Importance of Non-Pharmacologic Interventions in Osteoporosis Management: A Case Series Finding Value in Nutrition and Exercise Counseling by a Fracture Liaison Service.

Background: Bone mineral density (BMD) warrants attention given its role in secondary fracture prevention and pre-surgical optimization in orthopaedic surgery. While fracture liaison services (FLS) offer expertise in the management of osteoporosis medications that are known to increase BMD, these resources further coordinate the prescription of vitamin D supplementation and provide nutritional counseling to include adequate amounts of dietary calcium and protein, along with recommendations of intentional exercise to improve a patient's overall bone health and decrease fall risk. This case series describes patients who experienced increase in bone mineral density with these non-pharmacologic interventions. Methods: Retrospective review was performed to identify patients experiencing an increase in BMD on dual-energy x-ray absorptiometry (DXA) scan after presenting to the bone health clinic of a level one academic trauma center since January 2020. Patients prescribed an osteoporosis medication were excluded. Each patient's prior bone health history, comorbidities, prior injuries, DXA data, and laboratory values were recorded. Bone health interventions including nutrition optimization, to include adequate daily dietary intake of calcium and protein, intentional exercise, as well as vitamin D supplementation were noted. Results: 12 patients experienced an increase in bone mineral density with non-pharmacologic interventions. Average age of the series was 64.8 years (range 51-76 years) and seven were female. 75% were referred by orthopaedic subspecialty services with 50% being referred after sustaining a fracture. All 12 patients experienced an increase in total hip BMD with and average increase of 3.7% (range 1.0-6.8%), while spine BMD was seen to increase in 10 patients for an average increase of 6.0% (range 1.4-10.5%). Increases in femoral neck BMD were only seen in eight patients with an average increase of 1.5% (range 0.6% - 2.8%). Interval time between initial DXA and repeat DXA was 21.7 months (range 12.2-47.4 months). Conclusion: Incorporation of vitamin D supplementation along with a nutrient dense diet to include adequate dietary intake of calcium and protein, along with exercise counseling may provide a method of improving bone mineral density in orthopaedic patients. These findings highlight the importance providing additional non-pharmacologic interventions for patients treated by the FLS.