A Diet for Healthy Bones

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This project has been funded with federal funds from the U.S. Department of Agriculture, under the Food Stamp Nutrition Education Program. The contents of this training session or of these educational materials do not necessarily refect the view or policies of the U.S. Department of Agriculture, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. USDA is an equal opportunity employer.

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Lesson 1 A Diet for Healthy Bones University of California, Berkeley • Center for Weight & Health http://www.cnr.berkeley.edu/cwh/ This project has been funded with federal funds from the U.S. Department of Agriculture, under the Food Stamp Nutrition Education Program. The contents of this training session or of these educational materials do not necessarily reflect the view or policies of the U.S. Department of Agriculture, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. USDA is an equal opportunity employer.
Lesson 1 A Diet for Healthy Bones Goal • Increase knowledge of osteoporosis and the importance of diet for healthy bones. Key Messages • Osteoporosis is a common condition that can be prevented. • Eating a balanced diet that includes adequate amounts of foods rich in calcium and vitamin D will help prevent or delay osteoporosis. Summary This lesson will describe osteoporosis and discuss how to maintain healthy bones through all stages of life. Participants will learn about the risk factors for osteoporosis, as well as ways to improve bone health. Emphasis is on including calcium and vitamin D-rich foods as part of a balanced diet. Learning Objectives 1. Identify the risk factors for osteoporosis. 2. Identify foods that promote bone health. By the end of the lesson, participants will be able to: • Define osteoporosis. • List the risk factors for osteoporosis. • Learn how osteoporosis is diagnosed. • Identify calcium needs for each age group. • Identify calcium-rich foods and sources of vitamin D. • Identify calcium-rich foods that people with lactose intolerance can eat. • Explain when a calcium supplement may be recommended. Lesson 1: Page 1
Learning Activities Suggested time: 60 minutes 1. Getting started (5 minutes) 2. Pretest (optional) (5 minutes) 3. Calcium screener (optional) (5 minutes) 4. Learning about osteoporosis (10 minutes) 5. Osteoporosis: risks and prevention (10 minutes) 6. Calcium and vitamin D-rich foods (20 minutes) 7. Post test (optional) (5 minutes) Materials • Styrofoam (9 x 12 inch sheet can be purchased at a fabric store or craft store, to be cut into smaller pieces) • Bone model (provided) • “Picture Your Bones” packet and/or powerpoint presentation (English, Spanish, Vietnamese) • “Bone Health Q & A” discussion cards (English, Spanish, Vietnamese) • “Yogurt with Fresh Fruit Recipe” ingredients for food demonstration Handouts (English, Spanish and Vietnamese) • Lesson 1 Pre and post test (optional) • “Calcium Screener” (optional) • “A Diet for Healthy Bones” with goal setting pamphlet • “Yogurt with Fresh Fruit Recipe” recipe cards Lesson 1: Page 2
1. Getting Started (5 minutes) • Greet the participants. • Complete FSNEP forms as required. • The theme of this lesson is bones are a complex living tissue. 2. Pretest (optional) (5 minutes) Handout • Pretest • Pass out and collect pretest. The pretest questions can be used as openers for discussion. 3. Calcium Screener (optional) (5 minutes) Handout • “Calcium Screener” (English, Spanish and Vietnamese) The calcium screener is a quick and easy way to determine who may not be getting enough calcium from their diet. There are many high calcium foods that are not on this screener. The screeners are ethnic-specific, and are in English, Spanish and Vietnamese languages. They each have different foods to better represent the calcium intake of the diets of African Americans, Latinos and Vietnamese. Learning Activity • Pass out the ethnic-appropriate screener and have the participants check the boxes under the pictures of foods they eat one or more times each week. • Have participants follow the instructions in the last panel. • Discuss the results with the class. • Collect the screeners. Lesson 1: Page 3
