Number 81 June 1, 2009 13,002 Readers
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Did you know that May was National Osteoporosis Awareness and Prevention Month? In this issue of our patient newsletter, we have another guest writer, Susan Spinuzza, PA-C, who is a certified Physician's Assistant working at Grandview Medical Center in Uniontown, PA. She has kindly submitted an excellent summary of what our patients should know to protect them from this common condition. For more info, read on...

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How to Keep Your Bones Strong

Susan Spinuzza, PA-C

Editor's Note from Dr. Fusco:
I have tried to be a good patient as well as a doctor. For decades, I have had an annual checkup including the usual blood tests. Over the years, I have had stress tests, heart monitors, EKG's, chest x-rays, three colonoscopies, prostate exams, and even a few CT scans. However, I don't recall that my doctor ever checked my vitamin D level. It is just not part of the standard chemistry panel. After reading this month's article by Susan Spinuzza on Keeping Your Bone's Strong, I began to wonder what my vitamin D level might be. So, I had it checked.

Boy, was I surprised! In the 32 years I have been a doctor and seen tens of thousands of patients, I have only seen one other vitamin D level lower than mine. Laboratories vary, but the normal blood level for vitamin D is around 30. Most of the patients I have checked have levels in the range of 20 to 35. Mine was 9!

In retrospect, I shouldn't be surprised. I work indoors and seldom go out into the sun. I don't play golf, am not a big milk drinker, and not very fond of fatty fish. It's just the way I was raised. So, now I am on a calcium and vitamin D supplement every day, drinking low fat milk with dinner, and a large glass of fortified orange juice each night... Physician, Heal Thyself....


Osteoporosis is a devastating condition.

One out of every 2 women over the age of 50 will suffer an osteoporosis related fracture in her remaining lifetime. A woman's risk of fracturing a hip is equal to her combined risk of being diagnosed with breast, uterine and ovarian cancer!

Here is something that may surprise you even more-one out of every 4 men over the age of 50 will suffer an osteoporosis related fracture in his remaining lifetime!

The problem with osteoporosis is that it makes your bones frail, and you can fracture a hip, a bone in your back, or your pelvis from activities that are part of your daily routine. There are some things you can change about the way you live to minimize your risk of fracture. These important things include the following:


Calcium is a mineral that is very important in the structure of bone. It is also important for other functions in your body- like your heart beating! If you don't get enough calcium in your diet -rest assured-your heart will still beat- but your body will steal calcium from your bones to keep your blood level constant. To prevent this "stealing" from your bones, get enough calcium in your diet, either from dairy products or from calcium pills. You can assume that a single serving of most dairy products contains about 300 mg of calcium. If you do not get enough in your daily diet, you will need to take supplements. Here are some tips about calcium pills:

Take 1200 mg of calcium every day, but be sure to divide it into 2 doses. The body can only absorb about 500-600 mg of calcium at a time. Calcium can be found at the grocery or drug store, as well as at big discount stores. Calcium comes commonly in two forms:

    1) Calcium carbonate is the most commonly available calcium, is cheaper, and must be taken with a meal.

    2) Calcium citrate is a little bit more expensive and may be taken with or without food. If you use a proton pump inhibitor for stomach acid or GERD such as Prilosec, Prevacid, Nexium or Aciphex you will need to take calcium citrate rather than calcium carbonate.

Some people experience constipation when using calcium. If this becomes a problem, try the calcium citrate rather than the carbonate, and you may have no problem at all.

When you first purchase a new type of calcium, give it the vinegar test! Put the pill in a glass with an inch of white vinegar and gently give it a stir every few minutes or so. If after 20 minutes the pill is dissolved, you are in good shape! If it is still partially in pill form, you are likely not absorbing it. Try returning it to the store and explaining the reason. You will then need to try another until you find one that works. Most major brands dissolve with this test, but if you are a discount shopper and would like to try a brand from the dollar store, that is OK, as long as it passes the test!

Selected Calcium-Rich Foods
Food Calcium (mg)
Fortified oatmeal, 1 packet 350
Sardines, canned in oil, with edible bones, 3 oz. 324
Cheddar cheese, 1½ oz. shredded 306
Milk, nonfat, 1 cup 302
Milkshake, 1 cup 300
Yogurt, plain, low-fat, 1 cup 300
Soybeans, cooked, 1 cup 261
Tofu, firm, with calcium, ½ cup 204
Orange juice, fortified with calcium, 6 oz. 200–260 (varies)
Salmon, canned, with edible bones, 3 oz. 181
Pudding, instant (chocolate, banana, etc.) made with 2% milk, ½ cup 153
Baked beans, 1 cup 142
Cottage cheese, 1% milk fat, 1 cup 138
Spaghetti, lasagna, 1 cup 125
Frozen yogurt, vanilla, soft-serve, ½ cup 103
Ready-to-eat cereal, fortified with calcium, 1 cup 100–1,000 (varies)
Cheese pizza, 1 slice 100
Fortified waffles, 2 100
Turnip greens, boiled, ½ cup 99
Broccoli, raw, 1 cup 90
Ice cream, vanilla, ½ cup 85
Soy or rice milk, fortified with calcium, 1 cup 80–500 (varies)


Vitamin D is important for making and keeping your bones strong. Without it, calcium cannot be absorbed.

Vitamin D is known as the sunshine vitamin, because the sun can convert biochemicals in your skin to what we commonly know as vitamin D. This process requires a reasonably healthy liver and kidneys, as they are involved in the process of conversion.

