Osteoporosis

1. Osteoporosis Jennifer Trost & Heather Mocny

2. What is Osteoporosis? What is Osteopenia? Osteoporosis means “porous bone” and is a condition in which low bone density or weak bone structure leads to an increased risk of bone fracture Osteopenia is decreased bone mass and can occur due to undermineralization

3. What is a Dual Energy X-ray absorptiometry (DXA) scan? What is a T-score? Uses a machine to measure your bone density Estimates the amount of bone in your hip, spine and other bones Results of the bone density scan will produce a T-score T-score between 1.0 and -2.5 means low bone density A person with a T-score of -2.2 has lower bone density than a person with a T-score of -1.2

4. How is vitamin D produced in the body or obtained from food? How is it activated? Two forms of vitamin D, Ergocalciferol and Cholecalciferol Both forms are converted to 25-hydroxyvitamin [1,25(OH)D] in liver. Serum level of 25(OH)D measures vitamin D level In the kidney, 25(OH)D is hydroxylated to 1,25-dihydroxyvitamin D [1,25(OH)2D] , the biologically active form of vitamin D [1,25(OH)2D] can be made by body with sufficient exposure to sunlight and without dietary sources

5. Suggested intakes for calcium and vitamin D for individual with Osteoporosis, NOF vs. RDA Calcium- National Osteoporosis Foundation (NOF) vs. RDA Vitamin D- National Osteoporosis Foundation (NOF) vs. RDA **Some people need more vitamin D. According to the Institute of Medicine (IOM), the safe upper limit of vitamin D is 4,000 IU per day for most adults. *Includes amount from food/supplements

6. Commonly available forms of calcium and recommended usage Chewable and liquid forms Start with 200-300 mg every day for a week with 6-8 oz. water, increase amount once tolerated Best absorbed when taken in amounts of 500-600 mg or less and in small amounts throughout the day All at once is better than nothing at all

7. Effects of excessive amounts of calcium Renal insufficiency Vascular and soft tissue calcification High levels of calcium in the urine and kidney stones Commonly associated with primary hyperparathyroidism and malignancy

8. Commonly available forms of vitamin D and recommended usage Many calcium supplements, multivitamins and medications also contain vitamin D 2 types of supplements- Vitamin D2 (Ergocalciferol) and Vitamin D3 (Cholecalciferol) Can be taken with or without food

9. Effects of excessive amounts of vitamin D Anorexia Weight loss Polyuria Heart arrhythmias Raise blood calcium levels which can lead to vascular and tissue calcification with damage to the heart, blood vessels and kidneys

10. Case Study- Subjective Pt. states that she is a 55 y/o secretary. She is 4 weeks s/p right wrist fracture and has been out of work because she can’t type. Pt. is having difficulty with ADL’s due to inability to use her dominant hand. Pt. has a hx. of lactose intolerance. Pt. states that she has never tried lactose-reduced milk and is unaware of alternate dietary sources of calcium. Pt. does not enjoy cooking so eats fast foods or dines out frequently. Since her wrist fracture, she has been eating mostly finger foods. Pt. avoids many dairy products due to nausea and gas. Pt. does not smoke and drinks socially.

11. Case Study- Objective Female; age 55; 4 weeks s/p right wrist fracture; Caucasian; alendronate sodium once weekly; no supplements; ht.- 64”; wt. -117#; UBW-120#; post-menopause 5 years; asthma since childhood; steroid inhaler used, oral glucocorticoids used during winter; osteoporosis diagnosed one year ago per dexa scan T-score lumbar spine, -2.7. dexa scan T-score hips, -1.5; lactose intolerant; BMI pre-wrist fracture, 20.6; BMI post wrist fracture, 20.1

12. Case Study- Assessment Analysis of one day’s diet reveals intake of 418 mg of calcium and 1 µg vitamin D. NB 1.1 Food and nutrition-related knowledge deficit RT poor diet and avoiding dairy products due to nausea and gas AEB 418 mg intake of calcium, and 1 µg intake of vitamin D per 24 hour recall and T-scores of -2.7 in lumbar spine and -1.5 in hips per Dexa scan. NB-2.4 Impaired ability to prepare foods/meals RT wrist fracture AEB eating finger foods.

13. Case Study- Plan (E-1.1) Nutrition education ofpt. on food sources rich in calcium and vitamin D, daily usage of calcium supplement with vitamin D and recommended healthful diet based on MyPlate (ND-4.3) Meal setup assistance for patient to assist with preparation, cooking and feeding

14. Case Study- Monitor Monitor: (BD 1.2.10) calcium, ionized and (BD 1.13.3) vitamin D intake through bloodwork, supplemental vitamin intake (1.6.1)(3) and mineral intake (1.6.2)(1) through patient keeping daily dosage record, types of foods/meals (FH-1.2.2.2) with keeping food diary through SuperTracker to focus on healthfuldiet with recommended sources of calcium and vitamin D, (FH-7.2.10) nutrition related ADL’s. Follow up in one month

15. Evaluation of patient’s overall dietary patternSource: SuperTracker

16. Is the patient meeting her calcium and vitamin D needs? The patient is not meeting her calcium and vitamin D needs as shown above. *This includes the total amount you get from food and supplements. **Some people need more vitamin D. According to the Institute of Medicine (IOM), the safe upper limit of vitamin D is 4,000 IU per day for most adults.

17. What risk factors does this patient have for low bone density? 55 years old Female Thin Caucasian Post-menopausal, 5 years Use of steroid inhaler and several courses of glucocorticoids during the winter

18. How can long-term glucocorticoids contribute to osteoporosis? Glucocorticoids relieve inflammation and are similar to certain hormones made by our own body. If they are taken for a long time or at high doses, the can cause bone loss which can lead to osteoporosis and fractures

19. Would this patient benefit from supplements and if so, what would you recommend? This patient would benefit from a supplement, however it is recommended that she wait at least one half hour after taking her medication Alendronate Sodium before consuming a calcium supplement or calcium containing foods. Alendronate Sodium has a low bioavailability and calcium can act as an inhibitor preventing her osteoporosis medication from absorbing correctly. Choose a calcium supplement (in chewable or liquid form) that has vitamin D which will help in the calcium’s absorption. Start with 200-300 mg and once tolerated, increase amount. Take supplement in small amounts throughout the day (500-600 mg or less).

20. Additional lifestyle changes for patient Read food labels to look for foods and beverages that provide calcium Add a single tablespoon of nonfat powdered milk to recipes. This contains About 50 mg of calcium Reduce frequency of eating out at restaurants Incorporate daily weight-bearing activities 150 minutes/week Utilize nutrition-related services available for meal setup, shopping, feeding Make sure not to consume more than 2-3 alcoholic drinks per day

21. Questions?

22. References http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/ http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ http://nof.org/ Thacher, MD, T. D., & Clarke, MD, B. L. (2011). Vitamin D insufficiency. Mayo Clinic Proceedings, 86(1), 50-6, doi:10.4065/mcp.2010.0567 http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=e6ffadda-2ace-4e99-8bb4-75631c54f39b “Current Medication Information”. Daily Med. U.S National Library of Medicine. National Institute of Health. 18 March. 2014.