Frequently Asked Questions Q: What is a calcium screener? A: A calcium screener helps identify who may have a very low calcium diet. It doesn’t tell us exactly whether someone is getting enough calcium nor does it tell us specifically how much calcium is in our diet. To get a complete analysis of your dietary intake of calcium, you may need a more extensive review of your diet. Q: Why can’t we keep the calcium screener? A: The calcium screener was not designed as an educational tool. We have developed other materials that will provide you with information on calcium- rich foods, such as the “A Diet for Healthy Bones” pamphlet. 4. Learning about Osteoporosis (10 minutes) Materials • Picture Your Bones Packet and/or Picture Your Bones powerpoint presentation Osteoporosis is often called the “silent disease” because a person can have it and not know. You usually won’t experience any pain, signs or symptoms during the early stages. Then one day, you break a bone while doing a routine task, or break a wrist or a hip after a fall. Many people don’t know they have osteoporosis until a fracture happens. Getting enough calcium from your diet and doing weight-bearing exercises help make bones healthy and work to prevent or slow down osteoporosis. Weight bearing exercise is about being on your feet. Walking is a good example of a weight bearing exercise. When you’re young, bone grows larger, stronger and denser as the rest of the body is developing. As we age, we begin to lose bone. One of the symptoms of osteoporosis is a loss of height. One could lose as much as 2 to 4 inches of height in later life due to bone loss. It is possible to slow bone loss through proper diet and exercise. Lesson 1: Page 4
Calcium is a mineral essential for strong bones. The body does not make calcium, so we must get it from food. Children and teenagers need to eat a lot of calcium-rich foods because their bodies and bones are actively growing. Adults need calcium to maintain their bones and to slow down bone loss. If you cannot get enough calcium from foods, talk to your doctor or health professional about taking calcium supplements. Bone is complex living tissue. The body is constantly building new bone tissue and breaking down old bone. Today we will learn how diet and exercise affect bone growth and what we can do to keep our bones healthy. 4.1 Learning Activity Osteoporosis means “porous bones”. Porous bones become weak and easily break. With a loss of bone tissue, bones that were once dense and strong may not be able to withstand the stress of even normal activity, such as bending over or twisting. • Use the bone model to show the difference between a normal and an osteoporotic bone. • Use the styrofoam to show how easily a porous bone can break by snapping the styrofoam in half. • Show “Picture Your Bones” picture (slide 1). • Share the information on the picture (slide). Did You Know? • One out of two women will have osteoporosis in her lifetime. • Two out of every ten men will develop osteoporosis. 4.2 Learning Activity There is no cure for osteoporosis. However, you can slow down bone loss by increasing your daily calcium and vitamin D intake, and doing 30 minutes of physical activity each day. • Show “Picture Your Bones” picture (slide 2). • Share the information on the picture (slide). Lesson 1: Page 5
Discussion Questions • “Does anyone here know someone with osteoporosis?” • “How is his or her life affected by osteoporosis?” • “How common is osteoporosis?” 4.3 Learning Activity Bone fractures impact the quality of life. Promoting bone health early in life can prevent fractures later in life and help older people live more independent lives. Having weak or porous bones can increase the risk of fracturing or breaking bones. Older people with osteoporosis are especially at risk for breaking bones in the hip, spine or wrist. Fractures are painful, serious health conditions and can: • be disfiguring • be disabling • limit quality of life by severely reducing the ability to lead an active life • Show “Picture Your Bones” picture (slide 3). • Share the information on the picture (slide). Discussion Questions • “Has any elderly person you know fallen and broken or fractured a bone?” • “How did that affect his or her life?” 4.4 Learning Activity Age and the effects of osteoporosis can cause a curvature of the spine called kyphosis. • Show “Picture Your Bones” picture (slide 4). • Share the information on the picture (slide). Lesson 1: Page 6
