Osteoporosis and Exercise: How to Prevent and Treat Individuals with Osteoporosis Using Exercise and Nutrition

Osteoporosis and Exercise: How to Prevent and Treat Individuals with Osteoporosis Using Exercise and Nutrition

            In America alone, more than 44 million people have or are affected by osteoporosis. That is just about fifty-five percent of American’s who are 50 year or older. Sixty-eight percent of those 44 million are females. More accurately stated, there are about ten million people in the United States whom are already affected. This leaves another 34 million estimated to have osteopenia. Osteopenia means someone has low bone mass (McArdle, 2014). This is just statistics for America. A study in 2010, put over twenty-two million women and 5.5 million men, ages fifty to eight-four years old, in Europe being diagnosed with osteoporosis. In Latin America, it is predicted that there will be a told of 655,648 hip fractures in 2050 due to osteoporosis. The Middle East and Africa’s statistics show that anywhere starting at 28.4 percent of Middle Easter and African women have osteoporosis, and close to 53.9 percent suffer from osteopenia. In males, 21.9 percent of the population suffer from osteoporosis. These statistics are coming from areas with ample sunshine all year long. Finally, the statistics from Asia top all other areas in the world. It is predicted by 2050, over 50 percent of all hip fractures will be caused by osteoporosis and occur in Asian regions. In China, osteoporosis affects over 70 million individuals over the age of fifty and causes 687,000 hip fractures per year (Facts). With these worldwide statistics being this significant, it is no doubt that osteoporosis is close to being an epidemic (McArdle, 2014)

In general terms, osteoporosis literally means porous bone. It is the breakdown and weakening of bones that then cause the bones to break. Going into more depth of osteoporosis, this disease is when osteoclasts (cells that break down bone mass) are breaking down bone mass much faster than osteoblasts (cells that form and build up bone mass) can reproduce themselves. As osteoclasts break down the bone mass, the cells begin to create small holes, or “porous” inside the bone. This, in turn, weakens the bone and causes it to become more fragile (NIH Osteoporosis and Related Bone Diseases National Research Center [NIH], 2015). Osteoporosis can be broken down into two different categories: Primary Osteoporosis and Secondary Osteoporosis. Primary Osteoporosis is the most common type of osteoporosis because it is the natural breakdown of bone mass. Therefore, it is caused by the body’s natural physiological process of aging and in women is exacerbated by menopause. The breakdown of bone mass in women because of menopause will be explained later in the paper. Therefore, any reason that an individual’s bone mass is decreased because of natural causes is known as primary osteoporosis (Web MD, 2016).

Secondary osteoporosis has the same breakdown of bone mass, but in secondary osteoporosis, the breakdown is caused by the person already being predisposed to medical conditions such as hyperparathyroidism, hyperthyroidism, or leukemia (Web MD, 2016). Secondary osteoporosis can also be caused by certain medications, which will be explained when explaining risk factors. Unlike primary osteoporosis, secondary osteoporosis can occur at any age because of the unnatural causes.

A rarer type of osteoporosis that occurs in adolescents, ages eight to fourteen, is known as Idiopathic Juvenile Osteoporosis. There is little known evidence of why this type of osteoporosis occurs in juveniles, but it said to be the lack of bone formation or the bones have excessive bone mass loss at an earlier age. Although this is a type of osteoporosis, this paper will not go further in depth with Juvenile Osteoporosis (Web MD, 2016).

Osteoporosis occurs mainly in the elderly and in post-menopausal women, however men are not excluded from the effects of osteoporosis. In the elderly, there can be many reasons for osteoporosis. Some examples are aging, family history, lack of exercise, etc. Women typically are affected more by osteoporosis than men are because of menopause. This will be explained in more text, but the loss of estrogen in women makes women’s bones more prone to breakdown. As for men, a significant loss or drop in the male sex hormone testosterone can cause a man to be more prone to osteoporosis. Most men will develop osteoporosis from secondary reasons.

