Nutrition & bone Health

• Adequate nutrition is essential for the

development and maintenance of the skeleton.
• Although diseases of the bone such as
osteoporosis and osteomalacia (a condition of
impaired mineralization caused by vitamin D and
calcium deficiency) have complex causes, the
development of these diseases can be
minimized by providing adequate nutrients
throughout the life cycle.

Bones

• Bone used to mean an organ, the femur, and

tissue such as trabecular bone tissue.
• Bone mass is a generic term referring to bone
mineral content (BMC).
• Bone Mineral density (BMD) mineral content of
bone per unit of bone (BMC/bone area)
 Composition of bones
• Bone consists of organic matrix –Osteoid-
(collagen fibers), in which salts of calcium and
phosphate are deposited in combination with
hydroxyl ions in Hydroxyapatite:
• Hydroxyapatite: mineral crystals around
collagen designed to bear weight.
• The cable-like tensile strength of collagen an the
hardness of hydroxyapatite combine to give bone
its great strength.
• Other components of the bone matrix include
osteocalcin, osteopontin, and several other matrix
proteins.

Types of Bone Tissue

• Cortical bone (compact bone)
• 80% of the skeleton
• Outer surface of bone
• Consists of osteons or Haversian systems that Undergo
continuous but slow remodeling.
• Trabecular bone (cancellous bone) –
• 20% of the skeleton (in the knobby ends of the long bones,
the iliac crest of the pelvis, the wrists, scapulas, vertebrae,
and the regions of bones that line the marrow.)
• Less dense (open spongy structure)
• Supports outer cortical bone
• Faster turnover rate (sensitive to hormonal changes and
nutritional deficiencies)
• Loss of tissue is largely responsible for fractures especially
of the spine
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Cartilage

• In the embryo, cartilage forms the first temporary

skeleton, until it develops into a mature bone
matrix.
• In the adult, cartilage is found as flexible
supports in areas such as the nose and ear.
• Cartilage is not bone and is neither vascularized
nor calcified.
 Calcium Homeostasis

• Bone tissue serves as a reservoir of calcium and

other minerals.
• Calcium homeostasis the process of maintaining
a constant serum calcium concentration.
• The serum calcium is regulated by complex
mechanisms that balance calcium intake and
excretion with bodily needs. When calcium intake is
not adequate, homeostasis is maintained by
drawing on mineral from the bone to keep the
serum calcium ion concentration at its set level
(approximately 8.5-10 mg/dl).

Calcium Homeostasis
• can be accomplished by drawing from two major
skeletal sources:
• readily mobilizable calcium ions in the bone fluid
• Or, osteoclastic resorption from the bone tissue.
• Serum calcium concentration is regulated by two
hormones:
• parathyroid hormone (PTH)
• 1,25 dihydroxy vitamin D3 (calcitriol).
If serum calcium levels fall, PTH increases reabsorption from
the kidney and bone, and calcitriol increases gut absorption
and initiates osteoclastic activity for bone breakdown.
Increased serum calcium or hypercalcemia, occurs primarily
as a result of hyperparathyroidism.
Serum calcium includes free calcium (formerly called ionized
calcium) and albumin-bound calcium.
 Bone modeling
• is the term applied to the growth of the skeleton
until mature height is achieved.
• at each location cells undergo division and
contribute to the formation of new bone tissue.
• Bone modeling typically is completed
• in females by ages 16 to 18
• in males by ages 18 to 20.
• During this growth period, formation exceeds the
resorption of bone.

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• Peak bone mass (PBM) is reached by 30 years of age or so.
• The long bones stop growing in length by approximately age 18
in females and age 20 in males, but bone mass continues to
accumulate for a few more years by a process known as
consolidation (i.e., filling-in of osteons in the shafts of long
bones).
• PBM – related to nutrient intake, physical activity and genetics.
• The age when BMD acquisition ceases varies, depending on diet
and physical activity.
• PBM is greater in men than in women because of men’s larger
frame size.
• BMC, but not necessarily BMD, is typically lower in women due
to The lean and fat components of body composition.
• BMD is also different among ethnicities i.e greater in blacks and
Hispanics than in whites and Asians, (larger muscle mass,
differences in body weight, lifestyle, diet)
• Heridity 50-80% of BMD

