DEAR DR. ROACH: I am 77 and have been diagnosed with osteoporosis. I am taking Fosamax and taking all the steps recommended for strengthening bones. But I have two questions: First, is it possible to avoid a fracture without taking medication. Second, is it necessary to avoid coffee completely? I am confused about both questions, having read a lot of conflicting information online. I recently finished reading a book that strongly condemned osteoporosis medication, and have also read that coffee is OK, even good for bones; though, other sources say it leeches calcium from bones. I would appreciate some clarity on these issues. — J.M.
ANSWER: I have also read dire warnings about osteoporosis drugs, particularly the bisphosphonate class such as alendronate (Fosamax), but the truth is more complex than it first appears.
The most important thing to realize is that every person has their own individual risk of developing an osteoporotic-type fracture. For young, healthy people with strong bones, the risk is very small, but as we age, the risk of fracture increases. Many medical conditions, as well as diet, exercise and some medications, affect the risk of fracture. Whether we are men or women, and even what our ethnicity is, affects fracture risk. The bone mineral density measured by a DEXA scan provides much information, but an accurate fracture risk prediction needs to take a person’s whole history into account. Only people at high risk for a fracture should be taking medication like Fosamax.
A standard guideline is that people should be recommended medication therapy if their 10-year risk of a hip fracture is greater than 3%, or their 10-year risk of any kind of major osteoporotic fracture is 20% or higher. If a person’s risk is less than these numbers, they may be subjecting themselves to the risk of medication unnecessarily. The FRAX score is a standardized, country-specific way of estimating risk (www.sheffield.ac.uk/FRAX/tool.aspx).
If a group of people has a risk of fracture of 20% in the next 10 years, then 80% of them will not have a fracture if they don’t take medication. Like treatment for high blood pressure or high cholesterol, medication treatment helps only a small proportion of those who receive it. We don’t have the ability to predict with certainty who will have a bad outcome from these conditions, so we recommend treating people at some degree of risk.
Treating only higher-risk patients leads to the drug helping a higher proportion of the group, but some people who were not offered medication will develop the bad outcome we’re trying to avoid. A person who gets a hip fracture that could have been prevented with medication treatment is a tragedy. In my opinion, a person should know the risks of treatment and the risk of withholding treatment before making a decision.
The calcium question is also controversial, but while it is true that caffeine causes the body to lose calcium, if you take in enough calcium through diet, coffee does not seem to increase your risk of a fracture.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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