Researched by Marianne I
Submitted June 2001

Testing, however, is the easy part, then comes the hard part: taking things into your own hands to stabilize, maintain, improve and, if you are really diligent, reverse your condition through a combined program of exercises, diet, and medication. If you can manage all this, you are the winner.

  Exercise

In order minimize your risk of osteoporosis it is important to have an exercise program that contains a mix of weight-bearing and impact exercises. Weight-bearing activities support the body's weight as it works against gravity. This puts stress on the bones, especially the lower back and legs. The impact exercises refers to the amount of force that is transferred to the bone while performing the activity.

• Children and young adults need high impact activities like ballet, gymnastics, soccer, volleyball, weight training and basketball.



• For mature adults vigorous low to moderate impact activities are recommended. These include walking, jogging, running, aerobics, step aerobics, hiking, weight training, rope skipping and cross-country skiing.



• If the bone mass is normal, menopausal and post-menopausal women should continue with the exercise program they have been doing.



• If the bone mass is low then it is recommended to follow a program of low to moderate impact activities like walking, dancing, cross country skiing, and supervised weight training.

Now comes the part most people are dreading, exercise. The most important of all is weight bearing aerobic exercise - brisk walking. A mile (1.6km) a day is a good start. How long that takes depends on how briskly you can walk. A fast walker can easily do that in twenty minutes.

I realize that some people do not feel comfortable walking because they associate it with problems – public safety, wearing the right clothes and shoes. But this should not keep you from exercising. Just remember a few important things:

• In Hamburg it is safe to walk anywhere even after dark.



• Be prepared for weather changes.



• Wear as many layers of clothes as necessary to feel comfortable in cold or warm weather. The layers closest to your body should be light weight and moisture absorbent (cotton or fleece). If you get too warm, peel a layer off and tie it around your waist.



• Carry a small backpack for things such as water bottle, umbrella, sun screen, hat, etc.



• Wear the right shoes - they should not squash your feet in either length or width. Heels should not be run over. If I do not watch that one, I get hip pains. Thick soled shoes keep tender soles happy. The shoes should have good support for the feet.



• When walking, put your foot down firmly, in a heel-toe rolling movement, not the short stepped, flat footed shuffle. Do not forget to swing your arms in a natural rhythm to your pace.



• Do not be afraid to walk alone. Although it may be more fun to walk with company, you can much better walk at your own speed when you are alone. Better even, you have time for yourself to relax and take in the environment. The "spiritual" essence is an important part of it.

When I was younger, I loved to walk very fast. Getting that tempo up was a real pleasure in life as I would go whizzing by everyone. During my vacation last summer I had the opportunity to walk my old course, which in the past I could do in an hour. The course included one steep hill, one not so steep but very long hill, some little ups and downs, and concluded with a lovely walk around a lake. Much to my regret, this last summer I only walked around the lake and it took me forty-five minutes. That part was really sad compared to what I used to be able to do. The joyous part was how much I appreciated what I could do. Due to health problems my abilities and achievements have been greatly reduced, but I appreciate and enjoy so much more what I am able to achieve. What I have learned and can not stress enough is: do whatever you like in the way of exercise. It is the best protection for whenever you should be faced with a serious health problems. It will help you to cope with the situation and make a more satisfactory recovery. You may not be able to achieve your old standards, but you will have a very driving desire to become as strong as you can, so you will be able to deal successfully with any future problems.

A very important aspect of walking is balance. If you are not well balanced, you will trip and stumble over things resulting in unnecessary falls. If you have fragile bones, this could mean breaks, very serious breaks, even life threatening breaks. With time, poor balance leads to insecurity in walking and being afraid of falling.

Do a simple balance test: Stand with your hands just over a firm support, such as a counter top or the back of a chair. Close your eyes shut, slowly lift one foot and stand firmly on the other leg. Count how many seconds you can remain balanced. Most woman past forty will have trouble holding this position for more than 15 seconds.

Children have good balance. In the early forties our balance is normally good and does not limit our everyday activities. Imperceptible changes start occurring in mid forties. By mid seventies real fear of falling can occur, but does not have to.

• In order to have good balance, good eyesight helps. If you wear glasses keep your lens prescriptions up to date.



• The inner ear is the balance center; if you have any problems in this area, balance is disturbed.



• Strong muscles and flexible joints result in a firm stand and better balance.



• Other conditions that can influence your balance are weight gain or loss, neurological diseases, hypotension and osteoporosis.



• Medications can effect balance, as can alcohol.



• Environmental factors can also effect balance, such as slippery surfaces, uneven pavements, appliance cords, and unseen obstacles.

