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Bone Matters with Dr. Marla Shapiro

This article is the first in a series, exclusive to Health and Bone.ca. Discussing issues that are important to you, a postmenopausal woman concerned about her bone health, Dr. Marla Shapiro will draw upon her expertise and that of other expert colleagues to keep you up-to-date on the latest thinking in osteoporosis.

Osteoporosis and the Sandwich Generation

What is the “sandwich generation”?

“Sandwich generation” is the term often given to those caught between the generations. People just like me find themselves focusing on either end of the spectrum of caring. On the one hand, we are balancing the often difficult demands of raising our own children, and on the other hand, caring for aging parents or relatives. Dealing with these demands can make life interesting but also very stressful.

According to a 2002 Canadian General Social Survey, almost 30% of those between the ages of 45 and 64 with unmarried children under 25 are caring for a senior (approx. 712,000 people). That is indeed a large number.

...almost 30% of those between the ages of 45 and 64 with unmarried children under 25 are caring for a senior.

It is very likely that the number of people making up the “sandwich generation” will continue to grow at a quick pace. Projections show that, by the year 2056, the proportion of Canadians over the age of 65 will more than double to over 1 in 4 and the proportion of people 80 and over will triple to about 1 in 10, according to figures taken from the 2007 General Social Survey (GSS) on Family, Social Support and Retirement. We look at this aging demographic and some liken it to an advancing tsunami of the aged. There is no question that as a result of this, the shift in diseases we see will reflect this growth in the older population.

Osteoporosis – a family affair?

According to Osteoporosis Canada, as many as 2 million Canadians suffer from osteoporosis. Women seem to be affected by it more than men. One in four women over the age of 50 has osteoporosis while it affects only 1 in 8 men of the same age here in Canada.

Osteoporosis has certain characteristics. These include low bone mass and deterioration of bone tissue, which can make bones weaker and more fragile, thereby increasing one’s risk of experiencing a bone break or fracture.

Fractures are the most important complication of osteoporosis that I see in the office and can have a devastating impact. Osteoporotic fractures can lead to deformity that progresses over time. One such deformity is a pronounced forward curve in the upper spine or hump-back appearance (also known as kyphosis). Osteoporotic fractures can also negatively impact one’s self esteem and can make it difficult for one to get around independently. They can even make simple activities of daily life hard to do without help from others.

A 50-year-old woman has a 40% chance of developing hip, vertebral or wrist fractures during her lifetime. Simply put, that means out of 10 women, 4 will suffer some kind of broken bone. Over 80% of fractures that occur in people 60 and over are believed to be osteoporosis-related.

What is particularly troubling about osteoporosis is the fact that it often occurs without our knowing. It is sometimes referred to as the “silent thief” because the bone loss occurs without symptoms. It may not be until a fracture occurs that we even realize anything is wrong. And that is too late from my point of view. While we have treatments, which I will discuss, prevention is the primary goal.

...80% of fractures that occur in people 60 and over are believed to be osteoporosis-related.”

One of the major risk factors for osteoporosis is having a family history of osteoporotic fracture (especially if your mother has suffered a hip fracture).

As part of the “sandwich generation”, you may already be dealing with the effects of osteoporosis, first hand. You may be concerned, and rightly so, about your risk and perhaps even the risk for your daughter developing osteoporosis as she gets older. I often tell my patients that what we did while we were young can have an impact on how strong and dense our bones are later in life. In particular, the amount of dietary calcium we get when we are young influences the development of bones and their density. That is because we build our bones to their maximal strength during the growing years.

Osteoporosis is not a normal part of aging nor is it a certainty if you have a family history of osteoporotic fractures. There are things you can do to help yourself and your daughter and your son now. Furthermore, if you are caring for a parent or relative with osteoporosis, there are treatments available.

The best thing you can do is educate yourself and speak to your doctor.

Educate thyself

In the Solutions Newsletter, produced by Family Service Canada, titled “The Sandwich Generation: Caught in the Middle”, author Lisa Pridmore offers several important tips for caregivers including the following tip:

“Become an expert. Learn as much about the medical condition you are dealing with as you can. This will alleviate the stress of not knowing what to expect, and will make you better able to care for your loved one.”

In the case of osteoporosis, learning as much as you can may not only enable you to better care for your loved one but also help you care for yourself and potentially your daughter.

