping rope, hiking, dancing, yard work, elliptical machine, elastic bands, free weights or weight machine)

All will benefit from exercises, such as Tai Chi or Yoga, that will improve coordination, flexibility and strengthen muscle, decreasing the chance of a fall.

Women who have a lower bone density should discuss the risks and benefits of starting a prescription medication, along with the above lifestyle modifications.  When medication is initiated, treatment often continues for three to five years and there is no benefit in continued DEXA testing during this period. Evidence shows that even if no increase in BMD occurs, women still have fewer fractures when treated with pharmacologic treatment.

The prescription medication works by slowing down the destructive process of the bone matrix, hence the cells that build bone are able to work more effectively.  It can be given via tablets that are taken weekly or monthly, through an injection every 3 months or an annual infusion directly into the bloodstream.

If oral tablets are used, it is important to take the medication on an empty stomach with a full glass of water and remain upright for 30 minutes afterward in order to allow for proper absorption and the least amount of side effects. Your dentist should be aware of the medication you are taking and regular dental check-ups are important to detect a rare side effect that decreases the blood flow to the jawbone.  Heartburn or difficulty swallowing should be reported to your provider and calcium and vitamin D need to be continued during the course of treatment.  Use caution with other medications (ie: ibuprofen or aspirin) that may cause more irritation to the stomach and esophagus.


Personal risks and coexisting conditions should be discussed when deciding how aggressive treatment needs to be.  When symptoms of menopause need to be treated, hormone therapy will also help maintain bone mass.  Clinicians believed that when a woman stopped hormone therapy the rate of bone loss would increase at the same rate after stopping hormones as it would with natural menopause.  However, further analysis and reanalysis of the Women’s Health Initiative (WHI) trial data shows that even 5 years later, women who stopped hormone therapy had no increase in the hip or total fractures.  This suggests a residual benefit in reducing bone fractures for even several years after cessation of hormone therapy.

Risk and treatment need to be individualized for each woman.  Talk to your provider if you have questions regarding your bone health. 

To succeed in life,
you need three things:

a wishbone,
a backbone
and a funny bone.

-Reba McEntire

Are you Going to Break Your Hip? (bone health part I)

….probably not, when you’re young. However, you may be making choices that will weaken your bones and put you at risk for a fracture later in life. Bones are a living and changing organ over the course of a lifetime. During childhood and adolescent years, bone remodeling takes place where bone mass and density continues to increase even after you stop growing taller. Peak bone mass usually occurs by the mid-twenties, where you reach the greatest amount of bone you will ever have.  Higher peak bone mass means stronger bones and lessens the change of getting osteoporosis or fracture later in life.

When we are young and starting a family, age 50 seems old and so far off.  We think we’ll never be that old….but time passes quickly and our bodies change.  As we age, our bones continue to remodel but the balance between bone destruction and new bone formation also changes.  Slowly, the bones begin to weaken.  This is one of the reasons that people get shorter with age.  Less bone mass causes the spine to slowly collapse, making the bones more fragile and susceptible to cracking just from holding up our own body weight or breaking from a simple slip or fall.  During midlife, men and women experience more bone loss. This frequently impacts women because women tend to have smaller bone structures and frames compared to men.  This means women tend to start with thinner bones and less peak bone mass and bone loss may be compounded when the protective benefit of estrogen is lost as a woman becomes menopausal.

Just like putting money into a retirement account when you first begin working in your twenties produces profound dividends over time, regular deposits of calcium to the bone matrix during childhood up through your twenties can make or break you (literally) in advanced years.  In order to create strong bones, the right ingredients are necessary.  This includes calcium, vitamin D and regular physical activity.  Sound familiar?

We should all eat healthily and exercise regularly, period.

These things are key ingredients during every stage of bone health; during the time of rapid bone formation (in childhood and adolescence), during the maintenance period (from the 30-s to mid-’50s) and with bone loss (with aging).

Here is the Recommended Dietary Allowance (RDA) for calcium:

AgeDaily RDA (mg)Practical Application
Adolescent girls1,300This is approximately 4 cups (measuring cup, not glasses of milk)of milk per day, or calcium equivalents.
Women 19-50 years1,000Approximately 3 cups/d
Women 51 & older1,200Approximately 4 cups/d
Women with bone loss (osteopenia)1,500Approximately 5 cups/d

The body also needs vitamin D in order to absorb calcium.  The RDA for vitamin D is 600 IU per day, however, 1000-2000 IU may be recommended for people with certain health conditions.

The best dietary sources of calcium are from dairy products such as milk (including fortified soy and almond milk), yogurt and cheese. Calcium is also found in dark green leafy vegetables, seafood, legumes, and tofu.  The chart to the sideshows examples of how much calcium is found in popular foods.  The United States Department of Agriculture also has a free Food Composition Database that can give you accurate information about all kinds of foods and nutrients.  It can help you search to find which foods contain the most calcium or tell you the calcium content of foods you normally consume.  Go to

NATURAL SOURCES are better absorbed.

dairy products

MILK (1 cup) – 300 mg


YOGURT (1 cup) – 350 to 450

CHEESE STICK (1 oz.) – 225 mg

COTTAGE CHEESE (1 cup) – 140 mg

ICE CREAM (1/2 cup) – 110 mg

FROZEN YOGURT (1/2 cup) – 90 mg


TOFU (1/2  cup)- 250 mg

CANNED SALMON (3 oz.) – 180 mg

KALE (1 cup, chopped) – 100 mg

BROCCOLI (1 cup) – 180 mg

BREAD (1 slice, fortified) – 70 mg

NOTE: The amounts may vary slightly depending on the brand.

Supplementation may be necessary for people at risk of not getting adequate calcium.  This includes:

  • Vegans
  • Those don’t like milk or have lactose intolerance
  • People with digestive conditions causing malabsorption of nutrients (ie: uncontrolled celiac disease or colitis, certain types of bariatric surgery or those who consume large amounts of protein or sodium causing excess secretion of calcium through the urine)
  • Smokers
  • People who consume large amounts of caffeine or alcohol
  • Those requiring long-term use of corticosteroid therapy

Sometimes, we erroneously think that “more” is better. You simply need ADEQUATE calcium consumption. Excess calcium may increase your risk for kidney stones and some studies show that calcium supplements may increase the risk of heart disease or prostate cancer. Research regarding these potential links is necessary and ongoing.

If you have questions about your risk for fracture, now or in the future,
please discuss this with your provider.

For more information, search bone health, osteoporosis or fractures on websites such as the National Osteoporosis Foundation or National Institutes of Health (NIH) or the Office on Women’s Health from the U.S. Department of Health and Human Services at

Haley Pledger, PA
Women’s Care
Matthew Walton, DO
Austin Bills, DO
Family Medicine
Aaron Fausett, PA
Family Medicine
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