Discussion Question • “Have you ever noticed an elderly relative or friend who became shorter as she/he aged?” 4.5 Learning Activity A common way to diagnose osteoporosis is to have a DXA scan (pronounced “dexa”) that tells us how strong your bones are. The DXA scan: • measures how dense bones are • measures the bones in the hip, spine, wrist, forearm and other areas • is painless • is safe • Show “Picture Your Bones” picture (slide 5). • Share the information on the picture (slide). Discussion Questions • “Has anyone here had a DXA scan?” • “What did it feel like?” Frequently Asked Questions Q: I think I have strong bones. I eat pretty well and exercise too. Do I really need to have a DXA scan to know if I have osteoporosis? A: For now, it is the best way to tell if you have osteoporosis. Q: At what age should a person get a DXA scan? A: A DXA scan is generally recommended for women after menopause, or sometimes earlier. It may also be recommended if repeat bone fractures have occurred or a person has lost more than two inches of height. Lesson 1: Page 7
5. Osteoporosis: Risks And Prevention (10 minutes) Handout • “A Diet for Healthy Bones” Osteoporosis can affect everyone as we get older. Women are more likely than men to get osteoporosis because of their different hormonal makeup. White and Asian women are at highest risk for developing osteoporosis; however, African American and Hispanic women, and men can still get osteoporosis. 5.1 Learning Activity • Pass out “A Diet for Healthy Bones” pamphlet for participants to refer to during the discussion. Discussion Questions • “Do any of you think you might be at risk for osteoporosis?” Here are factors that increase a person’s risk for osteoporosis: • Not eating enough calcium-rich foods • Not getting enough vitamin D • Not doing enough weight-bearing exercise • Hormonal changes with menopause or stopped menstruation • Having had a hysterectomy or ovaries removed • Family history • Current smoking • Drinking too much alcohol • “What can I do to prevent osteoporosis?” Building healthy bones by getting enough calcium and exercising is important at every stage of life. Children and teenagers need more calcium because their bodies and bones are actively growing. Lesson 1: Page
Adults need calcium to maintain their bones and help slow bone loss as they get older. It is very important for a person who has been diagnosed with osteoporosis to get enough calcium to slow further bone loss. The four steps to osteoporosis prevention1 • Meeting your daily value of calcium and vitamin D • Getting 30 minutes of weight-bearing exercise daily • Avoiding smoking and drinking alcohol only in moderation • Talking to your doctor or health professional about bone health and bone mineral density tests Frequently Asked Questions Q: What is a weight-bearing exercise? A: Weight-bearing exercise is any exercise where your feet and legs carry your own weight. Examples are walking, jogging and dancing. Q: What does drinking alcohol “in moderation” mean? A: Studies show that drinking too much alcohol can hasten bone loss and reduce the body’s ability to absorb calcium. If you drink alcohol, limit intake to no more than one ounce a day for women and two ounces a day for men. An ounce equivalent would be a small glass (3 to 4 ounces) of wine for a woman; a two ounce equivalent would be two beers for a man. Q: t what age do I have to start being concerned about osteoporosis? A A: A t all ages. Building strong bones during childhood and adolescence through e xercise nd a healthy diet, adequate in calcium, can be the best defense against a d eveloping steoporosis. Osteoporosis is largely preventable for most people. o A lthough steoporosis is generally diagnosed during later life, we should be aware o o f the mportance of taking steps toward developing strong bones during early life. i National Osteoporosis Foundation. Available at: http://www.nof.org/prevention/. 1 Lesson 1: Page 9