As osteoporosis is usually not diagnosed until late, there are some risk factors that can be looked at to observe if an individual is at risk for osteoporosis. There are uncontrollable risk factors that you cannot change or that are given to the individual by their parents. Then there are the risk factors that an individual can change to assist with prevention by undergoing life style changes and behavioral changes. The risk factors that are uncontrollable and inherited from an individual’s parents are those that would fall into the category of primary osteoporosis. These risk factors are gender, age, genetic body size, ethnicity, and family history (What).

As seen in some of the statistics above, women are more likely to be affected by osteoporosis. Once women go through menopause, they lose the ability to produce their sex hormone estrogen. This is a contributor to osteoporosis because of estrogen’s effect on osteoblasts and osteoclasts. Osteoblasts and osteoclasts have estrogen receptors that cause maintenance of bone mass density. Once menopause occurs, and with the absence of estrogen, these receptors are not responsive. Once the receptors become unresponsive, osteoclasts will continually reabsorb the bone’s mass. This allows the breakdown of bone mass in women more rapidly than in men (Alami). Although men do suffer from osteoporosis, the gender does not have a great impact. Most men will receive it from one or more secondary factors.

As the human body goes through a natural aging process so do the bones. During childhood and into the middle of an individual’s twenties is when the bone mass density is built up. During the ages of 25 to 30 is usually when most individuals will reach peak bone mass. Peak bone mass is when your bones reach their maximum density. Therefore, during childhood into the early twenties is the best time to build up bone mass density to prevent break down of bone mass as a human continues to age (OrthoInfo). Usually, the decrease in bone mass density begins during the ages of 40 or 50 and continues to naturally break down throughout the rest of life. Also, having multiple fractures within a lifetime, increases the risk of osteoporosis, especially for individuals who have fractures after their 50’s.

Natural genetic body size also plays a factor into developing osteoporosis. This means the smaller an individual naturally is, the higher chance the individual will be prone to osteoporosis. As said above, females are typically more susceptible to osteoporosis, but thin bodied, smaller bone women have higher chances of having osteoporosis (NIH, 2015). This means the smaller ethnicities, such as Caucasians and Asians are at a higher risk because of the naturally smaller body sizes of these populations. For the Asian populations, they tend to be smaller in body structure, which puts this ethnicity group at the highest risk (National, 2016). This being said, all ethnicities can be at risk for osteoporosis. Lastly, having all these natural risk factors, osteoporosis does run within families and it is hereditary. Therefore, it is important to find out the individual’s family history as well of their risk factors.

Along with the above natural risk factors, there are some non-natural risk factors, or the secondary factors, that can have roles in developing osteoporosis. These risk factors are factors that can be changed by life style changes or modern medical knowledge and medicine. As stated above, males tend to get osteoporosis through secondary ways. As men and women age, the loss of the sex hormones occur. Women tend to have more of these hormonal issues than men because of the primary risk factor of gender. Hormones can be treated through hormonal replacement treatments.

Another preventable measure to reduce the risk of osteoporosis is avoiding malnutrition. In greater detail avoiding having anorexia nervosa. This is a mental disease that an individual believes that they are obese or over weight, when in reality they are not; most commonly they are severely under their weight protocol. These individuals either watch what they intake to a point where they are starving themselves or intake too low of calories. This mental disorder is typically found in higher number of women. This is found to be greater in in the teenage years. This is less common in men. Only about 5 to 15 percent of the anorexia population are men (WebMd, 2016c). Anorexia is correlated with osteoporosis because of the physical and hormonal problems it causes the human body. Females who suffer from anorexia have extremely low body weight which lessens or even causes the body to stop producing estrogen. This condition is called amenorrhea. This relates to osteoporosis because osteoblasts lessen the amount of estrogen. Also, individuals with anorexia tend to produce larger amounts of cortisol which influences bone mass loss (Shier, 2010). Other hormonal issues that occur during osteoporosis are the lack of growth hormone that is produces (WebMdb, 2016b). Anorexia is just one disease or disorder that can play tribute to osteoporosis. Other diseases that can decrease bone density are, but are not limited to, breast and prostate cancers, celiac disease, Parkinson’s disease and more (National Osteoporosis).

