Lecture 8

Calcium upper limits

- Adults 19-50 2500 mg/day - Adults >50 2000 mg/day

Risks of calcium supplementation

High-dose calcium supplementation has been associated with - Renal calculi in older women (not drinking enough fluids > effect?) - Cardiovascular events in older women - Prostate cancer in older men

Calcium recommendations from other foods

- Calcium in other foods: - Tofu - Nuts and seeds - Oysters - Fish with small bones - Spinach? - Little calcium - Binders (oxalates) • Calcium - dairy sources are the best. Why? - Elemental content is greater - Highest rate of absorption - Low cost for greatest benefit

What are bones made of?

- Composed of: - 65% mineral crystals - Strength and structural support - 35% collagen - Flexibility - Bone mineral density = bone strength - Two types of bone tissues: - Cortical bone - Very dense; part of outer walls of larger bones and main tissue of small bones - Trabecular bone - Lacy architecture; responds readily to hormones

Calcium absorption

- Increased calcium intake ensures adequacy - Differs during different stages in life: - Adults: 30% - Pregnancy: 50% - Children: 50-60% - Factors: - Enhancers: stomach acid, vitamin D, lactose (in infants) - Inhibitors: lack of enhancers- (acid suppressor medication, vitamin D deficiency), high phosphorus intake, phytates (nuts, seeds, grains), oxalates (beet greens, rhubarb, spinach and sweet potatoes), fibre

Calcium roles in the body

- Most abundant mineral in the body - 99% in bones - Forms a matrix on collagen (hydroxyapatite - insoluble salt of calcium and phosphorus) - Gives strength and rigidity - Remodelling occurs continuously - 1% in body fluids - Extracellular and intracellular compartments - Different functions - Role in hypertension and weight management

Food guide servings of milk + alternatives

- Young children (2-8yr) 2 servings/day - Older children (9-18yr) 3-4 servings/day - Adults (19-50yr) 2 servings/day - Adults (51+yr) 3 servings/day

Protein recommendations

- for bone, intake should be at least 1g/kg - in 2002 OC guidelines were "Maintain adequate protein" - OC is willing to accept the recommendation of 1g/kg (compared to RDA of 0.8g/kg) - protein is not the "bad" nutrient for bone unless calcium intakes are low

Protein intake

- reduces fracture risks - attenuates femur bone loss - insufficient protein intake in the elderly can lead to: - decreased mobility - increased risk of falling + fracture

Time to stop calcium supplementation?

No, but high doses (i.e., 1000 mg) of calcium supplements should not be used by post-menopausal women who do not need extra calcium or just a more modest amount. It's important to assess total intake from diet and supplements.

Osteoporosis and men

• 1 in 8 men over 50 has the disease. • In Canada 20-30% of osteoporotic fractures occur in men. • Lower testosterone levels in men can lead to an increase in bone loss. • Prostate cancer treatment • The decline is more gradual in men and is not universal. • A Canadian osteoporosis study (CaMOS) has found that 25% of Canadian men have vertebral fractures, similar to rates found in women. • Elderly men account for almost 30% of hip fractures. • Men are more likely to die or experience disability after a hip fracture than women.

Canadian prevalence

• 2 million Canadians suffer from osteoporosis. • One in four women over the age of 50 has osteoporosis. (1 in 3 will suffer a fracture) • One in eight men over 50 also has the disease. (1 in 5 will suffer a fracture) • However, the disease can strike at any age. • osteoporosis especially common in white + asian women over 50 years old

High proportion of people at risk for osteoporotic fracture

• 29% were women over 50 years of age. • 33% were men over 50 years of age. • 7% reported having had a fracture of the wrist, upper arm, spine and/or hip, after 40 years of age. • 15% reported weighing less than 132 lbs (or 60 kg). • 19% reported smoking daily or occasionally. • 12% reported drinking alcohol every day.

What is osteoporosis?

