Men`s Osteoporosis Support Group
Volume III, Issue 1	January 1, 1999

Happy New Year 1999

What`s new?

We have an endocrinologist with an excellent background in men`s osteoporosis who has volunteered to answer questions from members of the support group in future editions. You`ll see more information on this in the Ask the Experts segment of this newsletter.

I`m hearing from several men each week who have osteoporosis and find out about our group via the Internet and this newsletter. So, I`m convinced it was a good move to go to Internet publication. I also heard from Mr. Jerry Friede from the Cooper Clinic(R) at the Cooper Aerobic Center in Dallas, TX. He is the Director of the Cooper Clinic(R) Preventive Imaging lab and is the gentleman who invited me to Dallas to view the Ultrafast CT(R) Scan. Their use of that device was the topic of the special edition of our newsletter in May 1998. He reported to me that there have been several people who have gone to the clinic as a result of reading the special edition newsletter. This is also assuredly due to the Web site in most cases and another indication of the power of the Internet.

Ask the Experts

Dr. James Schuster, our radiology and bone densitometry expert, has submitted the following information in response to questions.

Q1. Is the DXA result accurate for very small-boned individuals or is QCT (quantitative computed tomography) better? A. I think the DXA results for small-boned individuals can be inaccurate, but I can`t quantify it yet. I had an interesting group discussion with some folks at the recent major radiology convention in Chicago (RSNA) who were firm believers in QCT for this and many other reasons. 3D-QCT in particular seems superb.

Q2. What are your feelings about very large increases or decreases in BMD in a one-year follow-up DXA? A. This may be related to positioning of the patient on the table. Remind the technologist that to get the most reliable readings, extremely careful positioning is required to match that from your prior scan. On our Hologic DXA machine, we are able to pull up an outline of the bony structures of the prior scan and superimpose that on the active scan to assure proper positioning. Our technicians sometimes spend a good ten minutes just setting up each scan when done for follow-up purposes.

Here are a couple of additional points concerning DXA. I would like to point out the problem of trying to compare DXA results from different machines, particularly from different manufacturers. We do have formulas available to help convert readings from various manufacturers, but for the most reliable follow-up, it is probably best to have scans performed on the same exact machine as earlier scans. A further point that could be made is that DXA is probably less sensitive than QCT for detection of response to therapy, as a QCT assesses the more metabolically active trabecular bone. Finally, one of the big limitations of DXA is that in the frontal (AP) scan projection, degenerative change in the spine (as occurs in osteoarthritis, for instance) can spuriously elevate the bone density reading even though the spinal column is no stronger. Lateral DXA of the spine bypasses this limitation, and I would encourage members to search out sites that offer that technology. These comments are somewhat controversial, however, with both sides quoting data to support their views, much like at the end of this newsletter on the topic of calcium supplements and BMD. I am basing my opinions on my literature review and results from my practice.

Dr. Schuster reports that he has heard from some members with questions about their diagnosis and will try to answer additional questions in the future. You can send e-mail to him at schuster@rochester.rr.com.

I`m happy to report that Dr. Jeffrey A. Jackson has volunteered to answer general medical questions about osteoporosis in future issues. Dr. Jackson has a strong interest in men`s osteoporosis with both a research and clinical background in that area. He is board certified in both Internal Medicine and Endocrinology and is an Associate Professor of Internal Medicine at the Temple Scott and White Clinic, Temple, Texas. For an excellent article on osteoporosis in men, read his article in Medicine (Baltimore), 1990 May;69(3):137-52 entitled, "Osteoporosis in men: diagnosis, pathophysiology, and prevention." I hope to have his first responses to questions in the April 1999 newsletter.

BMD Questionnaire Results

We had a rather disappointing 16% response to the request for members of the support group to submit results of their bone mineral density tests. These small numbers are certainly not enough to allow any strong generalizations. But I will try to give my interpretation of the results.