Q: here can I go for more information on osteoporosis? W A: Your health professional can provide you with additional information on osteoporosis. If you have access to the internet, the National Osteoporosis Foundation website has a lot of information on osteoporosis. Their website can be found at: http://www.nof.org. 6. Calcium and Vitamin D-Rich Foods (20 minutes) Materials • “Bone Health Q &A” discussion cards (optional) • “ Yogurt with Fruit Recipe” ingredients for food demonstration and tasting (optional) Handouts • “ A Diet for Healthy Bones” • “ Yogurt with Fruit Recipe” recipe cards 6.1 Learning Activity What foods have calcium? • Discuss the list of calcium content in foods from the “How much calcium is in foods?” table in the “A Diet for Healthy Bones” pamphlet. • Engage class in a discussion using the “Bone Health Q & A” cards. Lesson 1: Page 10
C alcium is found in many foods, but some foods have more calcium than others. Dairy foods such as milk, yogurt and cheese are good sources of calcium. It is important to have a balanced diet. If for some reason you avoid dairy foods, there are other foods that have calcium. Some of these are listed below. Food2 Serving size ~Calcium in milligrams Milk, fat free, 1%, 2%, whole, lactose free 1 cup 300 mg Orange juice, calcium-fortified 1 cup 350 mg Milk, nonfat dried 1/4 cup 375 mg Yogurt 1 cup 370 mg Soymilk, calcium-fortified 1 cup 365 mg Sardines, canned, with bones 3 oz. 325 mg Cheese 1 oz. 205 mg Salmon, canned, with bones 3 oz. 165 mg Almonds, raw 2 oz. 150 mg Beans, black, cooked 1 cup 120 mg Nopales, cooked 1/2 cup 120 mg Cereal, calcium-fortified 1 cup 100 mg Greens, turnip, cooked 1/2 cup 100 mg Kale, cooked 1/2 cup 45 mg Beans, red, cooked 1 cup 90 mg Okra, cooked 1/2 cup 60 mg Broccoli, cooked 1/2 cup 35 mg Greens, collard, cooked 1/2 cup 130 mg Orange, fresh 1 medium 50 mg Sweet Potato, baked 1 medium 40 mg USDA National Nutrient Database http://www.nal.usda.gov/fnic/foodcomp/search/ 2 Lesson 1: Page 11
Ethnic-Specific Tips If most people in your class are from a certain ethnic group, you may want to include some of the following tips for increasing calcium intake: Vietnamese When making soup with chicken or other animal bones, add one teaspoon of vinegar to the soup. This will enable the calcium to cook out of the bones and will make a calcium-rich soup base. Also when making curry sauce, use reduced-fat or low fat milk instead of coconut milk. African Americans If you like eating sardines, remember that they are a good source of calcium. However, be careful not too eat too much. Sardines are high in salt. If packed in oil, sardines are also high in fat. Try sardines packed in tomato sauce for a lower-fat variety with the same amount of calcium. Latinos Pinto beans and cheese are excellent sources of calcium, along with milk. Whole milk, reduced-fat, low fat and nonfat milk all have the same amount of calcium in them. Try using low fat or nonfat milk as they are low in fat but still high in calcium. Discussion Questions • “ Do you eat any of these high calcium foods?” • “ If yes, which ones?” • “ If no, which ones might you try to add to your diet?” Lesson 1: Page 12
6.2 Learning Activity How much calcium do I need every day? Age3 Daily calcium needs in Daily cups of milk milligrams 51 years and older 1,200 mg 4 cups 19-50 years 1,000 mg 3-4 cups 9-1 years 1,300 mg 4+ cups 4- years 00 mg 3 cups 1-3 years 500 mg 2 cups 7 months-1 year 270 mg 1 cup Birth-6 months 210 mg Breast milk/formula* * American Academy of Pediatrics recommends exclusive breastfeeding for approximately the first 6 months after birth. It is recommended that breastfeeding continue for at least 12 months. Infants weaned before 12 months of age should not receive cow’s milk but should receive iron-fortified infant formula. Discuss the “How much calcium do I need every day”? in the “A Diet for Healthy Bones” pamphlet. You can think of the calcium needs of your bones as a bank. Much like depositing money into a bank, you deposit calcium into your body, which helps make your bones stronger. Your body withdraws calcium to help with everyday functions of the body. You make deposits and withdrawals every day of your life. From childhood until about age 30, you are making more deposits than withdrawals, and bones continue to grow and become denser. After