Bone Remodeling
• Resorption:
• is a process in which bone is resorbed
continuously through the action of the
osteoclasts and reformed through the action of
the osteoblasts.
• The remodeling process is initiated by the
activation of preosteoclastic cells in the bone
• surface of bones is broken down by osteoclasts
(cells that erode the surface of bones)
• New bone matrix formed by osteoblasts (bone
builder cells) Synthesize new bone matrix by
laying down collagen-containing component of
bone
• Acids and proteolytic enzymes released by the osteoclasts form
small cavities on bone surfaces and resorb bone mineral and
matrix on the surface of trabecular bone or cortical bone. The
resorptive process is rapid, and it is completed within a few days
• whereas the refilling of these cavities by osteoblasts is slow
(i.e., 3 to 6 months or even as long as a year or more in older
adults).
• With aging, osteoclastic resorption becomes relatively greater
than formation by osteoblasts . This imbalance between
formation and resorption is referred to as “uncoupling” of the
osteoblastic and osteoclastic activity.
• Age is an important determinant of BMD. At approximately
age 40, BMD begins to diminish gradually in both sexes,
but bone loss increases greatly in women after
menopause because of the loss of estrogen’s effects on
bones.
• Men continue to have bone loss, but at a much lower rate
than women of the same age until age 70, when the loss
rates are about the same for both genders
• Cortical bone tissue and trabecular bone tissue undergo
different patterns of aging. Loss of cortical bone eventually
plateaus and may even cease late in life. Trabecular bone
loss begins in both sexes as early as 40 years of age.
Premenopausal loss of trabecular bone in women is much
greater than that of cortical bone.
• Loss of both kinds of bone accelerates in women after
menopause, although trabecular bone is lost at a much
higher rate than cortical bone.

Bone Remodeling (conclusion)

• Bone resorption and formation are equal in

young, healthy adults
• Resorption exceeds new bone formation after
age 40: density begins to decrease
• High peak bone mass through proper nutrition
and exercise: stronger skeleton
• Protective against osteoporosis
OSTEOPENIA AND OSTEOPOROSIS
• 9% of adults over
age 50 have
osteoporosis.
• Another 49% have
low bone mass, or
osteopenia, at the
femur neck or
spine,
• leaving about 49%
with healthy bone.
National Health and Nutrition
These results differ
Examination
by age, gender, Survey of 2006 to 2008
race and ethnicity

Osteoporosis

• Most prevalent disorder affecting bone health

• Characterized by:
• Low bone mass
• Deterioration of bone tissue
• Fragile bones leading to bone-fracture risk
• Bone compaction: decreased height
• Shortening and hunching of the spine
Types of osteoporosis

• Primary osteoporosis
There are two types of primary osteoporosis,
distinguished in general by sex, the age at which
fractures occur, and the kinds of bone involved.
• Secondary osteoporosis results when an
identifiable drug or disease process causes loss
of bone tissue

• Estrogen-androgen deficient osteoporosis

• occurs in women within a few years of
menopause from loss of trabecular bone tissue
and cessation of ovarian production of
estrogens.
• BMC and BMD measurements of the lumbar
spine of women with postmenopausal
osteoporosis may be as much as 25% to 40%
lower than in age-matched nonosteoporotic
control women of the same age range.
• Age-related primary
osteoporosis occurs at
approximately age 70 and
beyond. Many women lose
several inches in height
between 50 and 80 years of
age (see Figure 24-6).
Although age associated
osteoporosis affects both
sexes, women are affected
more severely because they
have a smaller skeletal mass
than men

Causes & Risk factors

• Low BMD is common to all types of
osteoporosis, but an imbalance between bone
resorption and formation results from an array of
factors characteristic of each form of this
disease.
Causes & Risk factors

• Alcohol and Cigarettes

• probably because of toxic effects on
osteoblasts
• Excessive consumption more than three drinks a
day) for an extended period may result in bone
loss. The combination of smoking and alcohol,
common among young women and men, places
them at increased risk for osteoporosis.