More specifically of having a poor diet, individuals with osteoporosis typically have a poor intake of calcium and vitamin D. Calcium is one of the most abundant minerals in your body and is used in so many ways. It builds healthy bones, keeping them strong as they grow. It sends messages from the nervous system for muscle contraction, heart rhythm regulation, etc. This means calcium intakes need to be in great amounts. If not, the body will take the needed calcium from bones, which in turns weakens your bones, which increase the risk of osteoporosis. Calcium intake is primarily from the foods that you eat. Supplements are another option that you can use to get the ample amount of calcium needed if you are not getting enough from the foods you eat. It is important for all ages, not just older individuals to have a proper intake of calcium. As stated above, the best time to build and increase bone mass is under the age of thirty years old to protect against osteoporosis later in life. This is, also, the best time to have ample intake of calcium to assist in building bone mass density. Throughout life it is important to intake proper amounts of calcium, like all minerals. However, many individuals do not know how much they need. This chart from helpguide.org is about calcium and bone health and shows the proper amount for all age groups:

How much calcium do you need?
0-6 months 210 milligrams / day
7-12 months 270 milligrams / day
1-3 years 500 milligrams / day
4-8 years 800 milligrams / day
9-18 years 1,300 milligrams / day
19-50 years 1,000 milligrams / day
50+ years 1,200 milligrams / day

(Healthguide). Good sources of calcium are dairy products, vegetables, greens, and beans. Some herbs and spices, such as the most common and most used ones; basil, garlic, oregano, and parsley. Vitamin D is another thing needed to help with the prevention of osteoporosis. This can be intake of certain foods and from spending time outside in sunlight and with supplements when needed (Healthguide). With a proper diet, calcium and vitamin D can be obtained through the intake of food and is the most preferred way to get these. The body can absorb minerals and vitamins better from foods than it can from supplements. Although saying this, calcium and vitamin D can be received from supplements as well.

Some medications, if taken over long periods of time, can also cause osteoporosis or speed up the effects of bone mass loss. Some of these medications are glucocorticoids, which are steroids to treat arthritis and asthma, and certain medications that prevent seizures, endometriosis (which is when the lining of a woman’s uterus lining grows and develops outside the uterus), (Womenshealth), and cancer drugs (National). Also, overuse of thyroid hormones to focus on treating an underactive thyroid can also cause bone mas problems (National).

Lastly, a large contributor of osteoporosis, is having a poor lifestyle. Exercise is a huge necessity to help with prevention and will be talked about further in the paper. Other life style choices that can contribute to osteoporosis is smoking and alcohol consumption. With smoking, it is unclear if the effects of cigarette smoking is directly related to the loss of bone mass, or if it is the contributing factors of smoking. Smokers usually have less body mass, are less active and have poorer diets than those of nonsmokers. Also, in women who smoke, they tend to have an earlier menopause, which starts the loss of estrogen and the breakdown of bone mass much more rapidly. The best way to manage the risk of osteoporosis, even in later ages, is to quit smoking (NIH, 2016). As for alcohol, it is important to limit alcohol consumption to a moderate amount. Abuse of alcohol has shown to lead the decrease in bone density. Also, being in an impaired state with alcohol increases the risk of fracturing bones due to falling, running into objects, and poor decisions (Berg, 2009).

Other than the decreasing of bone mass and the weakening of bones, osteoporosis has other effects that causes dysfunctions and injuries. Most of these dysfunctions are falls. Falling or having high impact to surfaces can cause weakening of the bones and can cause fractures of the bones. Therefore, fractured bones are the injuries that can occur. Most common fractures dealing with osteoporosis are spine, hips and wrist fractures. As elderly individuals are at higher risk for falls, most assume that impact of the fall caused the bones to fracture. Which is a possibility, but sometimes the bone can snap and cause the individual to fall. Saying this, it is difficult to determine if the fall caused the fracture or if the fracture caused the fall (What).