• A metabolic bone disease characterized by low bone mass and micro-architectural deterioration of bone tissue with a resulting increase in fragility fractures

Benefit of hip-protectors in long-term care

• A modest reduction in hip fractures in elderly long-term care residents • Cost effective for fracture reduction in longterm care • Compliance poses a challenge • Not effective for older adults residing in the community

Bone mass loss

• After age 35, men and women begin to lose bone mass at about .5% to 1% per year. • Women - in the first 5 to 10 years after menopause, lose 2% to 5% of their bone mass every year - 20% during 6-8 years after menopause • Men - typically experience accelerated bone loss after the age of 65 and lose about 2/3 that of women.

Major risk factors

• Age > 65 years • Vertebral compression fracture • Fragility fracture after age 40 • Family history of osteoporotic fracture (especially maternal hip fracture) • Systemic glucocorticoid therapy of >3 months duration • Malabsorption syndrome - Celiac or Crohn's Disease • Primary hyperparathyroidism • Tendency to fall • Osteopenia apparent on x-ray film • Hypogonadism • Early menopause (before age 45)

what is DEXA

• Bone density measured using a technique called dual energy x-ray absorptiometry, or DEXA. • Large studies have shown that the bone mineral density of the hip as measured by DEXA helps to predict whether a person will have a hip fracture. • Hip data is the best predictor of all fractures. • Spinal data can include osteoarthritic changes such as spurs which give false negatives • 1/10 of radiation of a chest x-ray • Gold standard • Normal verses osteopenia or osteoporosis • Compared to young healthy bone (age 25 years) - not to age-comparable bone • An x-ray machine sends out two rays with different energies. As the rays pass through a patient, some are stopped by the bone mineral or by the other tissues in the body, such as fat, water, or protein. • An x-ray detector above the patient can tell how much energy got through, and this information is sent to a computer, which analyzes it and forms an image.

Bone remodeling

• Bone is living tissue, constantly renewing itself. Subject to wear and tear. • Remodeling process completed every 3 to 4 months in a healthy young adult. • Osteoclasts excavate any areas of crumbling or weakened bone. • Osteoblasts fill in the crevices with material that calcifies to form new bone.

How to avoid

• By: 1. eating a calcium-rich, balanced diet 2. getting enough vitamin D from their diet 3. getting enough vitamin D from sun exposure or supplements 4. getting plenty of physical activity 5. falls prevention 6. avoid smoking 7. avoid excessive alcohol

Caffeine

• Caffeine can contribute to calcium loss through the kidneys. • Up to four caffeine drinks per day are not considered to be detrimental providing there is adequate calcium intake. • >4 - decaffeinated beverages are recommended, or add extra calcium to counteract the effect of caffeine. • Caffeine is contained in coffee, tea, chocolate and some soft drinks like cola beverages

Blood calcium levels

• Calcium is an EXTREMELY important mineral for functions such as nerve conduction and muscular contraction-including the nerves and muscles of the heart, brain and spinal cord. • Because of this, the body is VIGILANT about maintaining calcium levels in the blood at a normal level. • And your body will do just about ANYTHING to maintain this level in the proper range. So, if you don't get ENOUGH calcium, your body will pull calcium from the bones in order to keep levels up high enough- leading to osteoporosis or osteomalacia. • If you take too MUCH calcium, you will almost never have a Calcium Overdose, instead the body will get rid of it in your urine (which can lead to kidney stones) or in your organs (which can lead to calcification). • Your body doesn't CARE if you get kidney stones or osteoporosis in the long term- it is a MUCH higher priority for it to maintain a proper blood calcium level for nerve conduction and heart function

Calcium supplementation + heart disease

• Calcium is essential for the achievement and maintenance of normal bone health. • Recent research, however, has raised concerns regarding the daily use of 1000 mg or higher of elemental calcium particularly in elderly individuals (>70 years of age) in the presence of impaired renal function. • Research from New Zealand evaluated the results of 11 randomized controlled trials of calcium supplementation involving more than 12,000 patients. • Ian Reid and his colleagues found an increase in the risk of heart attacks by 31% in the groups receiving calcium in comparison to placebo with 143 women experiencing a heart attack in the calcium groups and 111 women experiencing a heart attack in the placebo groups. • The reason for this increased risk of heart attacks is not yet clear and may be due to calcification of the coronary arteries following rises in blood calcium after the intake of calcium supplements. • Such findings have not been seen with intake of calcium from dietary sources.

