Providing adequate daily calcium and vitamin D is a safe, inexpensive way to help reduce the risk of fractures. Clinical controlled trials have shown that the combination of calcium and vitamin D supplementation can reduce the risk of fractures. A balanced diet rich in low-fat dairy products, fruits and vegetables provides the calcium needed for good health as well as numerous other nutrients. If adequate calcium cannot be obtained through diet, dietary supplements are needed to supplement the recommended daily intake of calcium. Adequate dietary calcium intake is recommended for all individuals. Adequate intake of calcium throughout life is necessary to maintain peak bone mass and bone health. Bone contains 99% of the body’s calcium stock; when exogenous supplies are inadequate, bone tissue is resorbed to maintain blood calcium at a constant level. NOF supports the Institute of Medicine (IOM) recommendation that men aged 50-70 years consume 1,000 mg of calcium per day, women aged 51 years and older and men aged 71 years and older consume 1,200 mg of calcium per day. Intake above 1200 mg to 1500 mg per day has limited potential benefit and may increase the risk of kidney stones, cardiovascular disease and stroke. The literature is highly controversial in this regard. There is no evidence that additional bone strength can be obtained with calcium intake above these amounts. Estimating Daily Dietary Calcium Intake Vitamin D plays an important role in the absorption of calcium, bone health, muscle performance, balance, and resistance to the risk of falls. NOF recommends a daily vitamin D intake of 800 to 1,000 international units (IU) for adults over 50 years of age. The Institute for Medical Dietary Reference Intake (IMDRI) recommends a daily intake of 600 IU of vitamin D until age 70 and 800 IU of vitamin D at age 71 and older. Preferred food sources of vitamin D include vitamin D-fortified milk (400 IU per quart, but certain products such as soy milk do not always supplement vitamin D) and cereals (40 to 50 IU or more per serving), the Saltwater fish and liver. Some calcium supplements and multivitamin tablets also contain vitamin D. Supplements containing vitamin D2 or vitamin D3 may also be used. Vitamin D2 is of plant origin and can be taken as part of a strict vegetarian diet. Many older patients are at high risk for vitamin D deficiency, including patients with malabsorption (e.g., celiac disease) or other intestinal disorders, chronic renal insufficiency, patients on medications that increase the breakdown of vitamin D (e.g., certain antiepileptic drugs), patients who are footloose, patients with chronic illnesses and limited sun exposure, individuals with very dark skin, and obese individuals. Patients with osteoporosis also have a high prevalence of vitamin D deficiency, especially those who have a combination of periprosthetic fractures. Vitamin D deficiency is also common in patients taking anti-osteoporosis medications. Because of the interindividual variability in vitamin D intake required to correct vitamin D deficiency, serum 25(OH)D levels should be measured in patients at risk for vitamin D deficiency. The amount of vitamin D supplementation should be sufficient to achieve a serum 25(OH)D level of approximately 30 ng/mL (75 nmol / L) and to maintain that dose, especially in patients with osteoporosis. Many patients, including those with malabsorption, will require more than the recommended 800-1000 IU per day. The safe upper limit of vitamin D supplementation for the average adult is 4,000 IU per day. Treatment of Vitamin D Deficiency Adults with vitamin D deficiency need to be treated with 50,000 IU of vitamin D2 or vitamin D3 or equivalent daily doses (6,000 IU of vitamin D2 or vitamin D3) per week for 8-12 weeks to achieve a blood 25(OH)D level of 30 mcg/mL. This is followed by maintenance therapy with 1500-2000 IU/d. Higher doses may be necessary to achieve and maintain target levels in obese individuals, patients with malabsorption syndrome, and patients with medications that interfere with vitamin D metabolism. Frequent weight-bearing and muscle-strengthening exercises are recommended to reduce the risk of falls and fractures. Weight-bearing and muscle-strengthening exercises have many health benefits, improving agility, strength, posture and balance, and may reduce the risk of falls. In addition, exercise can moderately increase bone mineral density. NOF strongly endorses lifelong physical activity for all ages, both to prevent osteoporosis and for overall health, and when exercise is discontinued these benefits cease. Weight-bearing exercise (where the bones and muscles fight gravity as the feet and legs bear the weight of the body) includes walking, jogging, tai chi, stair climbing, dancing, and tennis. Muscle strength exercises include weight training and other resistance exercises. Patients with osteoporosis starting a new strenuous exercise, such as running or weight lifting, are recommended to have an appropriate clinical evaluation. Fall prevention Table 2 lists the major risk factors for falls. In addition to maintaining adequate vitamin D levels and physical activity as described above, several other approaches have been shown to reduce falls. These include, multifactorial interventions such as individual risk assessment, Tai Chi, home safety assessment and improvement through an occupational therapist, and gradual reduction of psychotropic medications if possible. Correcting vision may improve mobility, but increases the risk of falls. Changing multifocal glasses to single lens glasses may reduce falls. Hip protectors may protect the hip joint in the event of a fall, but the effectiveness of hip protectors in reducing hip fractures is uncertain, and the evidence against fractures is not conclusive. Also most hip protector products sold have not been tested in randomized clinical trials. Smoking cessation and avoidance of excessive alcohol consumption Patients are advised to stop smoking. Tobacco product use is detrimental to bone as well as overall health. the NOF strongly encourages smoking cessation programs as an intervention for osteoporosis. Recognize and treat patients’ excessive alcohol consumption. Moderate alcohol consumption has no negative effect on bone and may even slightly improve bone density and reduce the risk of fracture in postmenopausal women. However, more than three drinks per day may impair bone health, increase the risk of falls and require further evaluation for alcoholism.