Causes & Risk factors

• Low body weight is a principal determinant
of bone density and fracture risk
adipose tissue mass is a major contributor
• The greater the body mass, the greater the
BMD.
• Fat and bone are linked by pathways involving
adiponectin;insulin, amylin, and preptin; and
leptin and adipocytic estrogens, which ultimately
serve the function of providing a skeleton
appropriate to the mass of adipose tissue it is
carrying
Causes & Risk factors
• The lower the BMI, the lower the BMD is.
• Young girls who are typically premenarcheal
may incur fractures with minimum trauma
because of low BMC and BMD related to rapid
growth in height that is not accompanied with a
proportionate increase in weight.
• Young, overweight males with low bone mass
also may suffer fractures
• dieting, bariatric surgery, or sarcopenia also are
associated with bone loss.
• Thus being overweight is protective against
osteoporosis and underweight is a risk factor
for fractures

Causes & Risk factors

• Ethnicity
• recent data suggest that Hispanics are at higher risk
than non-Hispanic whites, whereas blacks are at
lower risk for low bone density,
• non-Hispanic whites suffer more fractures than other
racial or ethnic groups.
• Nevertheless, the incidence of fracture has declined
in all racial and ethnic groups except Hispanics
 Causes & Risk factors
• Limited Weight-Bearing Exercise
• A good diet plus exercise from roughly ages 10 to 20 years is
particularly important for skeletal growth, accrual of bone mass,
and increased femoral bone dimensions
• Physical activity, especially upper body activities, is thought to
contribute to an increase in bone mass or density.
• Lack of exercise and a sedentary mode of living also may
contribute to bone loss, although the most important influence is
probably an inadequate accumulation of bone mass.
• Exercise is beneficial for reducing skeletal inflammatory markers
in frail older individuals.
• Stresses from muscle contraction and maintaining the body in an
upright position against the pull of gravity stimulate osteoblast
function.

Causes & Risk factors

• Loss of Menses
• Acceleration of bone loss coincides with menopause, either natural or
surgical, at which time the ovaries stop producing estrogen.
• Estrogen replacement therapies have been shown to conserve BMD and
reduce fracture risk within the first few years after menopause, at least in
short-term studies.
• Any interruption of menstruation for an extended period results in bone loss.
The amenorrhea that accompanies excessive weight loss seen in patients
with anorexia nervosa or in individuals who participate in high-intensity sports,
dance, or other forms of exercise has the same adverse effect on bones as
menopause.
• BMD in amenorrheic athletes has been measured at levels 25% to 40% below
normal.
• young women may benefit from the use of oral contraceptive agents plus
calcium and vitamin D supplements.
Causes & Risk factors
• Nutrients
• WHO recognizes that calcium, vitamin D,
protein, phosphate, vitamin K, magnesium, and
other trace elements and vitamins are related to
bone health.
• Energy intake is related as well.

Causes & Risk factors

• Medications either by:
• interfering with calcium absorption
• or by actively promoting calcium loss from bone.
• corticosteroids affect vitamin D metabolism and can
lead to bone loss.
• Excessive amounts of exogenous thyroid hormone
can promote loss of bone mass over time
DIAGNOSIS AND MONITORING

• Bone densitometry measures bone mass on

the basis of tissue absorption of photons
produced by x-ray tubes
1) Dual energy x-ray absorptiometry (DXA or
DEXA)
• Non-invasive measurement of bone density
• Results are compared with average peak
bone density of 30-year-old healthy adult
• T-score is used to assess a person's risk for
fracture and diagnose osteoporosis
• Recommended for postmenopausal women

DIAGNOSIS AND MONITORING

• 2) Ultrasound Measurements of Bone

• Ultrasound instruments measure the velocity of
sound waves transmitted through bone and
broadband ultrasound attenuation (BUA).
• Measurements at the calcaneus (heel) correlate
fairly well with BMD measurements at this same
skeletal site.
• However, ultrasound measurements are
considered screening tools, whereas DEXA
measurements are considered diagnostic.
Nutrients for Bone Health

• Calcium, phosphate, and vitamin D are essential

for normal bone structure and function.
• Protein, calories, and other micronutrients also
help develop and maintain bone

Energy

• Energy intake does not have a direct effect on

bone; rather, inadequate energy intake leading to
low body weight, or too many calories leading to
overweight have effects on bone.
• Being underweight is considered a risk factor for
osteoporosis, whereas being overweight may be
protective.
 Protein
• Protein and calcium are important components of PBM,
especially before puberty
• A meta-analysis of studies concerned with protein intake and
indicators of bone health found a slight positive effect on BMD,
but it did not influence the risk of fracture over the long term.
• The theory that higher protein intakes produce a higher acidic
load, which increases calcium urinary excretion, has not been
verified
• protein also may improve calcium absorption and increase
growth factors, which also could improve bone health.
• Very low protein intake may negatively affect bone turnover and
development. In cases of negative nitrogen balance, such as
with fracture or surgery, higher protein intake may be advised.