What you should know?
Building strong bones during childhood and adolescence can help defend against the development of osteoporosis later. Peak bone mass is achieved at an early age – age 16 in girls and age 20 in young men. Women and men begin to lose bone in their mid-30s. Women approaching menopause begin to lose bone at a greater rate – approximately 2-5% per year. Getting enough calcium and vitamin D daily is very important and beneficial. Regular physical activity, particularly participation in weight-bearing exercises, can help reduce the risk of osteoporosis. Smoking, excessive alcohol intake and excessive caffeine intake can all contribute to bone loss, so these activities should be avoided. There are several medications available for the treatment of osteoporosis.

What you should know?

Building strong bones during childhood and adolescence can help defend against the development of osteoporosis later.
Peak bone mass is achieved at an early age – age 16 in girls and age 20 in young men.
Women and men begin to lose bone in their mid-30s.
Women approaching menopause begin to lose bone at a greater rate – approximately 2-5% per year.
Getting enough calcium and vitamin D daily is very important and beneficial.
Regular physical activity, particularly participation in weight-bearing exercises, can help reduce the risk of osteoporosis.
Smoking, excessive alcohol intake and excessive caffeine intake can all contribute to bone loss, so these activities should be avoided.
There are several medications available for the treatment of osteoporosis.

Adapted from Osteoporosis Canada: Facts and statistics.

Why should you take calcium and vitamin D?

Calcium helps bones stay strong. It is also needed by almost every cell in the body to keep it working properly.

Maintaining an adequate calcium intake is an important step towards good bone health throughout life. The main goal of good calcium nutrition is to maintain an adequate supply so that our body does not have to dip into the reserve of calcium in our bones.

Calcium is important throughout childhood in helping with the development of a healthy skeleton. As mentioned, peak bone mass is achieved in women by the time they are about 16 and in men by the time they are approximately 20 years of age. The density of the bone, which will mean the strength of the bone, at this time is greatly influenced by the amount of calcium one has had before – in the growing years – during childhood and adolescence. The greater the bone mass at this point, the less likely the bones will become weak, porous and fragile later in life.

Vitamin D helps the body absorb calcium. Our bodies can produce vitamin D when we are exposed to sunlight. However, most Canadians do not get enough sun exposure to produce adequate amounts of vitamin D, nor do we get enough vitamin D through our dietary intake.

What is the best way to get the proper amount of calcium and vitamin D?

Some foods are better sources of calcium than others because their calcium can be easily absorbed by the body. Dairy products such as milk, cheese and yogurt contain high amounts of calcium that are easily absorbed by the body. Vegetables are often overlooked but can be a source of calcium too. Fish containing bones such as salmon and sardines also provide calcium as do meat alternatives such as lentils and beans.

Some foods have the potential to cause calcium loss. For example, did you know that excessive salt and caffeine consumption may have this effect?

If you have the opportunity to speak with a dietician to find out more about calcium-rich foods, it may be worthwhile, particularly if you cannot or choose not to eat dairy products.

Fortified milk contains vitamin D as do foods such as margarine, eggs, chicken livers, salmon, sardines, herring, mackerel, swordfish and fish oils (halibut and cod liver oils). It may be difficult to get enough vitamin D through diet alone. You may need to take supplements.

How much calcium and vitamin D do you require on a daily basis?

According to Osteoporosis Canada, the daily calcium and vitamin D requirements are as follows:

Age	Daily Calcium Requirement
4 to 8	800 mg
9 to 18	1300 mg
19 to 50	1000 mg
50+	1500 mg
Pregnant or lactating women 18+	1000 mg

Age	Daily Vitamin D Requirement
4 to 8	200 UI
9 to 18	200 UI
19 to 50	400 UI
50+	800 UI
Pregnant or lactating women 18+	400 UI

(IU = International Units)

How do you meet the nutritional needs of the young, the old and those in between?

You may be wondering to yourself: “How can I possibly meet the nutritional needs of all three generations in my household?” This is not always an easy task. It can also be a struggle finding ways to make sure that these healthy eating habits become a part of everyday life in a way that is accepted by both your kids and aging mother or relative in your care.

For expert advice, we turned to Nicole Shuckett, a Registered Dietician in private practice and the ALS/Stroke Clinic at Sunnybrook Hospital in Toronto. Here is her advice with two simple recipes to try.

Although their bones have stopped growing, the goal as a person ages is to prevent his or her bones from breaking. Eating foods that are rich in calcium and vitamin D is critical in ensuring good bone health.

