Current nonpharmacologic recommendations for osteoporosis treatment provide little information on its possible adverse effects and may require revision, according to a review article published in Osteoporosis and Sarcopenia.

Systematic Review: An Overview

Reviewers searched for literature published between 2012 and 2019 and selected 6 guidelines as the basis for their recommendations.

The selected guidelines were published by the American Association of Clinical Endocrinologists/American College of Endocrinology, the Malaysian Osteoporosis Society, the National Center for Health Technology Excellence in Mexico, the Royal Australian College of General Practitioners, the Spanish Society of Bone Research and Mineral Metabolism, and the United Kingdom National Osteoporosis Guideline Group. Overall, the 6 guidelines were responsible for 69 nonpharmacologic recommendations: 13, 16, 15, 14, 7, and 7 each, respectively.

Despite the high methodologic quality, many of the recommendations were based on observational studies or low-quality clinical trials.

Synthesized Guideline Recommendations and Updated Findings

Reviewers evaluated the most common clinical practice guidelines identified through the systematic review, the findings of which include:

Recommendation 1: Adequate protein intake is important to preserve musculoskeletal function in both postmenopausal women and men aged >50 years.

Recommendation 2: Among patients with hip fracture, the use of protein supplements minimizes bone loss, decreases infection risk, decreases length of hospital stay, and increases functional recovery. According to the National Center for Health Technology Excellence guideline, the recommended protein intake is 1.2 g/kg/d.

The prevalence of malnutrition ranges from 14% to 40% in elderly patients, according to data published in the Journal of the American Geriatrics Society.2 In both adults who are institutionalized and within the general population, protein intake and supplementation decreases bone mineral loss and increases muscle strength. The extracted recommended protein intake is 0.8 g/kg/d. Other evidence suggests that the recommended daily protein intake for an elderly population is 1 to 1.2 g/kg/d and is most effective when supplemented with exercise.3

Recommendation 3: Lifestyle modifications are recommended to help patients achieve adequate calcium and sufficient vitamin D intake.

Recommendation 4: Target blood levels of vitamin D are between 30 to 50 ng/mL. Among patients who require supplementation (those with low blood levels or those at risk for low blood levels), the minimum recommended dose is 400 IU. In patients with a greater risk for vitamin D deficiency, for eg, the elderly or the chronically ill, doses between 800 and 2000 IU are recommended.

Recommendation 5: Recommended daily calcium intake is 1000 to 2000 mg; it is preferred that this is received by patients through nutritional intake. If a patient’s diet does not contain enough calcium, supplementation is required and should not exceed 1200 mg/d. It is not recommended that doses exceed 500 to 600 mg/dose.

Recommendation 6: Calcium supplementation is not recommended in older, noninstitutionalized adults.

According to the reviewers, excessive calcium intake may lead to hypercalcemia, and those who take calcium supplements may be at a higher risk for kidney stone formation.1 When prescribing calcium supplementation, possible drug-drug interactions with protein pump inhibitors must be considered; for eg, omeprazole significantly decreases the absorption of calcium carbonate.4

According to the United States Preventive Services Task Force, there is currently not enough evidence to evaluate the balance between the risks and benefits of vitamin D and calcium supplementation to prevent fragility fracture in this patient population.5 Current evidence is also insufficient to assess the benefits and risks of daily supplementation greater than 400 IU of vitamin D and greater than 1000 mg of calcium, although supplementation lower than these doses are not recommended for the primary prevention of fragility fractures in postmenopausal women.5

“Our position is that the intake of calcium and levels of vitamin D and calcium should be assessed to determine the need of supplementation,” the reviewers wrote.1

Recommendation 7: Vitamin K, magnesium, copper, zinc, phosphorus, iron, or essential fat acid supplementation is not recommended to prevent or treat osteoporosis.

Recommendation 8: Caffeine intake reduction is recommended. Patients should not consume more than 4 cups of coffee/d.

Although evidence had shown an association between caffeine consumption, fragility fracture, and osteoporosis, there is controversy in the literature.1,6 Some studies, for eg, suggest that the effect of coffee on bone health can be mediated by different mechanisms. Heavy coffee intake has been associated with the increased urinary excretion of calcium,7-9 but recent evidence suggests that coffee consumption can reduce the risk for several diseases, including type 2 diabetes, Parkinson and Alzheimer disease, cardiovascular disease, and cancer.10 In addition, coffee may “exert beneficial effects” on bone health due to its high polyphenols composition, an effect that may be particularly prominent in men.11,12

Recommendation 9: Smoking cessation is recommended.

While there is evidence indicating that tobacco smoking increases risk for fragility fracture, there is a lack of evidence evaluating whether smoking cessation will then reduce fracture risk.1,13 It is difficult to analyze the effect of cigarette smoking resulting from indirect effects, including socioeconomic, physical, and nutritional factors, involved.

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Recommendation 10: Patients should not consume more than 2 units of alcohol/d.

Controversial evidence exists regarding the mechanism by which alcohol consumption affects the bone. Recent research has found that light alcohol consumption is linked to a higher concentration of bone mineral density compared to nondrinkers and heavy drinkers;1,14 however, reviewers indicated that these results should be interpreted with caution.