menopause, women experience bone loss and the “withdrawals” become much greater than the deposits. Therefore, you should be “saving” calcium for your future by eating more calcium-rich foods in your younger years. Nonfat and low fat dairy foods are healthy choices because they have the same amount of calcium as whole milk, but less fat. Every cup of milk has about 300 milligrams of calcium. Encourage your children to drink milk or water instead of soda. Children have small stomaches and fill up quickly. If they drink soda and other sweet drinks, they won’t have room for milk and the healthy foods they need to grow. Eating a balanced diet with a variety of foods, emphasizing water and limiting sodas is the best way to ensure children will build healthy, strong bones. http://dietary-supplements.info.nih.gov/factsheets/calcium.asp 3 Lesson 1: Page 13
• For children under one year old, breastfeed or use a formula with iron, unless your doctor tells you otherwise. Infants have difficulty digesting the protein in cow’s milk. reastmilk has all of the nutrients required by babies; iron-fortified formula is B recommended when breastmilk is not available. For children less than one year old, cow’s milk does not have all the necessary nutrients. • For children, one to two years old who are no longer breast feeding, use whole milk. They need the fat in whole milk for proper brain development. • For children over two years old, use low fat or fat free milk. • Women who are pregnant or breastfeeding need the same amount of calcium as other omen their age. w Frequently Asked Questions Q. hy do children and teenagers need more calcium? W A. B ecause they are growing, they need more calcium to help build strong bones. As y g ou et older, your bones do not absorb calcium as well and your body draws on t he calcium stored in your bones. It is important to “bank” bone tissue when you a re younger so that your bones remain healthy as you get older. Q: s it possible to get too much calcium? I A: es, it is possible and it is harmful. Too much calcium (more than 2,500 mg per day) Y can ead to decreased absorption of other minerals or possible kidney problems. It l s best o stay with the recommended daily value of calcium for your age. i t T o be on the safe side, read the labels on food packages to figure out the “percent d aily value” (% DV) of calcium in the food items you eat. Make sure all of your food i n one day does not add up to more than 200% DV for calcium. Q: hat affects calcium absorption? W A: itamin D is key to calcium absorption. Milk has added vitamin D (100 IU per cup) V hich helps your body absorb the calcium. w Lesson 1: Page 14
ther factors that decrease calcium absorption are: O • aking an iron supplement at the same time you are eating high-calcium food T r taking a calcium supplement o • moking S Scientists do not know what effects excess protein, caffeine, soda and diet soda may have on calcium absorption. It has been shown that teenagers who drink a lot of soda have weaker bones. This may be because they are drinking less milk, or because other minerals in soda interfere with calcium absorption. 6.3 Learning Activity What is vitamin D and how does it help build healthy bones? Vitamins are substances that are needed for health. You can get most of your recommended daily vitamins from eating healthy foods. Vitamin D is a vitamin that works to form and maintain strong bones by helping the bones properly absorb calcium. Without vitamin D, bones can become thin, brittle, soft, or misshapened. Vitamin D • i s found in a few foods • c an be found in dairy foods fortified with vitamin D • c an be made by the body by exposure of skin to sunlight • i s measured in International Units (IU) If you have dark skin or live in northern parts of the country with little sun, you may need to get more vitamin D from your diet. But remember, it is not wise to be in the sun for long periods of time without sunscreen or sun protection. Lesson 1: Page 15