When you do exercises to improve balance you will also improve coordination, posture, and flexibility. Walking and weight bearing aerobic exercises are good exercises for balance as well as training programs like Yoga, Tai Chi, and age adjusted exercises such as strength training for muscles.

After my last serious bout of health problems, I had the opportunity to take Tai Chi. Tai Chi is a slow form of the Chinese martial arts. I have attended classes once a week for 3 years and have mastered the basics. What I have learned is to move consciously, to be balanced when I move and how it feels to be mentally at ease when I move. Still I have a ways to go, because my balance could be better. Although I will most likely not need to put my foot down when standing on one leg, I make a very wiggly and unstable appearance. Nothing elegant as it should be.

Despite my poor appearance, I have self confidence and know I can easily support myself on one leg. This really paid off for me. At the end of our garden, we have railroad tie steps going down to a joint walkway with our neighbors behind us. Going down the middle of this walkway is a wooden fence. My husband and a neighbor were on the walkway talking. I wanted to join them. The railroad ties were damp and covered with wet moss. Half way down the steps, with one foot firmly planted on a step and the other one in the air, the "firmly planted foot" started sliding down. Naturally with the rest of me with it. There I was fully in the air, one foot up one foot down. What to do? Because of my Tai Chi training, I instinctively knew the best thing to do was not to alter my posture and balance in even the slightest way until I had securely landed on my one foot. Only after a fully secure landing did I put the other foot down. My husband and the neighbor were standing there fully shocked with their mouths hanging open. Other than being surprised by the way I descended the stairs, I did not think anything of what happened, until I saw their faces. I was fully confident in the situation because of my Tai Chi training. I am sure now, if it had not been that training, the story would not have had such an ending.

When visiting with Pandora, we naturally discussed osteoporosis and what to do. She knows I come from a family of "incredibly shrinking women". By old age they shrink about the height of one head. They do not lose their head, they just shrink that much. Pandora is in the process of improving and reversing her condition, so I consider her a good authority.

One of the things she recommended, and I feel I must pass on to you, is a book by Miriam E. Nelson, Ph.D., Strong Women Stay Young (to order from Amazon.de, see webpage AWCH_Osteo_Reference.html). This book is available in both English and German. The author recommends a program for weight training to improve muscle strength, balance, and most important of all, osteoporosis and other aches and pains such as arthritis. She initially developed this program for people in nursing homes. So it is probably ok for almost all of us. A lot of the information in this article comes from this book.

She developed a weight training program using either free weights or machines. Free weights are hand-held weights, dumbbells, and ankle cuffs with pockets so the amount of weight can be increased in one pound units. When you use free weights you can do the exercises in your own home whenever you please. To follow the weight machine program, it would be necessary to go to a gym. In a good gym you can have the trainer put together an exercise program adjusted to your condition and age. This costs more but then you are with other people.

In Germany I have not been able to find the proper ankle weights. The ones I have found only allow an increase of about half the weight recommended. I finally decided half the weight is better than none.

What I really like about this program, it does not matter at what level you start, you can advance at your own pace. Like a lot of us, I am not the most diligent one with my exercises. But I have found even doing these exercises sporadically and not as often as the book recommends, I do make progress and improve. Naturally the speed of improvement is much slower. In fact I have made more improvement with this program than with other forms of exercises. The same goes with improving my balance. My balance definitely improved with Tai Chi. However, since I started with the free weight program, I have made a noticeable improvement in a much shorter amount of time.

This weight lifting program can also help with other health problems, while it increases muscle strength and joint mobility. The book provides a weight lifting table for all age groups giving the weight range you should be able to achieve. The hard-covered edition has data only for women, the soft cover edition includes also data for men.

I have tried other muscle strengthening programs, where there is a lot of arm flapping and/or pushing with your body weight against walls. I found these programs to be limited in how far you can progress and not as challenging. Look for a program that satisfies your abilities and needs. For me this is not an exhausting program.

I accompanied Pandora to her muscle strengthening and stretching class. I had not experienced anything like that before. There was no bobbing around like a Hampelmann or arm flapping as though we were trying to take off and fly. Lots of stretching in ways I was convinced my body was not meant to. Some of those awful exercises I absolutely hate-to-do, thoroughly convinced no body, and particularly my body, was never meant to move in such a fashion. Some of those things I was not successful with as a child, so why should I be as an adult? I hate to admit this, but afterwards I felt much more agile and limber.

Everyone else in the class could do these exercises much better than I. Age-wise, I was pretty well in the middle of this group, some older some younger.

