3.2 Prevention: Nutrition, Exercise, Smoking Cessation, and Fall Prevention
Key Takeaways
- Bone Health and Osteoporosis Foundation guidance for adults age 50 and older is 1,000 to 1,200 mg of calcium daily from diet plus supplements as needed, and 800 to 1,000 IU of vitamin D daily.
- Effective skeletal exercise combines weight-bearing aerobic activity with progressive resistance training; swimming and cycling build fitness but provide little osteogenic loading.
- Balance and neuromuscular training such as tai chi reduces fall rate, which matters because most non-vertebral fragility fractures require both low bone strength and a fall.
- Current smoking and intake of three or more alcohol units daily are independent FRAX risk factors, and both are modifiable.
- Fall prevention combines exercise, medication review for sedating or hypotensive drugs, vision correction, home hazard removal, and appropriate footwear.
3.2 Prevention: Nutrition, Exercise, Smoking Cessation, and Fall Prevention
Quick Answer: Fracture prevention has two independent arms. The skeletal arm raises or preserves bone strength through adequate calcium (1,000–1,200 mg/day for adults 50+), vitamin D (800–1,000 IU/day), weight-bearing and resistance exercise, smoking cessation, and moderation of alcohol. The fall arm reduces the mechanical event that converts fragile bone into a fracture, through balance training, medication review, vision correction, and home hazard removal. Both are named ARRT content, and answering patient questions about them is a documented clinical activity for BD candidates.
Why This Is Technologist Content
ARRT lists "answer basic questions from patients or family members about lifestyle choices related to bone health, fall prevention, and drug therapies" as an elective clinical requirement, at 20 occurrences. The reason is practical: the DXA appointment is often the only unhurried clinical encounter a patient has about bone health, and the technologist is the clinician in the room. The boundary is equally practical — general education is in scope; interpreting the patient's result, recommending a drug, or setting a dose is not.
Calcium
Calcium is the substrate for hydroxyapatite. When dietary intake is insufficient, parathyroid hormone maintains serum calcium by resorbing skeletal calcium, so inadequate intake translates directly into bone loss.
| Population | Recommended daily calcium |
|---|---|
| Women 51 and older, men 71 and older | 1,200 mg |
| Men 50–70 | 1,000 mg |
| Adults 50 and older (BHOF practical guidance) | 1,000–1,200 mg |
Counseling points that come up repeatedly:
- Dietary calcium is preferred over supplements. Dairy, fortified plant milks, canned fish with bones, tofu set with calcium, and leafy greens are the usual sources. A rough estimate credits about 300 mg per cup of milk or fortified beverage and about 300 mg per standard serving of yogurt or hard cheese.
- Absorption is dose-limited. No more than roughly 500–600 mg of elemental calcium is absorbed efficiently at once, so supplement doses are split.
- Formulation matters. Calcium carbonate requires gastric acid and is taken with food; calcium citrate does not and suits patients on proton pump inhibitors or with achlorhydria.
- More is not better. Intakes substantially above recommended levels have not been shown to further reduce fracture risk and increase the risk of kidney stones and constipation.
- Recent oral calcium is a scan contraindication. Undissolved calcium tablets in the bowel overlie the lumbar spine and produce artifactually elevated values, which is why the pre-scan screening question exists.
Vitamin D
Vitamin D drives intestinal calcium absorption. Without it, calcium intake is largely irrelevant because it is not absorbed.
- BHOF guidance for adults 50 and older is 800–1,000 IU daily, with serum 25-hydroxyvitamin D maintained at an adequate level.
- Deficiency is common in older adults, in people with limited sun exposure or darker skin pigmentation, after bariatric surgery, and in malabsorptive disease.
- Severe, prolonged deficiency produces osteomalacia, a mineralization defect that lowers DXA BMD but is not osteoporosis and is treated differently.
- The laboratory test ordered is 25-hydroxyvitamin D, not 1,25-dihydroxyvitamin D. This distinction appears in the patient-history content because technologists record laboratory results.
