4.1 Introduction

A number of non-pharmacological factors have been implicated in the prevention of fractures in patients with osteoporosis either independently of, or in combination with, positive effects on bone density. Many anecdotal and non-peer reviewed comments suggest that a number of diet-related factors may have a positive influence on bone density. This guideline focusses on exercise, calcium, the fluoridation of water, and non-soy derived ipriflavone as areas where a body of evidence does exist.

Everyone with osteoporosis will benefit from a good calcium intake and weight-bearing exercise.

4.2 Exercise

There is mounting evidence to suggest that physical exercise reduces the risk of falling in older people.Gait training, appropriate use of assistive devices, and exercise programmes with balance training have emerged as key components of exercise programmes for community dwelling older people.³¹ Evidence level 1+

A number of systematic reviews and meta-analyses^86,87,88 have suggested that an exercise programme combining low impact weight bearing exercise and high-intensity strength training maintains bone density in men and postmenopausal women. Evidence level 1+

High intensity strength training is recommended as part of a management strategy for osteoporosis.

Low impact weight bearing exercise is recommended as part of a management strategy for osteoporosis.

Resistance training refers to training where an overload resistance is applied. The resistance can be low, usually referred to as muscular endurance training, or moderate to high, called strength training. Strength training needs to be of a high intensity to produce gains in strength and BMD. Any form of strength training should be site specific i.e. targeting areas such as the muscle groups around the hip, the quadriceps, dorsi/plantar flexors, rhomboids, wrist extensors and back extensors.

Weight-bearing activity is carried out when standing. Low impact weight-bearing activity is characterised by always having one foot on the floor. Jumping (both feet off floor) is termed high impact training. High impact training is not suitable for patients with osteoporosis.

Weight bearing exercises should be targeted to loading bone sites predominantly affected by osteoporotic change – ie hip and spine.

To be effective all exercise programmes need to be progressive in terms of impact and intensity as fitness and strength levels improve.⁸⁹ Programmes should begin at a low level that is comfortable for the patient. An initial assessment by a suitably trained individual such as a physiotherapist will give the patient a reference point from which to start the exercise programme. Patients and healthcare professionals should refer to the guidelines produced by the Chartered Society of Physiotherapists for an indication as to the kind of exercise that could be recommended to different patient groups.⁹⁰

All healthcare professionals should encourage regular exercise, such as walking, to promote good bone and general health.

4.3 Calcium

4.3.1 Dietary derived calcium

Two systematic reviews^91,92 suggest that dietary derived calcium is as effective as pharmacologically derived sources at maintaining adequate calcium balance in postmenopausal Caucasian women. A well conducted meta-analysis⁹³ suggests that 1000 mg per day of dietary calcium leads to a 24% reduction in hip fractures. Evidence level 1++

Postmenopausal women should aim for a dietary intake of 1,000 mg calcium per day.

As a treatment for osteoporosis, this is higher than the 700mg recommended nutrient intake advised by the Committee on Medical Aspects of Food and Nutrition Policy (COMA) for maintenance of bone health.⁹⁴

Milk, including skimmed or semiskimmed, offers a very cheap source of calcium with no associated risk for the majority of the population. A calcium intake of up to 2,500 mg per day does not promote hypercalciuria or stone formation in the absence of renal dysfunction. Patients with impaired renal function should avoid excessive calcium intake (>=2,500 mg per day) and consult with their doctor. An average daily intake of 1000 mg of calcium can most easily be obtained from 600 ml (1 pint) of milk with either 50 g (2 oz) hard cheese (eg Cheddar or Edam), one pot of yoghurt, or 50 g (2 oz) sardines.

Examples of dietary sources of calcium and their calcium content are provided in Annex 4.

4.3.2 calcium and vitamin d supplementation

Calcium supplementation using tablets is one means of ensuring an adequate calcium intake in those unwilling or unable to do so by dietary means. A daily calcium intake of 1,000 mg or more taken in tablet form is likely to reduce fracture rates by a similar rate to that seen with dietary derived sources of calcium. There is no evidence that a vitamin D supplement is needed for active people under 65 years of age. However, everyone over 65 years of age should aim to take 10 mcg (400 IU) daily of vitamin D. For the majority of people this can only be achieved by vitamin D supplementation.⁹⁴ Where vitamin D deficiency has been confirmed or is likely, such as in the case of housebound individuals, a vitamin D supplement of 20 mcg (800 IU) is the recommended dose.

The role of calcium and vitamin D supplementation in conjunction with pharmacological therapy is dealt with in Section 6.8.

4.4 Water fluoridation

Studies relating the fluoridation of drinking water to fracture rates in women with a low BMD consistently show no effect in patients with low bone density or osteoporosis,^95,96 although the duration of the studies may be too short to demonstrate such an effect. There is some evidence to support a modest effect of water fluoridation on improving axial BMD.^97,98 However, a well conducted meta-analysis has concluded that water fluoridation has no net effect on fracture rates.⁹⁶ Although these studies do not support water fluoridation for the prevention of osteoporosis, neither do they suggest any detrimental effect in relation to fracture rates.

4.5 Other dietary interventions

Natural progesterone, magnesium, boron, and homeopathic remedies have all been proposed as treatments for osteoporosis. Again, no evidence was identified regarding any role they may have in the management of osteoporosis and fracture prevention.

4.5.1 Ipriflavone

Ipriflavone is a flavinoid found in large amounts in soy-rich foods. It has been suggested that it may prevent fractures in patients with osteoporosis.

There is no consistent evidence of a beneficial effect of ipriflavone on BMD or fracture rates in patients with low bone density or osteoporosis. Two RCTs report a small beneficial effect on radial and vertebral BMD at two years,^99,100 whereas a recent well conducted RCT¹⁰¹ showed no effect on BMD at three sites or on biochemical markers of bone resorption. Evidence level 1+

Ipriflavone should not be used as a sole therapy for fracture reduction in patients with osteoporosis.

The effects of soy-rich foods containing ipriflavone or other flavinoids has not been tested in a rigorous enough manner to allow further consideration. Similarly, there are no data to address the role of flavinoids as adjuncts to other pharmacological agents to treat osteoporosis.

4.5.2 caffeine

It is frequently suggested that carbonated drinks or beverages containing alcohol or caffeine are detrimental to bone health. Available evidence regarding their intake by patients with low bone density or osteoporosis is, however, inconclusive and does not support any recommendation in relation to fracture prevention.