1. PODCAST TRANSCRIPT:
GENERAL STRATEGIES FOR MAINTAINING GOOD BONE HEALTH
Suzanne Jan de Beur, MD
In my practice the use of dietary and exercise interventions are critical. These help both in the
maintenance of skeletal health and the prevention of bone loss. I found that working closely with
physical therapists for the weight-bearing exercise component and the balance training and dieticians
and other allied health professionals for the dietary advice and how to get enough calcium and vitamin D
have been very, very helpful for my patients. When it comes to dietary calcium, one of the pitfalls I find
that many physicians fall into are just adding a blanket amount of calcium, 1200 mg of calcium a day. But
what I often find is there is not a dietary history taken, so really we do want between 1000 and 1200 mg
of calcium a day, but we want that to be combined in diet and in supplement. So it is important to take a
dietary history: how much milk, yogurt, cheese, other dairy foods is your patient consuming? Once you
tally that up (a serving of dairy-rich food is about 300 mg), you subtract it from 1000 to 1200 mg and that
is the amount of the supplement. I find that many patients when they come to my practice are over
supplemented because the dietary component has not been taken into account. I also find that patients
can do a lot of calcium supplementation in the diet if you just find out what they like and encourage them
to eat more of those foods. Studies have shown that if you get dietary calcium, they are much less likely
to suffer from kidney stone than if you take supplemental calcium. So the bottom line here is, make sure
you are getting 1200 mg of calcium in a combination of diet and supplements, and try to minimize the
use of supplements when you can.
Vitamin D is also a really important component. Unlike calcium it is very hard to get vitamin D in your
diet because most of it is going to be derived from things like fatty fish, egg yolks, and then a small
amount in vitamin D-fortified milk and cereal. So, for example, to get your entirely recommended daily
allowance 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 to
calcium, we end up resorting to supplementation. This requires about 800 to 1000 international units a
day for adults age 50 and older. What I am shooting for is a 25-hydroxyvitamin D serum level of greater
than 30 ng/mL. So sometimes that may take a little bit more vitamin D than 1000 a day, sometimes it
takes up to 2000 a day, but there are good fracture studies demonstrating that levels of 30 ng/dL and
greater can reduce fracture. Again, you are usually going to have to do this through supplements
because 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 in
helping individualize and tailor the program to the patient because you have people along a great
spectrum. There are some people that are older and do no have good balance and that is really
important 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.

2. So you have a whole spectrum between someone who can go out and jog daily to someone who it is a
challenge for them to get up out of a chair in a steady fashion. So, you really need a physical therapist to
help 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 bone
and improve bone formation.
Individualization is the key here. There are a number of different exercise programs to choose from and
as I mentioned there is a broad spectrum of patients that you are going to encounter. In a study from the
Netherlands, they did a controlled trial where they developed a program with 11 sessions developed by
physical therapists and occupational therapists as well as rheumatologists, including elements of
education, an obstacle course, walking, exercises and weight-bearing exercises as well as gait training and
training in fall techniques, and they found a 39% lower fall rate in the intervention group and balance
confidence increased by 13.9%. There is a program at Oregon State University where they are focusing
on balance and strength exercises using weighted vests, and there the goal was to gradually improve
balance and strength to avoid falls and maintain independence. They showed improvement in bone
mineral density measures in the clinical study, but not in the community setting. There are some good
data out there, but there are number of different exercise training programs so your physical therapy
professional can help tailor it to the patient. There are some exercises, for example, that are very
strenuous on the spine and may actually increase the risk of fracture, such as doing crunches where you
are pulling on your neck or twisting motions that are common in golf or bowling. These are types of
exercises and activities that may increase the risk of fracture, so having input from a physical therapist on
the proper way to do the different programs is generally advisable and very helpful.
Adrienne Berarducci, PhD, ARNP, BC, CCD
Diet can be something that we are often afraid to even look at in patients because we think it is too time
consuming 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 with
them and then ask them what their normal food preferences are, what they like to eat a lot. So, before
they even go into the room, we have a pretty good idea of the types of foods the patients like to eat and
what they are eating, so that we can counsel them towards calcium-rich foods and foods that are
fortified with vitamin D. Vitamin D has become huge issue. My practice is in Florida and you would think
with all sun that none of our patients have vitamin D deficiency; actually it is the opposite. The majority
of our patients are very low normal or do have deficiency. What we are doing now in all our patients, we
are 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 vitamin
D-fortified foods because they do not like them, then we are suggesting and asking that they take the
supplement. And usually it is, depending on the severity, anywhere from 1000 to 2000 international units
of vitamin D3 daily. We have been very successful in getting patients to do this, but again this was
something where we can show them a number; they can actually see a number on the laboratory tests
and we do share this with the patient and many of them will make a little notebook and they have little
graphs, 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.

3. In our patients that are deficient, we check them again at least within 6 months to see how they are
doing. Again if you give patients copies of their labs, if you have them start keeping a little notebook of
their own progress, they tend to be a little bit more engaged in their care; they feel like they have
control. Even when you are asking for dietary changes, if you know what a patient’s food preferences are
they 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 rain
in the summer. So, looking at what patients actually would like to do and being realistic with your
patient; if you have a patient who has been sedentary for many, many years, chances of getting them
exercise 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 in
the community. Many senior centers actually have dance sessions for patients and lot of patients like to
dance. How long does it take to ask the patient if they like to dance? Having them do mall walks; a lot of
malls offer early morning sessions for seniors or retired people or people who are employed who want to
get out and walk and they want to be in a climate-controlled environment; and it is free. All they have to
do 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 strengthen
muscle 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 they
just get them started and finding out the types of things they would like to do and being very realistic
about how hard we can push the patient early on. We can’t set goals so high for patients that they are
going to fail because you know they cannot do it. If we ease them into these changes over a long period
of time, we tend to be much more successful. Again as I said earlier to really utilize our entire staff, start
the bone health counseling the minute the patient walks into your office. Another thing we have been
pretty successful at, and this is something that is very easy to do -- we actually have taped vignettes that
we can put up and we have a television monitor in our waiting room where you can actually put in
health-related information about osteoporosis and a number of other health issues. So patients when
they are waiting for you, are already getting information about bone health. This was also a good way to
provoke conversation about the disease. The patients see it, they see different questions raised on the
screen and they can bring those same questions back to you. Also, what we do sometimes is actually
leave some little questionnaires out in the office for patients and we may have something attached to it
or have them done on colorful paper with a bone and a broken bone and have a few questions written
down (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 they
have 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.