First, it is very apparent that there is a need for a standardized report form to give DXA results. How are physicians or patients to know the results of osteoporosis treatment if the DXA results are reported in a haphazard and variable manner? The solution to this problem is simple. All of the following data should be in one easily readable location on every DXA report: Date of test, machine used, lumbar spine segments tested with results in g/cm2, femur neck (and/or other femur locations) tested with results in g/cm2, and which hip was tested (or results for both, if applicable), T-score (and Z-score if desired) for each bone location reported, increased fracture risk for each bone location printed, and MOST IMPORTANT, percentage of BMD gained or lost for each bone location reported based upon previous DXA results. A nice added feature, though not necessarily a requirement, on the best report forms I saw was the inclusion of the patient`s medications and exercise regimen. As I tried to compile the results that members submitted, there was no way to do it accurately or uniformly. Even the best results were still lacking in all the detailed information. One member submitted photostats of all his reports. These were some of the highest quality reports I have seen, still occasionally a required result was lacking. I don`t know the answer to getting uniform reports, but I suggest it starts with us asking that required results are printed on our BMD reports. If we complain, eventually clinics or hospital departments making out the reports will start producing adequate results. Perhaps a call or letter to the National Osteoporosis Foundation will start them on a campaign to standardize report forms, too.

Here are the general results based upon the medication used to treat osteoporosis.

1. Fosamax results ranged from one to 3 years on the medication. I`m suspicious of one member`s results for the hip neck since both hips were reported. One shows a 6.19% improvement and the other was 21.47% for a one-year period. Such a large discrepancy must almost assuredly be related to hip positioning rather than actual BMD increase (See Dr. Schuster`s comments on positioning). The other members` hip results showed no gain or loss over the test period. The spine improvements averaged about 15% with one member reporting a 53% increase in BMD over two years.

2. Human parathyroid results showed a 5.26% and 3.33% improvement in spine and hip BMD, respectively.

3. One member with osteopenia taking only vitamin D and calcium supplements showed an 8.65% increase in spine BMD along with -2.63% in hip BMD.

In summary, all the prescription medications to treat osteoporosis showed significant increases in BMD of the spine, the hip was much more variable. Some showed improvement, and some showed no improvement, but showed no additional loss either. Our members seem to be having the same success that has been shown in studies on women using either Fosamax or human parathyroid. No one submitted results after taking calcitonin in any form, so I can`t report on that.

Book Review

During a visit to the osteoporosis news group, news:sci.med.diseases.osteoporosis,

I discovered a reference to the book Strong Women Stay Young. The discussion was about the effect of exercise on BMD and health in general. I`m always interested in osteoporosis and health issues, so I checked out the Web site that was linked to the article. This brought me to http://www.strongwomen.com. I checked the information on the site and e-mailed the coauthor, Dr. Sarah Wernick, to get answers to my questions. Basically, the information showed that the weight-lifting exercises listed in the book had been found effective in reducing or preventing postmenopausal women`s bone loss. I wanted to know if these results also applied to men. Dr. Wernick replied promptly, answering all my questions to my satisfaction and indicating that men would benefit from the techniques described in the book. I thus ordered the book immediately through at an on-line book store. It arrived in three days, and I took about two more days to read it. I then bought the weights they recommended and started the weight lifting routine. I have been lifting the weights as suggested for about two months now and I`m very satisfied with the results that have gone about as expected.

Essentially, the program recommended by coauthor, Dr. Miriam E. Nelson, a PhD researcher at the Jean Mayer Human Nutrition Research Center on Aging at Tufts University, Boston, MA, involves a simple but effective routine using weights. The book shows examples of all the recommended exercises that I won`t discuss here, but I`ll just mention general principles.

You find your starting point by testing the weights until you find one that you can lift just once correctly doing the weight routine as shown in the book. That is 100% of your capability. You then begin the technique by lifting about 50-80% of that maximum weight. It is important to do the exercises slowly and correctly. The intensity and speed should be equal, e.g., while lifting a weight to do a curl as while lowering it back to starting position. You should be able to do eight repetitions of the exercise in two different sets about two minutes apart. The exercises should not be extremely difficult nor too easy to do. But, this is called high-intensity training, so they definitely require effort to do. The key to making the exercises effective is to then add a small additional weight-probably about one to two pounds at a time-that enables you to do the two sets of eight repetitions with the same degree of difficulty each time. Additional weights may be added weekly, or every couple of weeks depending upon each individual`s level of improvement. You don`t exercise according to a set weekly schedule of weights to lift, but according to your level of fitness. The exercises are done two or three times per week requiring about 45 minutes to complete. Always leave at least one day of rest after exercising for the body to recover.