Calcium and childhood

• Calcium is necessary to grow a healthy skeleton to support a growing body. • Age 17 in men and age 14 in women, bones stop growing in length and almost at peak bone mass. • The density of our bones depends on our calcium intake as children and teenagers. • Children who are active have 5-15% increase in bone growth • Ages 20-30 consolidation with some increase • Age 30 reach peak bone mass • More mass you have at peak - less likely to have fracture

Calcium and body weight myth

• Calcium may play a role in maintaining body weight • Calcium from dairy - not from supplements • The higher the calcium intake, the lower the prevalence of overweight • Adequate dietary calcium intake may help prevent excess fat accumulation by stimulating hormonal action to break down stored fat • Also reduces inflammation associated with overweight

Lycopenes

• Contain carotenoids which are antioxidative • Antioxidants prevent cell damage • Oxidative stress increases pathogenesis of osteoporosis • Found in tomatoes, pink grapefruits, watermelon • Dietary doses and sources being studied

Early prevention/intervention

• Critical for your future health • Critical for your future health care burden • Easily achieved!! • We already know how to do it.

Sources of calcium

• Dairy products such as milk, cheese and yogurt are excellent sources of calcium - high amounts of calcium that are easily absorbed by the body. • Skim milk products provide as much calcium as whole milk but less fat and cholesterol. • Some calcium-fortified soy beverages and orange juices may contain as much calcium as milk (check the labels). • Vegetables also provide calcium. • Fish products containing bones (canned salmon and sardines) and meat alternatives such as lentils and beans.

Exercise = bone mass

• Exercise can preserve bone mass --especially if it's the right kind. • Weight-bearing exercise and impact sports are best for maintaining bone mass, says the Surgeon General's report. • Studies have shown that exercise boosts bone mass -- but only at the sites of skeletal stress. Walking or jogging can increase bone density in the hips, but weight-lifting won't. • Not "impact" as in helmet-crashing, contact sports like football -- but sports where, when your foot hits the ground, there's some force and impact there. • Jogging, running around a basketball court, and jumping rope are big impact. • Walking, cross-country skiing, and inline skating are low-impact. • Ideally, the experts say, do at least: • 30 minutes of moderate activity, like brisk walking, on most days of the week • Strength training, like weight-lifting or resistance training with weight machines, twice a week

Nonpharmacologic interventions associated with reduction in falls

• Exercise-focused interventions for community-dwelling older people • Tai chi, gait, and balance training • Home safety assessment (only effective in those at high risk for falls) • Cataract removal

Fracture facts

• Fractures from osteoporosis are more common than heart attack, stroke and breast cancer combined. • 1 fracture every 3 seconds in Canada • The population aged 50 years and over has increased by 50% from 1993 to 2008. • This % population will continue to increase. • A 50-year-old woman has a 40% chance of developing hip, vertebral or wrist fractures during her lifetime. • The lifetime risk of hip fracture is greater (1 in 6) than the 1 in 9 lifetime risk of developing breast cancer. • Patients are at highest risk for subsequent fracture in the first few months following a vertebral fracture. • 1 in 4 women who have a new vertebral fracture will fracture again within one year. • Both vertebral and hip fractures are associated with an increased risk of death.