I am proud to say for the first time in my adult life, in my late fifties, I can do sloppy full extension push-ups. Not many. When the leader announced they were going to do push-ups, I thought, "great - I can do that". These people were not just doing full extension push-ups, they were holding themselves up while having a friendly conversation. They would let themselves down, without touching the floor, hold and continue chatting away like they had all the time in the world. They repeated this five or six times before finally stopping. I was flabbergasted. This is what people my age and older can do. I have never even considered anything like that. Before that experience, I was so proud that at my age, I could do very sloppy push-ups. Now I know sloppy is not enough.

Getting back to Pandora, she is walking, doing the weight strengthening exercises I mentioned, plus this exercise torture class, and Tai Chi. With the combination of all of this, plus taking medication, she is reversing her osteoporosis.

The most important thing is to do something. You are never to old to start. Strong muscles and flexible joints lead to a better quality of life. Walking is the best, but swimming and biking are also good, along with any of the other programs I have mentioned. Most important have fun with your choice of physical activities.

The main thing with diet is calcium, calcium, calcium and more calcium and vitamin D. It is necessary that babies, children, teens, and adults of all ages get enough calcium to build and maintain their bone structure. The body can not absorb the calcium we eat without adequate amounts of vitamin D. Naturally it is best to obtain all our calcium and vitamin D needs through good eating practices.

The Dietary Reference Intake issued by the Institute of Medicine at the National Academy of Sciences recommends that:

• Between the ages of 9 to 18, we need 1300 mg a day of calcium and 200 IU of vitamin D. The German Research Institute for Children recommends for teenagers up to the age of 18 three glasses of milk or 2 glasses of milk and one yogurt per day.



• From 19 to 50 years of age we need 1000 mg of calcium and 200 IU of vitamin D a day.



• The recommended calcium consumption increases to 1200 mg a day from the age of 51 to infinity. At this time, the amount of vitamin D doubles to 400 IU a day until we are 70. After 70, the vitamin D requirement increases to 600 IU a day.

The best sources of calcium are dairy products in any form, milk, sauces and soups made from milk products, cheeses, yogurt, ice cream, and milk based puddings and custards. It is possible to get half the amount of calcium you need by drinking two glasses of milk a day. Vegetables, especially broccoli and spinach, are good supplementary sources of calcium. If you do not like milk, maybe you are still getting adequate amounts of calcium from some of the alternative ways to consume dairy products. If you do not eat any dairy products, Tofu made with calcium sulfate is a very good source of calcium.

There are people, myself included, who have milk intolerances. I did very well as a child and into late teens with 3 eight ounce glasses of milk a day. Milk intolerance problems started developing then, so 3 glasses of milk were then out of my diet. I would eat some cheese and ice cream but never enough.

If intolerance is your problem, try experimenting - perhaps yogurt with live cultures which break down the lactose, or different types of cheeses. Hard cheese are usually better than soft cheeses. From personal experiences I found quark to cause problems just like milk. If the protein in milk is the culprit for the intolerance, than cooked dairy products might be the solution. Heat changes the protein.

The most common form of milk intolerance is lactose intolerance. This is the body's inability to break down the milk sugar, (lactose). Supplementing the diet with an enzyme called lactase helps.

Try eating or drinking dairy products in smaller portions. Perhaps half a cup of milk several times a day will be tolerated.

If you still feel you are not able to get adequate amount of calcium, take supplements that contain vitamin D. Since we live in the northern part of the world, it is difficult, particularly when it is dark and dreary, to get enough exposure to the sun to supply our vitamin D requirements. It is possible to lose up to 2 percent bone mass in the winter. If you are young and healthy, it is easy to gain it back in the summer.

It is very important to pick a good supplement. Calcium citrate and calcium carbonate are good supplements. Calcium citrate is easier to absorb. In Germany most of the calcium supplements are in dissolvable tablets. For me the carbonated tablets totally distress my stomach, therefore I get my calcium in tablet form from the States. It is best to take the supplements after dinner or before going to sleep. The digestive system is slower then and allows more time for the absorption of the calcium and vitamin D. If you take large doses of supplements, then it is a good idea to take part in the morning and the larger part at night.

For more information on osteoporosis and diet, there are lots of dietary books in both German and English that can provide much detailed information. I personally found in my research some of it contradictory and confusing. So I recommend on this point, if you want more information, do your own research. I have by no means covered this topic thoroughly. I have listed the sources I have used for my article on the webpage AWCH_Osteo_Reference.html.

  Medication

The last aspect of treating osteoporosis is medication.