As you all know, exercise is an important and highly recommended facet of preventing or treating osteoporosis. The question is, "What exercise is effective for maintaining or building BMD?" The answer to that question is the reason I became so interested in Dr. Nelson`s techniques as published in JAMA December 28, 1994;272 No. 24;1909-1914. This randomized one-year controlled trial shows the effectiveness of her methods. This particular study only addresses the effectiveness of weight lifting on postmenopausal white women 50-70 years old. Other studies done at Tufts, however, have shown the effectiveness of similar methods on both men and women up to 95 years old. The most noteworthy findings in the 1994 JAMA study were that, "Total body bone mineral content was preserved in the strength-trained women. . ." ". . . and (BMD) tended to decrease in the controls." Additionally, they found, "Muscle mass, muscle strength, and dynamic balance increased in the strength-trained women and decreased in the controls (P=0.3 to <.001)."

Although a more appropriate title would have been Strong Men and Women Stay Young, that is about my only criticism of the book and the techniques it recommends. I highly recommend this book to everyone who has osteoporosis or to anyone who wants to prevent it. The authors point out that with any weight lifting routine, use common sense and get your physician`s permission first if you are at risk of a fracture due to osteoporosis. The methods, however, have been shown to be safe and effective when performed as recommended.

Update from LunarNews

Male Osteoporosis. The Autumn 1998 issue of LunarNews, http://www.lunarcorp.com/library/library.html,

reviews several noteworthy articles that I want to mention. On the topic of Male Osteoporosis, page 8, the discussion of fractures is particularly interesting. There is one set of figures that gives a number to both men and women`s point of fracture risk with osteoporosis. They point out that, "The average axial BMD levels of men with spine and hip fracture is almost identical to those in women (spine BMD = 0.80 g/cm2 and femur neck BMD = 0.60 g/cm2." If you are like me, you often wonder what all those numbers on the DXA report mean to your day-to-day existence. If your spine BMD is near 0.8 g/cm2 and your hip BMD about 0.6 g/cm2, you are nearing the average of individuals who sustain a fracture of those bones. BMD results approximating those levels mean you need to do everything possible to maintain or raise BMD. That means to be sure (that under the direction of your physician) you exercise moderately (which can decrease fracture risk without an increase in BMD), modify your lifestyle to reduce the risk of an accident that could cause a fracture, and take appropriate medications as prescribed by your physician.

Hip Fractures: The Key to Cost-Effectiveness. Here is another instance of needing to be educated about your own problems (a common theme in the Men`s Osteoporosis Support Group Newsletter) cited on page 14. They point out that, "Unfamiliarity with densitometry and its interpretation has prevented many physicians from diagnosing or treating osteoporosis. Even in orthopedic practices, where fractures are common, few patients are referred for bone densitometry, or for osteoporosis evaluation. There have been similar findings of neglect for fractures, or corticosteroid [-caused bone] loss, in rheumatology, gastroenterology, and pulmonology; not all patients treated with high-dose corticosteroids are warned of the skeletal side-effects, and only a small subgroup receives densitometry." Sadly, the patient is often not going to receive proper therapy unless he/she knows enough to question the recommendations (or lack of recommendations) from the physician. If you don`t know that your fracture might be the result of osteoporosis or that corticosteroids cause loss of BMD, you may not be getting adequate therapy after a fracture or after receiving corticosteroids. Unbelievably, I had e-mail from a patient this month who asked his physician if his symptoms might be the result of osteoporosis. The physician`s comments were, "Men don`t get osteoporosis." If that isn`t reason enough to educate yourselves and ask questions, what is?