Why men have less fractures

• Greater cortical diameter confers greater bending strength • Fewer Men sustain fractures -due to: • Peak bone mass (10% higher) • Greater bone size (androgen effect) • Greater bone mass (androgen effect) • More Physically active • Low incidence of falls • Death (Men die earlier)

what is Bone mineral density

• If you take a sample of bone and wash out the liquid bone marrow, the remaining bone is about half mineral and half protein. • The weight of mineral per volume of bone is the Bone Mineral Density. The strength of the bone is largely determined by the bone mineral density. • This is determined by two things: - how many mineral atoms are deposited within the bone matrix - how porous the matrix is

Cost of osteoporosis

• In 1993, the cost of treating osteoporosis and its related fractures was estimated to be $1.3 billion in Canada. • The overall yearly cost to the Canadian healthcare system of treating osteoporosis and the fractures it causes was over $2.3 billion as of 2010. • This cost includes acute care costs, outpatient care, prescription drugs and indirect costs. • This cost rises to $3.9 billion if a proportion of Canadians were assumed to be living in long-term care facilities because of osteoporosis. • Without effective action on osteoporosis prevention and treatment strategies, it is estimated that by 2018 Canada will spend at least $32.5 billion treating osteoporotic fractures. • The costs are from: • Diagnosis - bloodwork, xrays, DEXA imaging • Monitoring - regular testing - DEXA, bloodwork • Treatment - office visits, specialists, medications • Fractures!!!$$$$ - "fragility fractures"

CAROC

• In 2005, Osteoporosis Canada, in association with the Canadian Association of Radiologists, launched the 10-year absolute fracture risk assessment - CAROC. • In addition to BMD (lowest T-score of hip and lumbar spine), age, gender, fracture history and steroid use are taken into consideration to determine an individual's 10-year risk of fracture. • The presence of both a fragility fracture and steroid use puts the patient at high fracture risk regardless of BMD result. • Version 2, now available for Canadian physicians, uses only femoral neck (hip) BMD rather than the lowest of hip and lumbar spine.

FRAX

• In 2008, the World Health Organization (WHO) launched the FRAX tool (Fracture Risk Assessment) In 2010 Canadian data were added to this tool. In addition to femoral neck (hip) BMD, age, gender, fracture history and steroid use, FRAX also takes into account other clinical risk factors to calculate the absolute 10-year risk of a hip fracture or other major osteoporotic fracture (spine, forearm, upper arm). These factors include: • BMI (weight to height ratio calculation) • Parental hip fracture • Rheumatoid arthritis • Other secondary conditions that contribute to bone loss • Current smoking • Alcohol intake (three or more drinks per day)

Systemic glucocorticoid use

• Includes prednisone and cortisone for more than 3 months. • Diseases that are often treated with glucocorticoid medications include: • Rheumatoid arthritis • Asthma • Crohn's disease • Colitis • COPD

What age related factors cause osteoporosis?

• Inefficient bone remodelling • The osteoclasts remove old bone faster than the osteoblasts are able to rebuild it. • Reduced calcium intake • Impaired calcium absorption • Poor Vitamin D status - decreased exposure, skin changes, decreased ability of kidneys to activate • Hormonal changes - parathyroid, calcitonin and estrogen

Many non-screened individuals at risk

• Less than half (47%) of Canadians over the age of 65 years reported having had a bone density test. • Almost one in ten (8%) Canadians reported having had a fracture at one of the common sites for an osteoporotic fracture after 40 years of age—a common complication of osteoporosis. • Only one in two (48%) Canadians who reported having had a fracture at one of the common sites for an osteoporotic fracture after 40 years of age, reported having had a bone density test. • In both cases, women were more than three times more likely to report having had this test compared to men.

Modifiable risk factors

• Low bone mineral density • Low body weight • High alcohol use • Smoking • Excess caffeine • Diet - low calcium intake • Low vitamin D exposure • Sedentary lifestyle

Men with osteoporosis

• Men with osteoporosis are often not diagnosed • Lack of awareness among men is similar to that among women 50 years ago • Osteoporosis is still perceived as a 'women's disease' • Fewer approved treatments for men than for women • Estrogen preserves bone density -- in both men and women. In fact, all men normally convert testosterone to estrogen to build bone mass.