Calcium
• Calcium intake in the primary prevention of osteoporosis has
received much attention
• Calcium bioavailability from foods is generally good, and the
amount of calcium in the food is more important than its
bioavailability.
• calcium absorption efficiency depends on:
1. the individual’s need for calcium,
2. the amount consumed because absorption efficiency is
inversely related to amount consumed
3. third the intake of absorption enhancers or inhibitors.
For example, absorption from foods high in oxalic and phytic acid
(certain vegetables and legumes) is lower than from dairy products.
 Calcium Intake

• Adequate Intake (AI) varies with age and

gender: 1,000 mg to 1,300 mg/day
• Upper limit (UL): 2,500 mg
• Bioavailability: Body's ability to absorb and
utilize calcium depends on
• Individual's age and calcium need
• Dietary calcium and vitamin D
• Binding factors (phytates, oxalates) in foods

Functions of Calcium

• Provides structure for bones and teeth

• Assists with acid−base balance
• Assists in transmission of nerve impulses
• Assists in muscle contraction
• Maintains healthy blood pressure
• Initiates blood clotting
• Regulates hormones and enzymes

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Sources of Calcium

• Excellent sources include milk products

• Skim milk, low-fat cheese, nonfat yogurt
• Other good sources include
• Green leafy vegetables (kale, collard greens,
broccoli, and cabbage are low in oxalates)
• Fortified foods (orange juice, soy milk)
• Fish with edible bones (sardines, salmon)
 Excess Dietary Calcium

• Excess dietary calcium is excreted in feces

• Mineral imbalances from supplements
• Hypercalcemia (high blood calcium)
• Cause: cancer or parathyroid hormone (PTH)
overproduction
• Symptoms: fatigue, appetite loss,
constipation, mental confusion, calcium
deposits in soft tissues

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Calcium supplements
• Calcium carbonate is the most common form of
calcium supplement.
• It should be taken with food because an acidic
environment enhances absorption.
• For those with achlorhydria, which often occurs in
seniors, calcium citrate may be more appropriate
because it does not require an acidic environment for
absorption and does not further reduce the acidity of
the stomach
• The absorption of calcium supplementation is optimal
when
• taken as individual doses of 500 mg or less. Many
formulations
• include vitamin D, because the likelihood of needing
 Phosphate

• Phosphorus is the major intracellular negatively

charged electrolyte
• The body’s reserve of phosphorus is found in
the bone as hydroxyapatite.
• Functions of phosphorus
• Critical in bone formation
• Required for proper fluid balance
• Component of ATP, DNA, membranes

Sources of Phosphorus

• High in protein-containing foods such as milk, meats, eggs,

legumes
• In processed foods as a food additive: smoothness, binding, and
moisture retention
• In soft drinks as phosphoric acid
• studies have found that the soft drink primarily”
• displaces milk as a beverage … the negative effect is from
lower calcium intake rather than higher phosphate intake.
• Negative affect of soft drink consumption on bones has to do
with the rapid rate of phosphorus absorption and greater
phosphorus bioavailability from processed foods such as cola
drinks.
• Those at high risk and those who have osteoporosis may want to avoid
these beverages (muscle spasms and convulsions)
Trace Minerals

• Iron, zinc, copper, manganese, and boron may

function in bone cells, but their specific roles in
preventing bone loss are not well established.

Fluoride

• Trace mineral, stored in teeth and bones

• Combines with calcium and phosphorus to form
fluorohydroxyapatite to form teeth
• Functions of fluoride
• Develop and maintain teeth and bones
• Combines with calcium and phosphorus to
protect teeth from bacteria
• Stimulates bone growth
Fluoride (cont.)
• Sources of fluoride
• Fluoridated dental products
• Fluoridated water (not in bottled water)
• Fluoride ions enter the hydroxyapatite crystals of bone
as substitutes for hydroxyl ions.
• Water containing 1 mg/liter has been determined to be
optimal for dental health. The upper limits (UL) for
fluoride vary by age, beginning with 0.7 mg/day for
infants 0 through 6 months, and up to 10 mg/day for
children over 8 years through adulthood (IOM, 1997)
• Fluoride does not help bone in the same way that it
helps tooth surfaces. Within narrow limits of safety,
fluoride ions have little effect on increasing the hardness
of bone mineral.