Vitamin D in Foods Food4 Serving ~Vitamin D (IU) Milk, fat free, 1%, 2% whole, fortified with vitamin D 1 cup 100 IU Orange juice, fortified with vitamin D 1 cup 100 IU Pink salmon, canned 3 oz. 530 IU Sardines, mackerel, canned 3 oz. 220 IU Cereal, fortified with vitamin D 1 cup 40-50 IU Did You Know? • A ll milk is fortified with vitamin D. • F at free, 1% (low fat), 2% (reduced-fat) and whole milk all have the same amount of v itamin and calcium. D Frequently Asked Questions Q. hat are fortified foods? W A. ortified foods are foods that have vitamins and minerals added to them by the F anufacturer. Examples are vitamin D-fortified milk and calcium-fortified m range uice. o j 6.4 Learning Activity What is lactose intolerance? Lactose is the natural sugar found in milk and dairy foods. Some people cannot digest lactose and may have stomach discomfort after eating milk or dairy foods. This is known as lactose intolerance. Asians and African Americans are more likely to have lactose intolerance than whites or Latinos. Lactose intolerance is not the same as milk allergy. Many people lose the ability to break down lactose in their body as they get older. People who have lactose intolerance still need calcium for healthy bones. There are many foods other than milk or dairy foods that have calcium. Discuss Menu 2 in the “A Diet for Healthy Bones” pamphlet. USDA National Nutrient Database 4 Lesson 1: Page 16
Calcium-rich foods for people with lactose intolerance include: • actose free milk or calcium-fortified soymilk L • anned sardines and canned salmon with bones C • ranges or calcium-fortified orange juice O • lmonds A • lack and red beans B • alcium-fortified cereals C • reens such as turnips, kale, collard or mustard greens G • kra and Broccoli O • weet potatoes S Here are some things that people with lactose intolerance can do to get enough calcium in their diet: • at calcium-rich, nondairy foods, including calcium-fortified foods, such as orange E uice. j • at small amounts of dairy foods throughout the day instead of all at once. E • ry eating dairy foods with a meal or other foods instead of by themselves. T • ry dairy foods besides milk, like low fat cheese or yogurt. These have less lactose T ut just s much calcium. b a • ry drinking lactose free or lactose-reduced milk. T Discussion Questions • “ What foods on the calcium foods list in the “A Diet for Healthy Bones” handout c ould a erson with lactose intolerance eat?” p • “ ow will I know if I have lactose intolerance?” H Lesson 1: Page 17
6.5 Learning Activity W ho should take calcium supplements? It is always best to try to get calcium from foods. Usually, the body more easily absorbs calcium from food. Elderly people who do not eat very much might be unable to meet their calcium needs with food. They may need to take a calcium supplement. Calcium supplements are pills that have calcium in them. Your doctor can tell you if you need a calcium supplement. Your body can absorb only 500 mg of calcium from a supplement. Do not take more than 500 mg of calcium from a supplement at one time. Take calcium supplements with meals. Frequently Asked Questions Q. re some calcium supplements better than others? A A. alcium carbonate is the least expensive calcium supplement and is fairly well C bsorbed by the body. Many of these supplements are flavored and chewable. Be a ure to keep them out of the reach of children. s Q: hat if I take medications? W A: alk with your doctor or pharmacist. Calcium supplements can interfere with some T rugs r minerals. d o Did You Know? • O ne TUMS® antacid tablet has 200 mg of calcium. There are generic or store-brand a ntacid tablets with comparable amounts of calcium. 6.6 Learning Activity Goal Setting & Food Demonstration Materials • Food for food demonstration (optional) Lesson 1: Page 1
Handouts • “A Diet for Healthy Bones” • “Yogurt with Fresh Fruit Recipe” recipe cards Ask participants what foods they will be able to try this next week and invite them to write down their goals on the last page of their “A Diet for Healthy Bones” pamphlet. • Pass out “Yogurt with Fresh Fruit Recipe” cards. • Show calcium in food table. • Demonstrate recipe. • Encourage participants to take the recipe card with them shopping. 7. Post test (optional) (5 minutes) Handout • P ost test ass out and collect post test. The post test questions can be used as a wrap-up P discussion. Answer any questions and thank participants for their time. Answers to test questions: 1. b 2. c 3. b 4. d 5. d Lesson 1: Page 19