Exercise + BMD

• New evidence shows that as we age, exercise only has a modest transient effect on increasing BMD • Does decrease fall risk though • Benefit lost within one year of not exercising - not long term • Exercisers don't fall as often and don't fall as injuriously - better neuromuscular control/balance/reflexes/muscle firing • Can't say that exercise increases BMD • exercises load target areas

What is a fragility fracture?

• One that results from minimal trauma, such as a fall from a standing height or less, or no identifiable trauma at all

A lesson for health care reform

• Osteoporosis is a unique example of a nutritional health issue that manifests itself many years later - "the silent thief" • Early prevention and intervention is essential • Example of a model of health care that is not economically feasible • A lifetime of nutritional and lifestyle habits that have resulted in a health cost tsunami! • Your generation will pay for the price of past and present generations health issues • The solutions to this health care tsunami were very simple! • Osteoporosis is a normal aging process which has been complicated by poor nutritional choices, lifestyle habits, understanding and education. • Crisis due to medical advances which have allowed the baby boomers to live longer in a skeletal framework which is compromised.

Hip fracture costs

• Over 80% of all fractures in people 50+ are caused by osteoporosis. • Osteoporosis causes 70-90% of 30,000 hip fractures annually. • 28% of women and 37% of men who suffer a hip fracture will die within the following year. • Each hip fracture costs the system $21,285 in the 1st year after hospitalization, and $44,156 if the patient is institutionalized. • Osteoporotic hip fractures consume more hospital bed days than stroke, diabetes, or heart attack.

Alcohol

• People who abuse alcohol more likely to suffer from osteoporosis and experience more fractures • Alcohol enhances fluid excretion leading to calcium losses in urine • Upsets hormone balance • Slows bone formation • Stimulates bone breakdown • Increases the risk of falling

Effects of Physical activity on bones

• Physical activity places an increased "load" or force on our bones. • Our bones respond by increasing in mass so the load can be spread over a larger amount of bone. • It improves our balance and coordination which, in turn, reduces our risk of falling — falls that can result in fractures. • Improved strength, flexibility and posture can reduce pain and enable people with osteoporosis to do daily tasks more easily. • Physical activity to prevent osteoporosis includes both: 1. weight-bearing 2. strength-training exercise • Weight-bearing is any exercise where the entire weight of the body is supported by the legs, such as walking, line dancing, low-impact aerobics or racquet sports. • Exercise programs for people at risk for or with osteoporosis should be aimed at: 1. increasing strength 2. coordination 3. balance 4. flexibility

How is osteoporosis measured?

• Plain radiographs - traditional method for many years • Bone would appear more radiolucent • Subjective to radiologist interpretation, equipment settings, exposure factors, film developing methods, positioning of patient • Not the gold standard anymore • DEXA has replaced plain radiographs • Osteopenia vs. osteoporosis more clearly identified • Measures the Bone Mineral Density • Measures the amount of calcium in the bone

Non-modifiable risk factors

• Previous fracture • History of fragility fracture in a 1st degree relative • Poor health/frailty • Advanced age • Female sex • White/Asian race • Secondary causes

Protein and bone health

• Protein important for bone health • Seniors - tea and toast diet - not enough protein in diet is a common problem (teeth, constipation, economic) • Decreased protein - results in low femoral bone density • Increased clinical outcomes with hip fractures with liquid nutritional supplements • Protein gives bone its strength and flexibility • Protein also important component of muscles • Muscles critical for pull on bone to stimulate bone activity, mobility, stability and preventing falls

Quality of bone

• Quality of bone is also important. • May have quantity - but not quality • Especially important for assessing fracture risk • Also important consideration for surgical outcomes • Now using a combination of BMD and fracture risk to assess and treat patients • Modified and adapted the risk measurement guidelines due to new information/data - ongoing process!

