Nonpharmacologic Therapy

The primary goal of nonpharmacologic therapy for osteoporosis is to prevent fractures. Strategies include maximizing peak bone mass, reducing bone loss, and using precautions to prevent falls leading to fragility fractures (Fig. 56-1).

Modification of Risk Factors

Some osteoporosis risk factors (see Tables 56-1 and 56-2) are nonmodifiable, including family history, age, ethnicity, gender, and concomitant disease states. However, certain risk factors for bone loss may be minimized or prevented by early intervention, including smoking, low calcium intake, poor nutrition, inactivity, heavy alcohol use, and vitamin D deficiency. In order to avoid certain risk factors and maximize peak bone mass, efforts must be directed toward osteoporosis prevention at an early age.

Nutrition

Good nutrition is essential for intake of sufficient nutrients and maintenance of appropriate weight. Dietary calcium intake is important for achieving peak bone mass and maintaining bone density. Adequate dietary intake of vitamin D is essential for calcium absorption. Table 56-4 lists calcium and vitamin D requirements for different age groups. Good dietary sources of calcium include dairy products, fortified juice, cruciferous vegetables (e.g., broccoli, kale), salmon, and sardines (see Table 56-5). The most common source of vitamin D comes from exposure to sunlight. Ultraviolet rays from the sun promote synthesis of vitamin D3 (cholecalciferol) in the skin. This generally occurs within 15 minutes of sunlight exposure. It is recommended that individuals receive twice weekly sun exposure to ensure optimal synthesis. Vitamin D may also be found in some dietary sources, including fortified milk, egg yolks, salt-water fish, and liver.

Exercise

Exercise can be beneficial in preventing fragility fractures. Weight-bearing exercise such as walking, jogging, dancing, and climbing stairs can help build and maintain bone strength. Muscle-strengthening or resistance exercises can help improve and maintain strength, agility, and balance, which can reduce falls.1 It is important to develop and maintain a lifelong routine of weight-bearing and resistance exercise as the benefits on bone can be lost after cessation of the exercise program.1

Table 56-4 Recommended Daily Calcium and Vitamin D Intake

Elemental Calcium (mg)

Vitamin D{IU}

A do lesce nt s/'You rig Ad u 1 ts

Men and Women

Age 11-24

1,200-1,500

Age less 200

Men

than 50

Age 25-65

1,000

Age 50 or 800-1,000

Age greater than 65

1,500

greater

Women

Age 75-50

1,000

Age 51-65

(postmenopausal)

On estrogens

1,000

Not on estrogens

1500

Agegreatei than 65

1,500

Pregnant and nursing

1,?00-ir500

'National Osteoporosis Foundation 2008 recommendations from Reft. 1,12,13.

Table 56-5 Calcium-Rich Foods" 1 cup skim milk

1 cup soy milk (calcium-fortified)

1 cup yogurt

1/ ounces cheddar cheese

1/ ounces jack cheese

1/ ounces Swiss cheese

1/ ounces part-skim mozzarella

4 tablespoonfuls grated Parmesan cheese

8 ounces tofu

1 cup greens (collards, kale)

2 cups broccoli

4 ounces almonds

2 cups low-fat cottage cheese

3 ounces sardines with bones

5 ounces canned salmon

1 cup orange juice (calcium-fortified)

a Foods containing approximately 300 mg of elemental calcium.

Falls Prevention

Another crucial step in avoiding fragility fractures is prevention of falls. Patients with frailty, poor vision, hearing loss, or those taking medications affecting balance are at

higher risk for falling and subsequent fragility fractures. '

A number of medications have been associated with an increased risk of falling, including drugs affecting mental status such as antipsychotics, benzodiazepines, tricyc-lic anti-depressants, sedative/hypnotics, anticholinergics, and corticosteroids. Some cardiovascular and antihypertensive drugs can also contribute to falls, especially those causing orthostatic hypotension.1

Efforts to decrease the risk of falling include balance training, muscle strengthening, removal of hazards in the home, installation of fall reduction measures such as handrails in the home, and discontinuation of predisposing medications.1,2,14 Use of hip protectors also helps prevent hip fractures, although adherence to this measure may be problematic.14

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