An older adult requires at least 1250 mg of calcium a day. A great way to start the day is a cup of milk with hot or cold cereal. One cup of milk provides 300 mg of calcium. Adding a slice of cheese to a sandwich or having a canned salmon sandwich are both excellent lunchtime ideas to get another 180 mg or 300 mg of calcium, respectively. For supper, a tofu stir fry with green vegetables such as broccoli and kale can boost your calcium by another 300 mg. Because often older adults prefer to eat smaller main meals, they should be supplemented with 2-3 snacks over the course of the day. Some great calcium-rich snacks include a serving of yogurt, a fruit smoothie (see recipe below) or a handful of almonds or soy nuts. For those who do not like the taste of milk, great alternatives include a cup of calcium-fortified orange juice or a fortified soy beverage. Often as a person ages and tends to live alone, the social part of eating becomes more difficult. Meeting a friend for a steamed latte at a coffee shop is a perfect way to see a friend and have a calcium-rich beverage.

It is crucial for children to eat calcium-rich foods during their early years in order to build a bone bank so their bones stay healthy and strong for many years to come. Although most children drink the right amount of milk when they are young, as they get older many tend to move away from milk in favour of other beverages. In these situations parents need to get creative and find other ways to sneak milk and other high-calcium foods into the meals that their children eat. A great dinner activity is to take a favourite of most kids and have “build a pizza” night with pizza toppings that introduce new cheeses and green vegetables like broccoli, bok choy and kale all of which are rich in calcium. Other meal ideas include milk-based soups and sauces, melted cheese on pasta and cheese omelettes. Most kids like to snack, so sending calcium-rich snacks like string cheese, single-serving puddings, yogurt, vegetables and dip (see recipe) in a child’s lunch bag is a great opportunity to inject some additional calcium into the day.

People often ask if chocolate milk is okay for their children. I always say it is better to have chocolate milk than no milk at all but a good tip is to make it at home by taking plain milk and adding a little syrup or cocoa to it.

Fruit smoothie

1 cup of yogurt or milk

1 cup raspberries, strawberries, or blueberries or another fruit

2-3 ice cubes

Place all ingredients in blender and blend on medium speed until smooth and thick.

Vegetable Dip

1 cup plain yogurt

1 cup low-fat sour cream

1 tsp parsley

1 tsp chives

1 tsp dill

1/2 tsp garlic powder

1 tbsp lemon juice

In small bowl, mix all ingredients together until well blended; refrigerate for 30 minutes.

Exercise is good for the bones

Regular exercise is important and is a positive step for healthy bones. Walking is great exercise, providing overall health benefits, not to mention the fact that it helps promote healthy bones.

Walking is also what is called a weight-bearing exercise. Bones get stronger and denser when you “work” them. “Working” bones requires them to be stressed (in a good way!) through weight-bearing exercise. The stress exerted on your bones by the weight of your body during walking is an excellent example of your bones being “worked”.

Other examples of weight-bearing exercises that may be beneficial to your bone health include:

Low-impact aerobics
Hiking
Elliptical training
Using a stair-step machine

Additionally, it is recommended that you speak with your physician and/or physiotherapist prior to beginning an exercising program. They will be able to tell you if you are healthy enough to take part in an exercise program and may recommend some activities best suited for you.

Exercising is not always easy to do. It can be difficult to find the time and the motivation to stick to a regular program. As a person in the “sandwich generation”, your time may be even more limited by the demands you face caring for your parent or relative as well as your children. But exercising does not always mean getting to the gym. Take the stairs, go for a walk at lunchtime and make a plan to keep it up!

You must take the time to look after yourself. Another insightful tip offered by Lisa Pridmore in her article titled “The Sandwich Generation: Caught in the Middle” is to:

“Take care of yourself and do what you need to do to stay healthy. This includes having some fun and living life to the fullest. Many caregivers feel guilty about taking time for themselves; however, it is critical that the caretaker makes his or her own health and well-being a priority in order to take care of others. Heavily stressed individuals are less effective and less efficient.”

When it comes to exercise, there are benefits to be had by all ages. Sticking to a regular exercise program is difficult at the best of times. You may want to consider setting up an exercise routine that you can do with your child and your elderly relative. Exercising as a family has a lot of other benefits! This provides an opportunity for all three generations to bond. Everyone will get that bonus from the overall health benefits and bone health benefits of participating in a regular exercise program. Obviously the activities may need to be modified according to the capabilities and fitness level of each person.

Here are 10 exercises for strengthening bones. You may want to consider incorporating some or all of these exercises into your own program. With simple modifications, these exercises can be challenging for all ages and all abilities. For example, younger, healthier individuals may want to add more resistance by increasing the weight used, perform more repetitions per set, and/or perform more sets of each exercise.