Vitamins
Vitamin A

• Vitamin A consumption consists of:

• retinol (animal sources)
• carotenoids (plant sources).
• Although the research is not definitive, a general
guideline is that retinol intake should not be
excessive, and carotenoids may have a
beneficial role in bone health.
• The window of safe consumption of retinol is
fairly narrow, especially for older adults.

Vitamin D

• In 2008, the FDA amended the label health

claim regulations concerning calcium and
osteoporosis so that they could also include
vitamin D - role in calcium uptake and therefore
bone homeostasis.
• Fat-soluble vitamin
• Excess is stored in liver, adipose tissue
• Can be synthesized by the body from exposure
to UV rays from the sun
• Considered a hormone: synthesized in one
location and regulates activities in other parts of
the body
 Functions of Vitamin D

• Regulates blood calcium and phosphorus levels/

• increase calcium availability:
• Stimulates osteoclasts when calcium is
needed elsewhere in the body
• Stimulating intestinal calcium transport
• A role in muscle tone and fall prevention.
• Although vitamin D supplementation for fall
prevention has had positive and negative
results older adults with vitamin D deficiency
as measured by blood 25-hydroxyvitamin
D3 (calcifediol) levels had muscle weakness
and poor balance.

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 Vitamin D Adequacy
• An individual’s vitamin D status depends mostly on sunlight
exposure, and secondarily on dietary intake of vitamin D.
• AI: Assume sun exposure is inadequate
• The synthesis of vitamin D by skin exposed to sunlight varies
considerably:
• skin tone
• Darker skin (more melanin pigment) reduces the penetration of
sunlight
• Sunscreen use
• environmental latitude
• Inadequate sun in the winter (latitude of more than 40°N or more
than 40°S)
• age
• The skin of older individuals is less efficient at producing vitamin D
after exposure to (UV) light because the skin is thinner and it
contains fewer cells that can synthesize vitamin D.
• typically have little exposure to sunlight.

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 Sources of Vitamin D

• Ergocalciferol (D2): plants, supplements

• Cholecalciferol (D3): animal foods, sun
• Most foods naturally contain little vitamin D
• Mostly obtained from fortified foods (e.g., milk)
• High amounts: cod liver oil, fatty fish (salmon,
mackerel, and sardines)
• Vegetarians not consuming milk products
receive vitamin D from the sun, fortified soy or
cereal products, or supplements

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Vitamin D Intake Recommendations

• To prevent rickets, the American Academy of Pediatrics
recommends
• all infants who are exclusively breastfed be supplemented
with 400 IU of vitamin D. ]
• Infants who are both
• formula and breastfed also should be supplemented until
they are consistently taking 1 L (1 quart) of formula a day.
• They further recommend continuing the supplementation
until 1 year of age, when children begin drinking vitamin D–
fortified milk
• RDA: 600 IU for men/women ages 19 to 70; 800 IU for adults
over age 70
• UL: 4,000 IU for everyone over 8 years of age
The most common blood test for vitamin D status is
serum 25-(OH) D level, and the normal range is considered to
be 30 to 75 ng/ml
 Vitamin D

• What happens if you consume too much?

• Results in hypercalcemia
• What if you don't consume enough?
• Loss of bone mass: from fat malabsorption
• Rickets (children), osteomalacia (adults)
• Medications alter vitamin D metabolism and
activity: glucocorticoids, phenobarbital

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Vitamin K

• Fat-soluble vitamin stored in the liver

• Phylloquinone: plant form (dietary) of vitamin K
• Menaquinone: animal form of vitamin K
produced by bacteria in the large intestine
• Vitamin K functions as coenzyme:
• Blood coagulation
• Bone metabolism
Vitamin K (cont.)

• Vitamin K is an essential micronutrient for bone

health. Its role in post-translational modification
of several matrix proteins,
• Osteocalcin: secreted by osteoblasts (bone
remodeling) and serves as a serum bone
marker for predicting the risk of a fracture.
• Matrix Gla protein: in protein matrix of bone,
cartilage, blood vessel walls, soft tissues.
May prevent calcification of arteries, reducing
risk of CVD

Vitamin K (cont.)