Minor risk factors

• Rheumatoid arthritis • Past history of clinical hyperthyroidism • Chronic anticonvulsant therapy (epilepsy) • Low dietary calcium intake • Smoker • Excessive alcohol intake (>2 cups/day) • Excessive caffeine intake (> 4 cups/day) • Weight <57 kg (125 lbs) • Weight loss >10% of weight at age 25 • Chronic heparin therapy

Genetics

• Risk increases with family history of fractures and osteoporosis - genetic disease • 1st degree relative with a fracture increases your risk two fold. • Specific genes for strength of bones as well as risk of falling • No genotyping available • Interaction of many genes plus environment

Decreasing return + reversibility

• See changes initially • Plateaus • Minimum of 4 months for changes • 10-12 months best • Hip > 12 months • Any gains lost very quickly • Requires lifestyle change • Adulthood bone gain lost without continued exercise

Smoking

• Smoking one pack of cigarettes per day throughout adult life can itself lead to loss of 5%-10% of bone mass. • Smoking cigarettes decreases estrogen levels (anti-estrogenetic) and can lead to bone loss in women before menopause. • Smoking cigarettes can also lead to earlier menopause. • Cessation can reverse changes. • Blood indicators apparent six weeks after a person stops • Takes 3-5 years to go back to non smokers risk level1 • Smokers have a higher risk of fracture -- a 55% higher risk of hip fracture than non-smokers, as well as lower bone mineral density, says a 2004 analysis of 10 international studies. • Nicotine has a direct toxic effect on bone cells.

Calcium supplementation

• Supplements are advisable for individuals who are not getting enough calcium from food sources and are unable to make changes in their diet. • Many types of calcium supplements on the market, with the most popular being calcium carbonate. • Look for a product where the label states the amount of elemental calcium per tablet, eg., 1000 mg of calcium carbonate contains 400 mg of elemental calcium. 1. Take calcium carbonate with food or immediately after eating. It is absorbed more effectively when there is food in the stomach. Calcium citrate, calcium lactate and calcium gluconate are well absorbed at any time. 2. Take calcium with plenty of water. 3. Take no more than 500 mg of elemental calcium at one time. 4. Take calcium at different times of day. Calcium in the evening may help with night time loss. 5. Calcium should not be taken at the same time as other medications due to absorption. 6. Antacids are an acceptable source of calcium. The calcium in these products is calcium carbonate and should be taken at mealtime to facilitate absorption.

Fast Facts from the 2009 Canadian Community Health Survey—Osteoporosis Rapid Response

• The Public Health Agency of Canada funded a questionnaire on osteoporosis for two months of the 2009 Statistics Canada Canadian Community Health Survey to provide information on the prevalence, assessment, prevention and management of osteoporosis. • A nationally-representative sample of 5,849 people 40 years of age or older living in the community participated in the survey. • The number of survey respondents was weighted to ensure that estimates would be representative of the total Canadian population 40 years of age or older. • The average age of respondents was 61 years, with a range of 40 to 100 years.

what is a T-score and z-score

• The World Health Organization has based definitions on the T- score, which is the number of standard deviations from the mean (average) value of a 25-year-old woman. • Normal bone: T-score better than -1 • Osteopenia: T-score between -1 to -2.5 • Osteoporosis: T-score less than -2.5 • The Z-score is the number of standard deviations below age matched average.