Physical Activity: Os Calcis Stiffness Indicates Status. There is an interesting discussion of physical activity and its effect on bone on page 18. This can be thought of in two general categories: Physical activity can cause skeletal hypertrophy (enlargement) as occurs in younger people during growth and development, or it can prevent or decrease accelerated bone loss often associated with aging. So, for most of us with osteoporosis, our goals from moderate levels of physical activity should be to hold on to the BMD we have with little realistic thought of increasing it much. They point out that, "Non-loading activities, like horse-back riding or swimming, have little influence on growing bone and none in the mature skeleton." Thus, the importance of doing physical activities that are weight-bearing in nature. Coincident with the reduction in bone loss from doing weight-bearing physical activity, "The Tromoso study showed that the physically active had half the risk of fractures in the weight-bearing skeleton compared to sedentary persons; there was no effect of activity on fractures on the non-weight bearing skeleton." So, even though there is no increase in BMD, there is a significant decrease in fracture risk brought on by moderate physical activity. This is probably the result of increased muscle strength and better balance that reduces falls. Keep on exercising and note the word "moderate." The exercise doesn`t have to be overly strenuous, just weight-bearing.

Calcium: Role in Prevention Questionable. Without going into great detail, I will tell you that LunarNews continues to question the role of calcium supplementation in osteoporosis treatment. That is a continuing LunarNews theme, along with that of vitamin D supplementation as being much more therapeutic. If I can, later in this issue, I hope to review some new studies with findings that relate to this topic. In the July 1998 newsletter, I mentioned that LunarNews had commented on the apparent risk of prostate cancer related to high calcium intake in men. They follow up that discussion with another in the most recent issue on page 22. They say, "For intakes over 1000 mg/day, the incidence of prostate cancer of any type is roughly double that expected compared to intakes <500 mg/day. Given this clear gradient of risk, it appears that men should question the risk-benefit ratio of calcium intake exceeding 1000 mg/day." They provide a table relating the number of prostate cancers at low and high calcium intakes from the original study by Giovannucci et al, Cancer Res 1998;58;442-447. Here is a summary of the table results that I have modified to show the cancer risk per person-years:

Here are some additional findings from the article by Giovannucci et al, that are not mentioned in LunarNews. The proposed reason that calcium causes prostate cancer involves its ability to suppress formation of 1,25(OH)2 vitamin D (calcitriol) from the 25(OH)D (calcidiol) precursor. Laboratory and clinical data show that an anti-tumor effect on prostate cancer occurs from calcitriol. Anything that lowers the concentration of this form of vitamin D, as does increased calcium intake, could increase prostate cancer risk. Calcium from food sources and supplements independently increased the risk of cancer. So, it appears that there is considerable evidence to keep calcium intakes below 1000 mg a day for men, at least as concerns prostate cancer. Deciding upon the right dose to treat osteoporosis should be a decision made between you and your physician based upon all the evidence available. Men with osteoporosis may have no option but to maintain higher intakes of calcium than this study shows optimal to reduce the incidence of prostate cancer. Those without osteoporosis may want to keep vitamin D intakes to at least 800 IU daily and calcium intakes to less than 1000 mg/day based upon their concern about getting prostate cancer.

Member profile

The following is a very interesting case history of one of our members told in his own words.

I`m a Caucasian male, nearly 62 years old, and retired from state employment April 1997. I`m 5`8", weigh 150 pounds, and believe I`m in relatively good health. For the last 25 years, I have tried to stay in good physical shape, working out at the "Y" each day before I went to work and walking on those days I didn`t work out. Now that I`ve retired, I work out at a health club several times a week, including walking on a treadmill, using the weight machines, and some light free-weights. I`m not a body builder, but have just tried to maintain reasonably good conditioning. Since 1992, in conjunction with my wife`s need to maintain a low-fat diet, I have been paying, what I sense is much above average, attention to a sensible diet. I never gave a thought about supplemental calcium, since I drank low-fat and skim milk regularly, from time-to-time ate calcium-rich food, and took a mineral supplement that had 200 mg of calcium. In fact, I recall sometimes when I would hear about osteoporosis, thinking, "Well, that`s something I won`t have to worry about." In short, I thought I was doing enough things right and that I wasn`t particularly at risk for the more publicized diseases. This summer I experienced some slight pain and discomfort in my left foot around the bone that connects to the little toe. I attributed that to my physical activities which now include the athletic club workouts and two nights a week of vigorous table tennis. It persisted, wasn`t debilitating, but was annoying. I obtained a referral from my primary care physician to see a podiatrist.