Exercise	Description
1. Stepping Up and Down	Stand with your feet slightly apart. Kneel down on your right knee, then your left knee. Pause a moment, and then place your right foot in front of you and lift yourself up. Repeat the move again, only this time, place your left foot in front of you and lift yourself up. Remember to hang onto something for extra balance. Do this once or twice to start.
2. Shoulder Press	Sit in a chair, back straight and feet flat on the floor. Hold a book or other weighted object in your hands, palms facing each other. Lift the book directly in front of you to eye level, with your elbows bent and in at your sides. Pause with the book (or weight) in front of your eyes, and then lift the book toward the ceiling until your arms are extended as far as possible above your head. Try this without any books or weight if you think you would feel more comfortable.
3. Bicep Curls	With light to moderate weights, stand with your hands to your sides, palms facing front. Feet should be about shoulder width apart. Make a fist with each hand and then, keeping elbows tucked into your sides, lift your fists toward your shoulders, using the resistance of your own muscles. Hold for a moment, and then lower. Repeat.
4. Forearm Extension	Holding onto a weight of some sort (e.g., soup can), sit in a chair, with your back straight. Holding the weighted object in your hand, let your arm rest on your leg such that the weight droops over your knee. Slowly straighten your hand (back of the hand is facing upward until it is even with your forearm). Don't lift the hand higher than the forearm. Repeat 3-5 times on each side.
5. Forearm Curl	This exercise uses the same starting position as the previous exercise except that the hand holding the weighted object is palm up (i.e., sitting in a chair, with your back straight, holding the weighted object in your hand, let your arm rest on your leg such that the weight droops over your knee). Slowly curl the hand upward as far as you can. Pause, and then slowly lower. Repeat 3-5 times on each side.
6. Shoulder Lifts	Hold onto soup cans or light weights. Stand with feet shoulder width apart. Hold your arms at your sides, hands fisted and elbows bent at a 90° angle. With your arms still bent, lift your arms outward to shoulder height, keeping fists slightly lower than the elbows on the way up. Your fists shouldn't move, only your arms. Hold for a moment, and then lower arms, keeping fists stable. Repeat 3-5 times to start.
7. Leg and Hip Strengtheners	Holding onto a chair for balance, stand with feet a little wider apart than shoulder width and toes pointing outward at about a 45° angle. Slowly lower your body several inches, pause, and then raise your body. Keep your back straight and abdominals pulled in. Do this 3-5 times to start.
8. Leg Lifts	Sit on the edge of a chair and stretch your legs out, slightly bent. Place a book or a weight on your ankles or balanced against your shins. Hanging onto the seat of the chair, slightly lift your legs, toes pointing upward, and hold for a few seconds, then lower. Repeat 3-5 times.
9. Heel Lifts	Sit in a chair with your feet flat on the floor in front of you. Place a weight or use your hands to press down on your knees. Slowly lift your heels, and then lower. Repeat 3-5 times, to make your calves work as well as your ankle joint.
10. Walk	You may want to use a pedometer to track your progress over time. Don’t overdo it at the start. Build up over time. Slowly increase the length and duration of your walks.

Adapted from Elderly Parents Activities – 10 Exercises for Bone Strength

In closing

The “sandwich generation” faces many hurdles and a kind of stress that may not have been experienced by generations before. Educating and taking care of yourself are a must as you move forward and face these challenging times ahead. You are your best protection in staying healthy!

We hope that you have found this article to be helpful and informative. Look forward to upcoming articles that will contain more bone-healthy recipes, advice from experts in the area of bone health management and much, much more.

About the authors:

Dr. Marla Shapiro is a practicing physician trained in Family and Community Medicine and has a Masters in Health Science. She also serves as Associate Professor in the Department of Family and Community Medicine at the University of Toronto. She has a keen interest in osteoporosis and has been recognized for her work, winning awards from The North American Menopause Society and the Society of Obstetricians and Gynecologists of Canada. She is also a member of several advisory boards, including Cancer Care Ontario, the Canadian Partnership Against Cancer, Baycrest Hospital and Research Canada. For her lifelong commitment to family medicine, Dr. Shapiro was awarded the College of Family Physicians of Canada's Award of Excellence for 2008.

Nicole Shuckett is a consulting dietician at nursing homes and at the ALS/Stroke Clinic at Sunnybrook Hospital in Toronto. With over 12 years’ experience at Baycrest, Toronto's renowned geriatric centre, she has a keen understanding of the dietary needs and issues facing today's "Zoomers".