Estrogen decreases bone resorption. This is the first choice for prevention and treatment of postmenopausal osteoporosis. If estrogen is not proving effective enough it may be necessary to add other drugs such as alendronate (Fosamax) or calcitonin (both to be discussed later). Estrogen improves high-density lipoprotein cholesterol. It appears also to decrease risks of cataracts, colon cancer, Alzheimer's, and osteoarthritis. Estrogen replacement treatment is most effective when combined with calcium.

Fear of cancer is probably the greatest deterrent to taking estrogen. The chances of getting uterine cancer is greatly reduced when the estrogen is combined with progesterone. Breast cancer risk does increase while taking estrogens. 5 years after the end of estrogen replacement therapy, the risk reverts to normal. If a women has two first-degree relatives with breast or ovarian cancer, do not take estrogen. The benefits do not outweigh the risks. The analysis of newer data has lead to a controversy, whether women with breast cancer should or could take estrogens. Naturally, the question of whether or not to take estrogen depends on the personal and family medical history and should be discussed with your doctor.

In the newer estrogen/progesterone tablets, the progesterone can be more problematic than estrogen. It may be necessary to try several different estrogen-progesterone preparations to find the one that will suit you best. Oral agents, patches, and vaginal creams work equally well. With cigarette smokers, oral estrogen is less effective than the topical formulation.

Long-term therapy is recommended because the benefits stop when treatment is discontinued. While taking estrogen, hip fractures risk decreases by 50%. It may rise again after discontinuation of therapy. When to discontinue estrogen therapy is a controversial issue, depending on whether you come from the cancer side or the osteoporosis side.

Alendronate, better known by the marketing name of Fosamax, is available in both the U.S. and Germany. This is the medication Pandora is taking to help restore her lost bone.

Alendronate is a bisphosphonate. It inhibits osteoclastic bone resorption. It binds preferentially to active sites of bone resorption and is not biologically active.

The medication has to be taken on an empty stomach, with non-carbonated water, first thing in the morning. Due to the side-effects it is absolutely necessary to remain quietly upright after taking Fosamax. Read a newspaper or book, just sit quietly and meditate. Do not start actively preparing for day, with such activities as showers, bed or breakfast making, and walking. Just sit quietly.

Because of reflux problems due to Fosamax, the medication is not apt to stay in the stomach where it belongs, but travels back up the esophagus (the tube connecting the mouth and stomach) and is very apt to cause ulcers. The other side effects are abdominal pain, diarrhea and other stomach and intestinal irritations.

5 mg of Fosamax should be taken daily for preventive purposes. For treatment 10 mg are necessary. In the U.S. there are now 35 mg tablets to be taken twice a week or 70 mg tablets to be taken once a week. Its effect may last longer after discontinuation, which does not happen with estrogens.

Calcitonin is a peptide secreted by the prafollicular cells of the thyroid gland. It inhibits bone resporption.

The calcitonin found in salmon (Lachs) is 50 to 100 times more effective than that found in human calcitonin.

In the U.S. calcitonin comes in a nasal spray form. The nasal spray increases spinal bone mass in postmenopausal women with full blown osteoporosis. It is not effective for early postmenopausal women.

Salmon calcitonin can also be injected. It reduces the pain of acute fractures.

The most frequent complaints with the nasal spray are nasal dryness and irritations. The injectable form can cause nausea.

With the nasal spray a daily dose of 200 IU is recommend accompanied by 1.5 g of calcium carbonate and 400 IU of vitamin D. The calcium supplementation is necessary to prevent secondary overactive para-thyroid (Nebenschilddrüsen).

In 1997 Raloxifene, a selective estrogen receptor modulator (SERM), was approved for osteoporosis prevention. It reduces bone resorption as estrogen does. Tamoxifen was the first SERM developed. It can help maintain bone mass and is effective in the short-term suppression of bone markers. Daily applications of raloxifene increases bone mineral density and lowers levels of low-density cholesterol.

Raloxifene is a suitable alternative to estrogen therapy. It can be taken without regard to meals. 60 mg daily is the recommended dosage along with calcium and vitamin D supplements.

Sodium Fluoride increases bone formation but too much can increase bone fragility. Various forms of sodium fluoride are available for osteoporosis in Europe. A slow-release fluoride preparation for osteoporosis is being considered in the U.S.

Risedronate (Actonel R) has been approved by the FDA for prevention and treatment of postmenopausal osteoporosis in women and glucocorticoid-induced osteoporosis in men and women. Risedronate increases bone mineral density and reduces the risk of fractures.