As osteoporosis is commonly not diagnosed until late, there are some warning signs that may indicate if an individual has or may be developing osteoporosis. A physical sign is a decrease in good posture or posture issues. Another sign is if an individual has continuous factures occurring. There are some ways to specifically diagnose osteoporosis. The most common way is for a healthcare professional to perform a bone mineral test. This test will determine your bone health, chance of fracture of bones, and responses to treatments. The most common types of BMD tests are central dual energy X ray absorptiometry (DEXA) and newly named central DXA test. (NIH, 2015). A DEXA scan is an x ray that uses very small amounts of radiation to show pictures of bone density (Radiology). Men typically have a larger peak bone mass, which is the greatest bone size and strength of our bones, than women. This means that men’s bones are typically greater in size and strength. This being said the DXA scan is scored by a T- score. This evaluation method allows or more accuracy for men and women scores. The T-score of a healthy, normal bone density is within +1 or -1 standard deviation of the adult mean. While being in the range of -1 to -2.5 standard deviations of the average adult is not technically considered osteoporosis, this is still a warning sign for osteoporosis onset and low bone density. Within the standard deviation of -2.5 is when an individual is considered to have osteoporosis. Anything lower in standard deviation of -2.5 is referred to severe osteoporosis (NIH, 2015). Other ways that osteoporosis is diagnosed is CT scans of the spine, and the amount of alkaline phosphate (AST), that can be higher following a bone fracture (Nurse).

Osteoporosis can be treated with a balanced diet, exercise, and precautions to prevent falls, which will be explained in further detail later. A doctor can prescribe some therapeutic drugs to assist in the prevention of bone mass loss. The proper order would be to try to increase you daily intake of vitamin and minerals from diet, and supplementation, if needed. The body can absorb more of these through food, unless an absorption condition is present. Supplements should come last in treatment if the individual is still not getting an ample amount. The intake of calcium and vitamin D should be focused on for the help and prevention of osteoporosis. Next on the list of to do’s would be exercise. Bones grow stronger with exercise. Exercise does not just increase bone strength, but also helps with muscle strengthening, neuromuscular training, and conditioning. These contribute to the prevention of falls that can cause fracturing of bones. Lastly, there are some therapeutic medications that are available for prevention and treatment of osteoporosis. These include bisphosphonates which are medications to stop or slow the natural process of bone mass loss (Web MD, 2016a). Hormone therapy is another option for medical uses. This treatment is where a doctor will evaluate the hormonal levels and see what hormones are in lesser amounts and prescribe hormones to assist in the decreasing of bone mass. These hormones can be estrogen agonists or antagonists or SERMs, calcitonin, and parathyroid hormone. A newly approved therapeutic method is RANK ligand. RANKL is a member of the tumor necrosis factor (TNF). This is where an individual can get an injection of inhibiting RANKL antibodies that have shown to reduce the reabsorption of bone material (McClung, 2007). Sadly, osteoporosis is not curable and will continue to occur as individuals keep aging, so prevention methods are the only way to help treat osteoporosis.

As stated, osteoporosis is incurable and treatments for it can vary depending on your needs. Diet and exercise are two of the biggest changes that can be made to help prevent and treat. As said above, a proper diet will help with the intake of vitamin D and Calcium and exercise can help. Specifically, exercise assists in increasing bone density and benefits in secondary areas of interest, such as muscular strengthening, balance, and flexibility. Exercise is a first layer to help prevent osteoporosis. This means incorporating exercise into daily life, at younger ages, will decrease the chances of osteoporosis later in life. The earlier an individual incorporates exercises the better, even if there is a family history of osteoporosis. Even though genetics plays a large role in determining osteoporosis, a healthy diet and exercise plays a major role in considering the health of your bone (NHS, 2016). When it comes to those individuals that are already diagnosed with osteoporosis, it is not too late to prevent further damage to the bones. Exercise can be added to the individual’s daily activities, but medication may have to be added to help assist with the diet and exercise changes. Before individuals with osteoporosis start an exercise program, they should consult with their doctor and an exercise specialist or physiologist.