Recommendation 11: Among patients aged >75 years, a validated, multifactorial assessment of fall risk, evaluating the history of falls and fragility fracture risk, is recommended.

Recommendation 12: Exercise incorporating weight, balance, and resistance is encouraged to reduce the risk for fragility fracture and prevent falls. These exercises will improve mobility, strength, and physical performance. Special attention should be paid to patients at high risk for fragility fracture.

“Evidence for exercise as osteogenic therapy is not sufficient,” the reviewers wrote. They added that many conditions should be considered when prescribing exercise for osteoporosis. There is extremely limited clinical practice guidelines related to the prescription of exercise, especially in terms of type, intensity, duration, and frequency.1

While most guidelines recommend that physicians analyze patients to determine their fall risk, the performance of these analyses are not detailed. There is limited evidence surrounding the benefits of physical therapy following vertebral and nonhip fragility fracture.1

Recommendation 13: For patients who are institutionalized with a high fall risk, the use of hip protectors is recommended.

Limited evidence exists supporting the recommendation for hip protectors in patients other than those who are institutionalized. Poor acceptance and adherence to hip protectors is a barrier.1

Recommendation 14: Both postmenopausal women and men aged >50 years with an osteoporosis risk or diagnosis should be provided with access to education and psychosocial support. Patients should be encouraged to seek support from appropriate sources based on individual needs.

The education should focus on disease awareness, prevention of fragility fracture, pain management, rehabilitation techniques, fall prevention, and the importance of compliance with recommended therapies.1 Currently, there is little information regarding how modifications should be assessed and achieved to ensure adequate adherence to therapy.1

Looking Ahead

Current clinical practice guidelines focus on integrating various interventions to modify lifestyle, incorporate exercise, limit caffeine and alcohol consumption, and prevent and appropriately treat fall risk factors. However, there is limited available information regarding the possible adverse effects of this information.1

Reviewers determined that “current recommendations on [nonpharmacologic] treatment options require revision.”1

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1.  Coronado-Zarco R, Olascoaga-Gómez de Leon A, García-Lara A, Quinzaños-Fresnedo J, Nava-Bringas TI, Macías-Hernández SI. Non-pharmacological interventions for osteoporosis treatment: Systematic review of clinical practice guidelines [published online October 4, 2019]. Osteoporosis Sarcopenia. doi:10.1016/j.afos.2019.09.005

2.  Kaiser MJ, Bauer JM, Rämsch C, et al; for the Mini Nutritional Assessment International Group. Frequency of malnutrition in older adults: A multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. 2010;58(9):1734-1738.

3.  Mithal A, Bonjour JP, Boonen, S, et al; for the IOF CSA Nutrition Working Group. Impact of nutrition on muscle mass, strength, and performance in older adults. Osteoporosis Int. 2013;24(5):1555-1566.

4.  Tahir R, Patel PN. Role of proton pump inhibitors in calcium absorption, bone resorption, and risk of hip fracture. J Pharm Technology. 2007;23(5):275-280.

5.  US Preventive Services Task Force, Grossman DC, Curry SJ, et al. Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(15):1592-1599.

6.  Hallström H, Byberg L, Glynn A, Lemming EW, Wolk A, Michaëlsson K. Long-term coffee consumption in relation to fracture risk and bone mineral density in women. Am J Epidemiol. 2013;178(6):898-909.

7.  Hasling C, Søndergaard K, Charles P, Mosekilde L. Calcium metabolism in postmenopausal osteoporotic women is determined by dietary calcium and coffee intake. J Nutr. 1992;122(5):1119-1126.

8.  Harris SS, Dawson-Hughes B. Caffeine and bone loss in healthy postmenopausal women. Am J Nutr. 1994;60(4):573-578.

9.  Barrett-Connor E, Chang JC, Edelstein SL. Coffee-associated osteoporosis offset by daily milk consumption. The Rancho Bernardo Study. JAMA. 1994;27(14):280-283.

10.  Yang P, Zhang XZ, Zhang K, Tang Z. Association between frequency of coffee consumption and osteoporosis in Chinese postmenopausal women. Int J Clin Exp Med. 2015;8(9):15958-15966.

11.  Choi MK, Kim MH. The association between coffee consumption and bone status in young adult males according to calcium intake level. Clin Nutr Res. 2016;5(3):180-189.

12.  Hallström H, Wolk A, Glynn A, Michaëlsson K, Byberg L. Coffee consumption and risk of fracture in the Cohort of Swedish Men (COSM). PLoS One. 2014;9(5):e97770.

13.  GIampietro PF, McCarty C, Mukesh B, et al. The role of cigarette smoking and statins in the development of postmenopausal osteoporosis: A pilot study utilizing the Marshfield Clinic Personalized Medicine cohort. Osteoporosis Int. 2010;21(3):467-477.

14.  Jang HD, Hong JY, Han K, et al. Relationship between bone mineral density and alcohol intake: A nationwide health survey analysis of postmenopausal women. PLoS One. 2017;21(6):e0180132. 

This article originally appeared on Rheumatology Advisor