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Note: The Base of the Pyramid: The first step in the prevention and treatment of osteoporosis and the prevention of fractures is to build a foundation of nutrition and lifestyle measures that maximize bone health. The diet should not only be adequate in calcium and vitamin D, but should have a healthy balance of other nutrients. A weight-bearing exercise program should be developed. Cigarette smoking and excessive alcohol use must be avoided. In the older individual, at high risk for fractures, the changes in lifestyle would include a plan not only to maximize physical activity, but also to minimize the risk of falls. The use of hip protectors can be considered in some high-risk patients. Diseases that increase the risk of falls by causing visual impairment, postural hypotension (a drop in blood pressure on standing, which leads to dizziness), or poor balance should be treated. Drugs that cause bone loss or increase the risk of falls should be avoided or given at the lowest effective dose.

The Second Level of the Pyramid: The next step is to identify and treat diseases that produce secondary osteoporosis or aggravate primary osteoporosis. These measures are the foundation upon which specific pharmacotherapy is built and should never be forgotten.

The Third Level of the Pyramid: If there is sufficiently high risk of fracture to warrant pharmacotherapy, the patient is usually started on antiresorptives. Anabolic agents are used in individuals in whom antiresorptive therapy is not adequate to prevent bone loss or fractures. Chapter 9 summarizes the indications for antiresorptive and anabolic therapy.