Lifestyle interventions to prevent and treat osteoporosis can have lasting effects, starting with encouraging education and understanding of individuals under the ages of 35. Usually the ages of 25 and 35 are when the bone mass reaches its highest average density (Nurse). After the age of 35, bones begin their process of breaking down, although this is usually a slow process in healthy individuals. In individuals with osteoporosis, the bone mass decreases much more quickly. This is why educating on a healthy diet, exercise, and proper maintaining of skeletal and muscular growth is important at younger ages. Along with diet and exercise, it is important for individuals to avoid harmful behaviors, such as smoking and abusing alcohol. These have great effects, not only to bone density, but for an individual’s health as well. These behavioral changes should be made for a better and healthier life style. Other prevention methods include to evaluate the life style that an individual has during daily living; such as jobs, leisure activity times, and avoiding fractures of bones. As aging occurs, the tendency of more high risk activities and high tendency of injury decreases. Although, this is typically bad for the activity side of health, decreasing the fractures of bone also decreases the chances of osteoporosis.

If an individual is already diagnosed with osteoporosis, it is important to give them the same educational and behavioral interventions as those who are in preventative stages. Additional information needed for the population already diagnosed is to take fall prevention interventions and neuromuscular treatments. Fall preventions include several protocols that can help prevent an individual from falling. Some interventions include, but are not limited to; walking with stability assistance, such as canes or walkers; wearing non-slip shoes; being aware and cautious of wet floor surfaces; maintaining floors to be clear of obstacles; and more. As for neuromuscular training, this will be explained further in the paper, but in basic terms keeping stability muscles strong and working on keeping an individual’s balance (NIH, 2015).

As exercise should be incorporated into everyone’s daily living, all aged adults should participate a minimum of 150 minutes of moderate intensity aerobic exercise. Aerobic exercise is considered to be activities such as walking, cycling, steps, rowing, jogging/running, etc. (Bowersock, 2015). These exercise guidelines especially apply for individuals that are at risk or already diagnosed with osteoporosis. As said previously, bones are similar to muscle and need to be stressed and worked out. If not, the bones will lose support and strength of themselves and can cause injuries or worse cause osteoporosis. This concept is called the, “Use it or Lose it” (Ex. Phys. Notes). Therefore, exercise should be stressed during the early teenage years and continued throughout life, to decrease the likelihood of osteoporosis, and other diseases and disorders.

For an individual with osteoporosis, an exercise program will have to be well rounded and have many different components. These components need to have a high focus on strength training, weight bearing aerobic activities, neuromuscular training (such as stability and balance training) and flexibility training. For an adult individual trying to preserve bone health, they should participate in weight bearing aerobic exercises three to five times a week. This should include walking, jogging, sports, and stair climbing at a moderate to high intensity. These individuals should also participate two to three days a week of strength and resistance training, such are machine weights, free weights, and even body weight (ACSM, 2016). They should participate about thirty to sixty minutes during the individual exercise sessions. For this group of individuals, high impact exercise, such as jumping, can be highly beneficial for bone strengthening. They need to be careful and monitored while performing these activities.

As for those individuals already suffering from osteoporosis, and elderly individuals, healthy individuals need to follow all of the above and focus greatly on neuromuscular and flexibility training. For the individual with osteoporosis, the American College of Sports Medicine recommends weight bearing aerobic training, strength training, and resistance training about two to three times a week. These individuals should perform about four to six exercises for weight bearing exercises and resistance exercise with one to three set or round. Within each round or set, they should perform about five to eight repetitions. With this exercises, these individuals should avoid high impact exercises, spinal flexion and extension under loads, fast trunk rotations, and compressive loads on the spine. These types of exercises can cause the spine to move out of alignment, and in turn cause stress throughout the body that occur in injury or fracturing of bones. Neuromuscular training should be done about four to five days a week to work on the body’s stability muscles and balances reaction. Flexibility should also be done close to every day, with a minimum of 4 days a week (ACSM, 2014). These training guidelines help prevent and treat individuals with osteoporosis by helping the individual continually build and maintain osteoblast production by stressing the bones, conditioning the muscles, and strengthening stability muscles. The continuing of osteoblast production is important to allow bone growth and to prevent the over presences of osteoclast turnover.

As osteoporosis will affect millions of people worldwide, there are way to help the prevent onset. Encouraging a healthy lifestyle such as proper nutrition and exercise between the ages of 16-30’s will help prevent the onset of osteoporosis. For the individual’s already past those ages, these factors are still important to do. Medication and treatments are not the answer to osteoporosis and like other diseases and disorders, proper nutrition and exercise can be the key prevention tool. 44 million people are estimated to develop osteoporosis in the next 20 years, in the United States alone. This number is an indication that healthcare provides need to start sooner and have more effective approach to osteoporosis. Providing stronger, healthier guidelines to assist in the prevention of this disease.

