PODCAST TRANSCRIPT: GENERAL STRATEGIES FOR MAINTAINING GOOD BONE HEALTHSuzanne Jan de Beur, MDIn my practice the use of dietary and exercise interventions are critical. These help both in themaintenance of skeletal health and the prevention of bone loss. I found that working closely withphysical therapists for the weight-bearing exercise component and the balance training and dieticiansand other allied health professionals for the dietary advice and how to get enough calcium and vitamin Dhave been very, very helpful for my patients. When it comes to dietary calcium, one of the pitfalls I findthat many physicians fall into are just adding a blanket amount of calcium, 1200 mg of calcium a day. Butwhat I often find is there is not a dietary history taken, so really we do want between 1000 and 1200 mgof calcium a day, but we want that to be combined in diet and in supplement. So it is important to take adietary history: how much milk, yogurt, cheese, other dairy foods is your patient consuming? Once youtally that up (a serving of dairy-rich food is about 300 mg), you subtract it from 1000 to 1200 mg and thatis the amount of the supplement. I find that many patients when they come to my practice are oversupplemented because the dietary component has not been taken into account. I also find that patientscan do a lot of calcium supplementation in the diet if you just find out what they like and encourage themto eat more of those foods. Studies have shown that if you get dietary calcium, they are much less likelyto suffer from kidney stone than if you take supplemental calcium. So the bottom line here is, make sureyou are getting 1200 mg of calcium in a combination of diet and supplements, and try to minimize theuse of supplements when you can.Vitamin D is also a really important component. Unlike calcium it is very hard to get vitamin D in yourdiet because most of it is going to be derived from things like fatty fish, egg yolks, and then a smallamount in vitamin D-fortified milk and cereal. So, for example, to get your entirely recommended dailyallowance of vitamin D if you are a person with osteoporosis, you would have to drink 8 glasses of milk,which in many times is not feasible for people to do. So many times with vitamin D, as opposed tocalcium, we end up resorting to supplementation. This requires about 800 to 1000 international units aday for adults age 50 and older. What I am shooting for is a 25-hydroxyvitamin D serum level of greaterthan 30 ng/mL. So sometimes that may take a little bit more vitamin D than 1000 a day, sometimes ittakes up to 2000 a day, but there are good fracture studies demonstrating that levels of 30 ng/dL andgreater can reduce fracture. Again, you are usually going to have to do this through supplementsbecause dietary sources are not plentiful.So, we talked about calcium and vitamin D and then the third type of prevention strategy is weight-bearing exercise and balance and posture training. Here I find physical therapists are very helpful inhelping individualize and tailor the program to the patient because you have people along a greatspectrum. There are some people that are older and do no have good balance and that is reallyimportant to focus on to prevent falls. There are some people that are younger that jog. Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
So you have a whole spectrum between someone who can go out and jog daily to someone who it is achallenge for them to get up out of a chair in a steady fashion. So, you really need a physical therapist tohelp you tailor these exercise programs. Exercise is not only weight-bearing exercise, things like jogging,dancing, walking, tai chi and stair climbing, but you also want to do resistance training and muscle-strengthening exercises in addition to the weight-bearing because this helps the muscle pull on the boneand improve bone formation.Individualization is the key here. There are a number of different exercise programs to choose from andas I mentioned there is a broad spectrum of patients that you are going to encounter. In a study from theNetherlands, they did a controlled trial where they developed a program with 11 sessions developed byphysical therapists and occupational therapists as well as rheumatologists, including elements ofeducation, an obstacle course, walking, exercises and weight-bearing exercises as well as gait training andtraining in fall techniques, and they found a 39% lower fall rate in the intervention group and balanceconfidence increased by 13.9%. There is a program at Oregon State University where they are focusingon balance and strength exercises using weighted vests, and there the goal was to gradually improvebalance and strength to avoid falls and maintain independence. They showed improvement in bonemineral density measures in the clinical study, but not in the community setting. There are some gooddata out there, but there are number of different exercise training programs so your physical therapyprofessional can help tailor it to the patient. There are some exercises, for example, that are verystrenuous on the spine and may actually increase the risk of fracture, such as doing crunches where youare pulling on your neck or twisting motions that are common in golf or bowling. These are types ofexercises and activities that may increase the risk of fracture, so having input from a physical therapist onthe proper way to do the different programs is generally advisable and very helpful.Adrienne