The podiatrist, not finding anything obviously wrong from his examination or my description, took x-rays. They revealed no fracture, not even a stress fracture. He couldn`t determine the cause of the problem, but did mention that he thought I had some signs of osteoporosis. I was incredulous, so he asked his nurse to pull at random a male foot x-ray. The difference was obvious even to my untrained eye.

About four weeks later at an appointment with my primary care physician, an internist, he said he didn`t think I had osteoporosis and had never seen it in a man. I told him I had seen the x-rays and the difference between my foot and another male foot was obvious, even to me. He arranged for a bone densitometry while I was at his office, and within 30 minutes or so, I was back in his office, with the news. I was stunned! He showed me the standard deviations etc., but knowing nothing about any of this, it didn`t mean much to me. I guess I was busy visualizing myself crumbling in a heap of bones out on the sidewalk before I could make it to the car. I didn`t get a copy of the report, but recall the femur neck being something like >3. He said there were several possible causes (most of which I don`t recall---except I surely heard it when he said CANCER). He assured me I didn`t have cancer and sent me over to the lab to get more blood for a parathyroid test. He gave me a prescription for 10 mg Fosamax and calcium (Citracal)---1,000 to 1,400 mg daily.

I got busy at the library and found just enough information to realize that maybe all the tests hadn`t been done that should have. Several days later the nurse called me and said that the test for hyperparathyroidism was negative.

As I began to learn more and more about osteoporosis, several questions came to my mind including whether I should be supplementing the calcium with vitamin D, whether the tests that had been done ruled out excessive excretion of calcium, and when a follow-up visit with the physician was in order. I wrote the physician a letter focusing on these issues.
Having heard nothing from the physician`s office in a month, I called his nurse. She didn`t have my letter in her record, but recalled having seen it and somewhat curtly reminded me that the hyperparathyroidism test was negative. I persisted with my concerns and she said she would visit with the doctor. Later in the day she called, saying that I should stop taking the calcium immediately and abstain from it for seven days. Then, I was to obtain a 24-hour urine collection in a container provided by the lab. I was to continue taking the Fosamax and when I started taking calcium again, I was to take the kind with calcium and vitamin D.

The urine collection was completed and the physician`s nurse advised me by phone that the lab tests showed there was excessive calcium in the urine. I was instructed to continue not taking calcium. I was given a prescription for hydrochlorothiazide, 50 mg daily. This, as you may already know, is primarily a diuretic and antihypertensive. Knowing nothing about the drug, I asked the pharmacist if I could look at his Physicians` Desk Reference (PDR). He gave me the product insert that contains what he said is also in the PDR. Buried deeply in the small print under "PRECAUTIONS General" is the statement, "Thiazides MAY (my emphasis) decrease urinary calcium excretion." So, I guess the idea is, while taking no calcium supplement, to determine if this thiazide decreases my calcium excretion. That is the reason I`m interested in asking an expert what studies, if any, are available regarding thiazides.

Since then, I have been giving attention to the Internet for information and am really grateful for the information and sense of direction I have received from your newsletters. My next follow-up visit is in early December.

I experienced first hand the necessity to take an active interest in one`s situation and to be prepared to help the physician by asking the right questions or providing information that might be useful. The thing I`m pondering right now is how to do this tactfully and in a way that doesn`t threaten egos.

In summary, the current treatment (still undergoing analysis) is 10 mg Fosamax and 50 mg hydrochlorothiazide. There have been no fractures. The source of the calcium shortage is urinary excretion, and the root cause is unknown.