Osteoporosis Program Guidelines:

  • Weight bearing aerobic or non-weighted (Do not stimulate Osteoblast) exercises 3-5x/wk.
  • Strength and resistance training 2-3x/wk (Weight Bearing) :
    • 6-8 exercises per workout (depending on fitness level)
    • 1-3 sets per exercise (depending on fitness level)
    • 8-12 (Moderate) or 5-8 (High) repetitions per set (depending on fitness level)
    • Equipment: Free weights, resistance bands, machines.
  • Flexibility minimal of 4 days a week, if not every day
    • Hold all stretch for 30-60 seconds
  • Neuromuscular 4-5x/wk
    • Fall Prevention exercises (Balance and core strengthening and stability)
  • All sessions should be 30 to 60 minutes in duration depending on fitness levels and should work to increase time.
  • Exercises to avoid:
    • High impact (jumping unless cleared by doctor)
    • Bending and twisting motions (ACSM, 2014)

Example Schedule

Monday Tuesday
Strengthen/

Resistance training & Flexibility

Weight Bearing

Aerobic training & Neuromuscular

 

Wednesday Thursday
Strength / Resistance training &

Flexibility (Yoga)

 

Weight Bearing aerobic training & Neuromuscular Trainer (Tai Chi)

 

Friday Saturday
Strength/ Resistance Training &

Flexibility

Weight Bearing Aerobic &

Neuromuscular

*Example schedule is not designed for all populations or one person. Assess fitness level and ability before program design*

Example Workout:

Strength/ Resistance Training:

Warm up: 5 minute treadmill walk/jog; Joint Muscle Activations (JMA’s)

Week 1-4

Day 1 Day 3 Day 5
Leg Press 3×10 BB RDL’s 3×8 Push Press 3×6
Resistance Band Lat. Pull Down 3×12 DB BO ROW 3×8/s TRX Inverted Row 3×12
DB Floor Press 3×10 Push-ups w/ Y Reach 3×6/s DB Chest Flies 3×10
Side Plank & Reach 3×6/s Banded Pillar Pulls 3×12 DB Step Ups 3×8/s
TRX Y’s 3×12 Reverse Flies 3×10 Banded SA Pull Down 3×12
Leg Curls 3×12 Rope Tri Push Down 3×10 Conc. Curl 3×8/s

 

Cool Down:

Stretching of all muscle groups! 2×30 seconds

Foam Roll if capable

 

 

*Example workouts are not made for all populations or one person. Please assess fitness and ability before program design*

 

 

Example Workout:

Weight Bearing aerobic and Neuromuscular:

Week 1-4:

Day 2 Day 4 Day 6
Run/jog/walk & Yoga Tia chi Sports of choice/ Run/ Jog/walk

*Example workouts are not made for all populations or one person. Please assess fitness and ability before program design*

 

References

Alami, S., Hervouet, L., Poiraudeau, S., Briot, K., & Roux, C. (2016). Barriers to Effective postmenopausal osteoporosis treatment: A qualitative study of patients’ and practitioners’ Views. PLOS ONE, 11(6), e0158365. doi:10.1371/journal.pone.0158365

American College of Sports Medicine. (2016). Exercise, menopause and osteoporosis. Retrieved from http://acsm.org/public-information/articles/2016/10/07/exercise-menopause-and-osteoporosis

American College of Sports Medicine. (2014). Guidelines for Exercise Testing and Prescription. Ninth edition.