Exercise
Bone responds to strain. The osteogenic stimulus is load that exceeds habitual loading, applied at reasonable rates, at the site you want to strengthen.
| Exercise type | Examples | Skeletal effect |
|---|---|---|
| Weight-bearing aerobic | Walking, stair climbing, dancing, jogging, racquet sports | Loads hip and spine; maintains rather than dramatically increases BMD |
| Progressive resistance | Free weights, machines, resistance bands | Site-specific loading at muscle attachments; the strongest BMD stimulus |
| Balance and neuromuscular | Tai chi, single-leg stance work, gait training | Little direct BMD effect; substantial fall-rate reduction |
| Non-weight-bearing | Swimming, water aerobics, cycling | Cardiovascular and muscular benefit; minimal osteogenic loading |
Two cautions belong in any patient conversation. Patients with known or suspected vertebral fracture should avoid repeated forward flexion with load, and exercises involving vigorous spinal flexion and twisting, because these increase anterior vertebral compression. And disuse causes rapid loss — prolonged bed rest and immobilization strip bone far faster than age-related loss, which is why early mobilization after hip fracture is a skeletal intervention rather than only a rehabilitation one.
Smoking and Alcohol
Current smoking is an independent FRAX input. Tobacco reduces intestinal calcium absorption, lowers estrogen levels, is associated with earlier menopause and lower body weight, and impairs fracture healing. Risk falls after cessation, though not immediately to never-smoker levels.
Alcohol at three or more units daily is the FRAX threshold (one unit is approximately 8–10 g of ethanol: a standard beer, a small glass of wine, or a single measure of spirits). Heavy intake suppresses osteoblast function, impairs vitamin D metabolism, and — importantly — raises fall risk. Intake below that threshold has not been shown to harm bone.
Fall Prevention
Roughly speaking, hip and wrist fractures require two things: bone that is weak enough to break and a fall to break it. Treating only the bone addresses half the problem. Fall prevention is therefore a named prevention topic in its own right on the ARRT outline, and it appears twice — as a prevention strategy and again as a patient-support skill in the scanning room.
| Risk domain | Intervention |
|---|---|
| Neuromuscular | Balance and strength training, tai chi, supervised gait training, physical therapy referral |
| Medications | Review of sedative-hypnotics, benzodiazepines, antipsychotics, anticholinergics, opioids, and antihypertensives causing orthostatic hypotension; polypharmacy reduction |
| Vision | Annual eye examination, cataract treatment, caution with new multifocal lenses on stairs |
| Home environment | Remove throw rugs and clutter, secure cords, improve lighting including night lights, install grab bars in bathrooms and handrails on both sides of stairs, non-slip mats |
| Footwear | Low-heeled, thin-soled, well-fitting shoes with non-slip soles; avoid walking in socks or loose slippers |
| Medical | Correct vitamin D deficiency, evaluate orthostatic hypotension, assess cognition, address peripheral neuropathy and foot pain |
| Assistive devices | Properly fitted cane or walker, used consistently and sized by a clinician |
Hip Protectors and Assistive Devices
External hip protectors have shown benefit mainly in institutional settings where adherence can be supported; adherence is the limiting factor in community use. Assistive devices reduce falls only when correctly sized and actually used, which is why "he has a walker" and "he uses a walker" are different answers to the screening question.
What the Technologist Says and Does Not Say
Appropriate: explaining recommended calcium and vitamin D intake, describing which exercises load bone, reviewing home fall hazards, describing what the scan measures, and encouraging the patient to discuss results with the ordering provider.
Not appropriate: telling the patient their T-score means they "have osteoporosis," recommending or discouraging a specific drug, advising a supplement dose for a patient with kidney disease or a stone history, or predicting fracture risk. Those belong to the interpreting physician and the treating clinician.
A patient asks which activity will best strengthen her bones. She currently swims three times weekly. What is the most appropriate general response?
Which intervention addresses fall risk rather than bone strength?
A patient taking a proton pump inhibitor asks which calcium supplement to use. What general educational point is appropriate for a technologist to make?