Berarducci, PhD, ARNP, BC, CCDDiet can be something that we are often afraid to even look at in patients because we think it is too timeconsuming to spend our visit on, but what we have done very successfully is when the patients come in,we actually ask our MAs, the medical assistants, to have the patient do a 24-hour recall on their diet withthem and then ask them what their normal food preferences are, what they like to eat a lot. So, beforethey even go into the room, we have a pretty good idea of the types of foods the patients like to eat andwhat they are eating, so that we can counsel them towards calcium-rich foods and foods that arefortified with vitamin D. Vitamin D has become huge issue. My practice is in Florida and you would thinkwith all sun that none of our patients have vitamin D deficiency; actually it is the opposite. The majorityof our patients are very low normal or do have deficiency. What we are doing now in all our patients, weare measuring their vitamin D levels at least once annually, and even if they are in the low side of normal,we are either asking them if they do not want to change their diet and they do not want to take vitaminD-fortified foods because they do not like them, then we are suggesting and asking that they take thesupplement. And usually it is, depending on the severity, anywhere from 1000 to 2000 international unitsof vitamin D3 daily. We have been very successful in getting patients to do this, but again this wassomething where we can show them a number; they can actually see a number on the laboratory testsand we do share this with the patient and many of them will make a little notebook and they have littlegraphs, that will show how they improve. Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.
In our patients that are deficient, we check them again at least within 6 months to see how they aredoing. Again if you give patients copies of their labs, if you have them start keeping a little notebook oftheir own progress, they tend to be a little bit more engaged in their care; they feel like they havecontrol. Even when you are asking for dietary changes, if you know what a patient’s food preferences arethey feel they have control and that is very important for compliance.As far as exercise, again look at what patients like to do. Not everybody likes to walk. In Florida,sometimes it is very difficult to get up and walk because it is 95 degrees in the shade or it is pouring rainin the summer. So, looking at what patients actually would like to do and being realistic with yourpatient; if you have a patient who has been sedentary for many, many years, chances of getting themexercise for 30 to 45 minutes 4 to 5 times a week is slim to none. We have to be realistic with patients.Have them start up very gradually and find out what their preference is. Again look at things that are inthe community. Many senior centers actually have dance sessions for patients and lot of patients like todance. How long does it take to ask the patient if they like to dance? Having them do mall walks; a lot ofmalls offer early morning sessions for seniors or retired people or people who are employed who want toget out and walk and they want to be in a climate-controlled environment; and it is free. All they have todo is get there. So there are a lot of different things you can look at.The other thing is to look at other forms of exercise and what we can we do to actually strengthenmuscle on patients. Again this is another area in patients who cannot always do their own muscle-strengthening exercises, to utilize our colleagues in physical therapy and exercise physiology, even if theyjust get them started and finding out the types of things they would like to do and being very realisticabout how hard we can push the patient early on. We can’t set goals so high for patients that they aregoing to fail because you know they cannot do it. If we ease them into these changes over a long periodof time, we tend to be much more successful. Again as I said earlier to really utilize our entire staff, startthe bone health counseling the minute the patient walks into your office. Another thing we have beenpretty successful at, and this is something that is very easy to do -- we actually have taped vignettes thatwe can put up and we have a television monitor in our waiting room where you can actually put inhealth-related information about osteoporosis and a number of other health issues. So patients whenthey are waiting for you, are already getting information about bone health. This was also a good way toprovoke conversation about the disease. The patients see it, they see different questions raised on thescreen and they can bring those same questions back to you. Also, what we do sometimes is actuallyleave some little questionnaires out in the office for patients and we may have something attached to itor have them done on colorful paper with a bone and a broken bone and have a few questions writtendown (such as, do I need to ask my provider about this today?) and different things about bone health.We do this for other diseases too because it prompts the patient to ask you and again they feel like theyhave control over their health care. Presented by The Johns Hopkins University School of Medicine in collaboration with the National Osteoporosis Foundation. Developed through a strategic educational facilitation by Medikly, LLC. Supported by an educational grant from Lilly USA, LLC, and Amgen Inc.