Vitamin D is not technically a "vitamin", but instead it is a "pro-hormone". It was discovered at the turn of the century when scientists wondered why some children developed rickets while other children living in the same conditions and with similar diets did not. Scientists found that what kept the healthy kids' bones strong lie in the secret of cod liver oil! When examined in a laboratory the pro-hormone was isolated and named vitamin D. The recommended daily allowance of vitamin D has been 400 IU daily for many years, as this is the lowest amount that kept keep kids from getting soft bones and bone deformities(rickets), and it is enough to keep most adults from getting osteomalacia or vitamin D deficiency.

Now we know that vitamin D can be taken safely at amounts of 800 to 1000 IU daily. The kind of vitamin D that is best for you is vitamin D3 or cholocalciferol. It is easier for your body to use than vitamin D2 or ergocalciferol. Any vitamins that you will find over the counter will be vitamin D3- the better of the two. It is inexpensive to buy, and can be found in strengths of 400 IU, 800 IU, 1000 IU and 2000 IU.

It is a good idea to have your vitamin D level checked with a simple blood test. Ask your family doctor to test your level the next time you have blood testing done if you are indoors a lot or if you have kidney or liver disease or if you have problems with chronic diarrhea or depression. Also people who have had stomach bypass surgery, or who have lost sections of small bowel or colon should be checked. Anyone with osteopenia, osteoporosis or a family history of either should have their levels checked.

If you get out in the sun in the Pittsburgh area between the months of May and September you can get enough vitamin D by exposing your face, upper chest and arms to the sun for 15 minutes three times weekly. This should be done without sunscreen because sunscreen blocks the absorption of vitamin D. If you choose to remain in the sun for a longer period, a sunscreen should then be applied to prevent sunburn. Between the months of October and April, vitamin D is not available from the sun in southwestern Pennsylvania because of the way the rays are slanted.


The old adage - if you don't use it you will lose it - is especially true for bone strength. Exercise strengthens our bones by producing tiny micro fractures that the body heals quickly by laying more calcium on the bone. This in turn keeps our bones strong.

If you are healthy and able, it is recommended that you get 40 minutes of weight bearing exercise 6 days a week. If you have not been in a habit of exercising, start slowly. Five minutes at a time is a good starting point. If you have heart disease, first talk with your family doctor. The exercise does not need to be strenuous; the important thing is to do the exercise regularly. A lot of people enjoy walking. In bad weather you can walk at a mall or large discount store. Weight bearing exercise is exercise where you bear the weight of your body on your skeleton by standing, walking, running, dancing, weightlifting, elliptical machines, yoga, and many more. Basically all types of exercise EXCEPT swimming and riding an exercise bike are good for your bones. When you swim, the water supports your body weight. When you ride an exercise bike the frame of the bike holds your body weight. Those exercises are still good for you, but they don't help to strengthen your bones.

If you have arthritis or if you have had a stroke or if you are frail and cannot exercise, you can still help your bones by starting a routine of standing at the kitchen counter for small periods of time and building up to several 10 minute standing sessions per day. Try reading the mail or newspaper at the counter. Start with just one section and before you know it you will be reading the whole paper while doing your weight bearing exercise. If you use a walker, keep it right in front of you in case you lose your balance. If you tend to get dizzy, please have a friend with you and take all precautions not to fall.


Here are some things that a physician, physician assistant or nurse practitioner may consider when evaluating you for osteoporosis:


    1. Being a postmenopausal Caucasian female
    2. History of fracture after age 50 caused by low impact
    3. Family history of hip fracture, osteoporosis or "dowagers hump"(kyphosis)
    4. Smoking or being exposed regularly to second hand smoke
    5. Using certain medications that may interfere with calcium absorption such as steroids, chemotherapy, seizure medications
    6. Lifetime average weight of less than 127#


    1. Drinking more than 3 alcoholic drinks daily
    2. Drinking more than 4 caffeinated beverages per day
    3. Excessive salt intake
    4. Sedentary lifestyle
    5. Diabetes
    6. Frequent falls
    7. Early menopause
    8. History of gastric bypass surgery
    9. Scoliosis
    10. History of eating disorder
    11. Dairy aversion
    12. Impaired vision
    13. Impaired balance
    14. Chronic lung disease
    15. Chronic kidney disease


Women over age 65 and men over age 70 should have a DEXA scan. Any man or woman with one or more of the above risk factors should be tested with a DEXA scan after age 50. This is a test that measures bone mineral density (or the strength of the bone). This test will give you a score that health care practitioners use to decide whether or not you need to take medication for your bones.

Bone density can also be tested by QCT on a CT scan machine. This is a very accurate test, but all treatment recommendations are based on studies using data from DEXA scans, so DEXA scans remain the preferred method of testing.

If you have had a hip fracture that was not caused by a high impact such as a car accident you have osteoporosis. In this case a diagnosis can be made whether or not you have been tested. You will need to take some medicine to help strengthen your bones.


Our bones are like a retirement account. What you have deposited in your bone account is what you have to take out. Some factors like family history, frame size, and diseases cannot be changed. Other factors like smoking, exercise, calcium and vitamin D intake can be changed, and can make a big difference in making your "retirement account" last.

Susan Spinuzza, PA-C
724.437.8200 X 129


Sara Parr, RD Sara Parr, RD Thank You, Dr. Stanley!

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