• Recommended intake
• AI values are 120 μg/day for men and 90
µg/day for women
• Sources of vitamin K
• Synthesized by bacteria in the large intestine
• Green leafy vegetables (kale, spinach, collard
greens, lettuce)
High Acid or Alkaline Diets
• Higher acid diets include those high in protein,
dairy, and grains
• It is theorized that these higher acid diets may
increase calcium excretion and have a detrimental
effect on bone.
• The theory also supports a converse beneficial
effect of an alkaline diet on bone.
• Several meta-analyses, experimental studies, and
reviews have not supported either the negative
effect of higher acid diets on bone or the positive
effects of an alkaline diet on bone.
• Higher protein intake may, in fact, have a positive
effect on bone

Sodium

• A high sodium intake may contribute to

osteoporosis because of increased calcium
excretion.
• Although the calciuric effect of sodium has been
speculated, there seems to be no adverse
effects when there is adequate calcium and
vitamin D intake
PREVENTION OF OSTEOPOROSIS AND
FRACTURES
• Consuming adequate amounts of calcium, and
vitamin D, along with lifelong muscle
strengthening and weight-bearing exercise,
avoidance of tobacco, moderate or no intake of
alcohol, and steps to avoid falls are all part of
the holistic approach to a lifestyle that promotes
optimal bone health

PREVENTION OF OSTEOPOROSIS AND

FRACTURES
• Exercise
• To preserve bone health through adulthood, the
American Academy of Sports Medicine
recommends weight-bearing activity three to five
times per week and resistance exercise two to
three times per week with moderate to high
bone-loading force for a combination of 30 to 60
minutes per week.
• Regular walking and swimming appear to have
minor benefits in older individuals.
• older adults, posture, balance, and flexibility are
also important.
Nutrition and Osteoporosis
• The National Osteoporosis Foundation recommends :
• includes adequate calcium and vitamin D, and a
balanced diet of low-fat dairy, fruits, and vegetables.
• Although the NOF recommends the same amount of
calcium intake as the IOM, the NOF recommends a
higher intake of vitamin D than does the IM for those 50
years and older (800 to 1000 IU/day). Food and
supplements .(NOF, 2013).
• In addition, achieving and maintaining a healthy weight
and consuming a lower sodium diet is recommended for
optimal bone health for women.

Prevention
• There is no cure for osteoporosis
• Factors that slow the progression of osteoporosis:
• Adequate calcium and vitamin D intake
• Regular (weight-bearing) exercise
• Resistance training
• Certain medications (may have side effects)
• FDA-Approved Drug Treatments
• Raloxifene and tamoxiphen, which are estrogen
agonist/ antagonist agents; alendronate sodium,
risedronate sodium, and zoledronic acid, which are
bisphosphonates; and estrogen replacement
therapy (ERT) are all approved for the prevention
Treatment
• Medical Nutrition Therapy
• Calcium (1000 mg/day) and vitamin D (800 to 1000
units/day) typically are recommended as supplements for
patients being treated with one of the bone drugs, either
antiresorptive or anabolic.
• a healthy diet emphasizing the key nutrients seems most
promising in achieving an intake for optimal bone health
• The dietitian nutritionist should evaluate the client’s diet for
all bone-related nutrients and tailor recommendations
• based on personal preferences, cultural differences,
• nutrient recommendations, and the need for supplements

Exercise

• For those with osteoporosis, exercises that exert

strong force against potentially weak bone are
not recommended, such as situps or twisting.
Exercises should focus on posture, balance,
gait, coordination, and hip and trunk stabilization
(IOF, 2014).
• For those in need of rehabilitation, the client
should be evaluated for capabilities and
deficiencies, with attention to weight-bearing
aerobic activities, posture, resistance training,
stretching, and balance training
 FDA-Approved Drug Treatments
• All the medications that are approved for prevention are also
approved for treatment of osteoporosis, with the exception of
estrogen replacement therapy.
• Another bisphosphonate, ibandronate sodium, is also
approved only for treatment.
• calcitonin, the hormone, is used to inhibit osteoclastic bone
resorption by blocking the stimulatory effects of PTH on these
cells.
• improves BMD, especially of the lumbar spine, and it may reduce the
recurrence of fractures in patients with osteoporosis.
• Calcitonin is approved by the FDA for postmenopausal treatment of
osteoporosis, but it is recommended that the women be at least 5 years
postmenopausal.
• PTH therapy is approved by the FDA for the treatment of
postmenopausal women and men at high risk for fracture and
for those on long-term glucocorticoid therapy.