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Universal Recommendations for Osteoporosis

First posted July 14, 2002 Published Revision May, 2002

[Note: All material on this site is written by Dr. Nelson, unless noted otherwise. This material was not written by Dr. Nelson, but by the NOF as indicated in the document. Formatting and minor changes by Dr. Nelson.]

National Osteoporosis Foundation's Recommendations for All Patients with Osteoporosis

Some interventions to maximize and preserve bone mass have mutiple health benefits and are sufficiently cost-effective that they can be recommended to the general population. These include an adequate intake of calcium and vitamin D, regular weight-bearing exercise, avoidance of tobacco use and alcohol abuse, and treatment of other fracture risk factors such as impaired vision.


All patients should obtain an adequate intake of dietary calcium (at least 1200 mg/d, including supplements if necessary) and vitamin D (400 to 800 IU per day for individuals at risk of deficiency).

A lifelong intake of adequate calcium is necessary for the acquisition of peak bone mass and maintenance of bone health. The skeleton contains 99% of the body's calcium stores; when the exogenous supply is inadequate, calcium is extracted from the skeleton to maintain serum calcium at a constant level.

Controlled clinical trials have demonstrated that the combination of supplemental calcium and vitamin D reduces the risk of fracture of the spine, hip, and other sites. Increasing daily calcium and vitamin D intake is a cost-effective way to help reduce fracture risk. The NOF recommends that all adults receive at least 1200 mg/d of elemental calcium; the typical American diet provides less than 600 mg/d. Table 2 illustrates a simple method for estimating the calcium content of a patient's diet. Increasing dietary calcium is the first-line approach, but calcium supplements should be used when an adequate dietary intake cannot be achieved. Recommend a calcium supplement with the USP designation that supplies the appropriate amount of elemental calcium.


STEP 1: Estimate calcium intake from dairy products*

No. of
Calcium Content
per Serving,
Milk (8 oz)
X 300 =
Yogurt (8 oz)
X 400 =
Cheese (1 oz)
X 200 =

STEP 2: Dairy calcium + 250 mg for nondairy sources = total dietary calcium

* About 75% to 80% of the calcium consumed in American diets is from dairy products.

Vitamin D plays a major role in calcium absorption and bone health. Chief dietary sources of vitamin D include vitamin-D-fortified milk (400 IU per quart) and cereals (50 IU per serving), egg yolks, salt water fish, and liver. Some calcium supplements and most multivitamin tablets also contain vitamin D. An intake of 400 to 800 IU of vitamin D per day is recommended for those at risk of deficiency, such as elderly, chronically ill, housebound, or institutionalized individuals.


Everyone should have regular weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures.

Among its many health benefits, weight-bearing and muscle-strengthening exercise can improve agility, strength, and balance, thus reducing the risk of falls. In addition, exercise may yield a modest increase in bone density. The NOF strongly endorses physical activity at all ages, both for osteoporosis prevention and overall health. Weight-bearing exercise (in which bones and muscles work against gravity as the feet and legs bear the body's weight) includes walking, jogging, stair climbing, dancing, and tennis. Weight lifting improves muscle mass and bone strength. Before a patient initiates a vigorous exercise program, a physician's evaluation is appropriate.


Everyone should avoid tobacco smoking and to keep alcohol intake moderate.

The use of tobacco products is detrimental to the skeleton as well as to overall health. The NOF strongly encourages a smoking cessation program as an osteoporosis intervention for patients who smoke.

Moderate alcohol intake has no known negative effect on bone and may even be associated with higher bone density in postmenopausal women. However, alcoholism is detrimental to bone health and requires treatment when identified.

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