Berg, K. M., Kunins, H. V., Jackson, J. L., Nahvi, S., & Chaudhry, A. (2009). Association between alcohol consumption and both osteoporotic fracture and bone density. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2692368/

Facts and Statistics | International osteoporosis foundation. (n.d.). Retrieved from https://www.iofbonehealth.org/facts-statistics#category-22

HealthGuide.org. (n.d.). Calcium and bone health: eating to protect your bones and prevent osteoporosis. Retrieved from http://www.helpguide.org/articles/healthy-eating/calcium-and-your-bones.htm

Josse, R. G. (n.d.). Bone biology and the role of RANK/RANKL/OPG pathway. Retrieved from http://www.healthplexus.net/article/bone-biology-and-role-rankranklopg-pathway

Mayo Clinic. (n.d.). Exercising with osteoporosis: stay active the safe way. Retrieved from http://www.mayoclinic.org/diseases-conditions/osteoporosis/in-depth/osteoporosis/ART-20044989?pg=2

McArdle, W. D. Essential of Exercise Physiology. (2014). Fourth edition.

McClung, M., & PubMed.org. (2007). Role of RANKL inhibition in osteoporosis. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/17634142

National Institutes of Health. (n.d.). NIHSeniorHealth: Osteoporosis – risk factors. Retrieved from https://nihseniorhealth.gov/osteoporosis/riskfactors/01.html

National Osteoporosis Foundation. (n.d.). What is osteoporosis and what causes it? Retrieved from https://www.nof.org/patients/what-is-osteoporosis/

NHS Choices. (2016, June 20). Osteoporosis – prevention. Retrieved October 2016, from http://www.nhs.uk/Conditions/Osteoporosis/Pages/Prevention.aspx

NIH Osteoporosis and Related Bone Disease National Resource Center. (2015, June). Osteoporosis in men. Retrieved from www.niams.nih.gov/Health_Info/Bone/Osteoporosis/men.asp

NIH Osteoporosis and Related Bone Disease National Resource Center. (2015, June). Bone Mass Measurements: What the Number mean. Retrieved from www.niams.nih.gov/health_info/bone/Bone_Health/bone_mass_measure.asp

NIH Osteoporosis and Related Bone Diseases National Research Center. (2016, May). Smoking and Bone Health. Retrieved from www.niams.nih.gov/Health_Info/Bone/Osteoporosis/Conditions_Behaviors/bone_smoking.asp#b

NIH Osteoporosis and Related Bone Diseases National Resource Center. (n.d.). Osteoporosis Overview. Retrieved from www.niams.nih.gov/Health_Info/Bone/Osteoporosis/overview.asp#e

Nursing Implications for Osteoporosis. (n.d.). Retrieved from http://www.austincc.edu/cenurse/Unit3/u3m4/u3m4lesson2.htm

OrthoInfor. (2012, July). Healthy Bones at Every Age. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=A00127

Radiologyinfo.org. (n.d.). Bone Densitometry (DEXA, DXA). Retrieved from http://www.radiologyinfo.org/en/info.cfm?pg=dexa

Riggs, B. L. (1998). A Unitary Model for Involutional Osteoporosis: Estrogen Deficiency Causes Both Type I and Type II Osteoporosis in Postmenopausal Women and Contributes to Bone Loss in Aging Men. Journal of Bones and Mineral Research, 13(5). Retrieved from http://onlinelibrary.wiley.com/doi/10.1359/jbmr.1998.13.5.763/full

Shier, D., Butler, J., & Lewis, R. (2010). Hole’s human anatomy & physiology (4th ed.). Dubuque: McGraw-Hill.

Web Md Magazine. (2016). Bisphosphonates for Osteoporosis. Retrieved November 14, 2014, from http://www.webmd.com/osteoporosis/bisphosphonates-for-osteoporosis

WebMd Magazine. (2016). What People Anorexia Nervosa Need to Know About Osteoporosis. Retrieved from http://www.webmd.com/mental-health/eating-disorders/anorexia-nervosa/anorexia-and-osteoporosis

Webmd Magazine. (2016). Types of Osteoporosis- Topic Overview. Retrieved from http://www.m.webmd.com/a-to-z-guide/tc/types-of-osteoporosis-topic-overview

What is Osteoporosis? (2010). Osteoporosis: A Guide to Prevention & Treatment, 5-7.

Womenshealth.gov. (n.d.). Endometriosis | womenshealth.gov. Retrieved December 5, 2014, from https://www.womenshealth.gov/publications/our-publications/fact-sheet/endometriosis.html

 

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