Milk allergy + decreased growth

• The children with cow's milk allergy were more likely to be: • lower weight • lower height • lower body mass index (a ratio of weight to height) • than those without milk allergy, • Keet said parents and doctors of children with cow's milk allergy should be attentive to the children's nutritional status, and make particular care to ensure adequate calcium and vitamin D intake. • Keet said that milk substitutes can vary widely in terms of protein, from rice milk and almond milks, which typically have very little protein, to things like soy milk, which has nearly as much protein as cow's milk

Canadians reported fracture

• The majority of these fractures occurred as a result of low trauma i.e., falls from standing height or lower (58%). • Fractures of the wrist were most common (63%), followed by fractures of the upper arm (19%) and spine (16%). • Among individuals who have had a fracture, nearly one in ten (9%) reported having had a fracture at more than one of these sites. • Wrist fractures tended to occur at a younger age then spine and hip fractures (average age of occurrence was 52 versus 56 and 63 years, respectively).

How is quality of life affected with osteoporosis?

• The reduced quality of life for those with osteoporosis is enormous. • Osteoporosis can result in: 1. disfigurement 2. lowered self-esteem 3. reduction or loss of mobility 4. decreased independence

How well Canadians are maintaining healthy bones

• The use of age-appropriate calcium and vitamin D supplementation and impact type exercise, such as walking and jogging, are recommended for the prevention of osteoporosis. • In addition, once diagnosed with osteoporosis, medication is recommended for its management. • Among Canadians 40 years of age or older: - Taking calcium (40%) - Taking vitamin D (42%) - Taking both calcium and vitamin D (32%) - Less than half (43%) reported regular physical activity - Among Canadians 40 years of age or older who had been diagnosed with osteoporosis, 59% reported having been prescribed medication for osteoporosis

What does osteoporosis do?

• This leads to increased bone fragility and risk of fracture, particularly of the 1) hip 2) spine 3) wrist • Osteoporosis is often known as "the silent thief" because bone loss occurs without symptoms. • Osteoporosis can be regarded as a paediatric disease with geriatric consequences. • Since peak bone mass is reached in adolescence, it is important for children and youth to build bone mass. • Issue - past and present generations did not build sufficient bone mass. • Future generations? TBD

Vitamin D: optimal levels

• To most consistently improve clinical outcomes such as fracture risk, an optimal serum level of 25- hydroxy vitamin D is probably > 75 nmol/L - For most Canadians, supplementation is needed to achieve this level

what should Lactose intolerant do

• Try lactose-free or lactose-reduced milk and other dairy products; a glass of lactose-free milk provides the same nutrients as regular milk. • Enjoy hard cheeses such as Swiss, Edam, Gouda and Cheddar, which contain very little lactose. There are some lower fat cheese alternatives. • Choose yogurt. The bacteria in some yogurts may help break down the lactose it contains. • Try Kefir (a fermented milk drink). It may be better tolerated. • Use lactase drops/tablets (available at a pharmacy) in milk to reduce the lactose content.

Effects of Non dairy replacements and Vit D in kids

• Young children who drank non-dairy replacement milks instead of cow's milk were more like to have low levels of vitamin D in their blood, a new study found. • Parents often choose non-dairy beverages, such as almond, soy, or rice milk, for kids who have milk allergies or lactose intolerance. • Some parents believe these beverages have health benefits even for kids who can drink regular milk. • In the U.S. and Canada, cow's milk must be fortified with vitamin D, but there is no such requirement for non-dairy alternatives.

Symptoms of osteoporosis

• Pain • Reduced height • Marked curvature of the spine (kyphosis)

Physical activity guidelines

- Check with your physician before starting an osteoporosis exercise program. - Don't do exercises that cause pain. - Stretch before and after exercise. - Choose a facility, leader or trainer who knows the exercise restrictions associated with osteoporosis. - Choose an activity or program that is enjoyable.

Calcium recommendations

• 1300 mg/day Adolescents up to the age of 18 • 1000 mg/day Between the ages of 19 and 50 for all adults • 1000 mg/day Males between the ages of 51 -70 • 1200 mg/day Females between the ages of 51 -70 •1200 mg/day All adults 71 years and older

Why osteoporosis is less common in men

1. Men have greater peak bone mass 2. Men do not experience the accelerated bone loss women do at menopause 3. Do not live as long 4. Less likely to fall than elderly women