This member profile once again shows the importance of arming yourself with as much knowledge about your condition as possible. It is your health and you can`t trust it totally to a busy physician who, competent though he or she may be, may simply not have the time to check every detail of your diagnosis or treatment. If an error is made, you don`t want the consequences to be serious or irreparable.

Literature review

In the interest of brevity, I`ll list only the author`s names and the Medline UI number as the means of finding the abstracts for the articles that are reviewed here. Here is how to use the UI number. Go to Medline, http://www.ncbi.nlm.nih.gov/PubMed/, and enter only the numbers in the search block, not the letters "UI." Then click on "Search" to find the referenced article.

Effects of alendronate on gastric and duodenal mucosa. Lanza F, et al. UI: 98286786. This study involved endoscopic inspection of 79 postmenopausal women for duodenal or gastric erosion after eight or fifteen days on 5 or 10 mg Fosamax, 650 mg aspirin four times daily, or a placebo. The authors found, "The incidence of gastric erosions in the alendronate groups did not differ significantly from the placebo group. In this study, unlike aspirin, alendronate did not induce gastric erosions." Alendronate (Fosamax) is often criticized as a gastric irritant, however, controlled research studies don`t find this to be the case. Here`s a study involving actual visual inspection of the stomach lining that found no difference in gastric erosions comparing Fosamax to a placebo. The site of potential irritation is the esophagus. Get the medication into your stomach with a large glass of water, don`t lie down until you eat (at least one-half hour later, and preferably 1-2 hours later), and esophageal irritation is not a problem either.

Excessive dietary intake of vitamin A is associated with reduced bone mineral density and increased risk for hip fracture. Melhus H, et al. UI: 99015313. Vitamin A, and its precursor, beta-carotene is found in the fats of dairy products, egg yolks, liver, kidneys, marine liver oils, green leafy vegetables, yellow vegetables, and red palm oil (found in the tropics). Additionally, beta-carotene is currently a highly touted antioxidant supplement. This study found, "For every 1-mg increase in daily intake of retinol (vitamin A), risk for hip fracture increased by 68% (95% CI, 18% to 140%, P for trend, 0.006). For intake greater than 1.5 mg/d compared to intake less than 0.5 mg/d, bone mineral density was reduced by 10% at the femoral neck (P=0.005), 14% at the lumbar spine (P=0.001), and 6% for the total body (P=0.009) and risk for hip fracture was doubled . . . " The results of this study warrant an examination of your dietary intake of all forms of vitamin A, especially if you have osteoporosis. If necessary, reduce the intake to get it below 0.5 mg/d. Fortunately, labels are on almost everything today, so it is easy to estimate your daily vitamin A intake.

Calcium supplements and BMD. Three recent studies look at the question of calcium supplements` effect on BMD with varying results. The first study is by Storm D, et al, UI:99029589. Sixty older postmenopausal women without osteoporosis living in New England received either four glasses of milk a day, calcium carbonate, 1000 mg/d in two doses, or a placebo. Those drinking milk had 1.5% loss of hip BMD, those on the placebo lost 3% of hip BMD, and those on calcium supplements had no change in hip BMD. In summary, ". . . at least 1000 mg/day of supplemental calcium was adequate prophylaxis against femoral bone loss." Another two-year study was done by Baeksgaard L, et al, UI:99014644, on 240 healthy women aged 58-67. Some women received supplements of calcium and vitamin D, others received placebos. Lumbar spine BMD was significantly higher in the treatment group at both one and two years. In a study by Hosking DJ, et al, UI:99044910, they looked at the placebo group in the Early Postmenopausal Interventional Cohort study, a clinical trial of alendronate. These women were advised to take additional calcium during the study. Results showed BMD decreased by 1.9% at the lumbar spine and 1.6% at the hip for the 24-month study. The authors found, "Even women whose total calcium intake was >1333 mg/d showed a decline in BMD of almost 2%. . ." The changes in calcium intake ". . . were not significantly associated with changes in BMD or bone turnover." So, take your pick, calcium supplements either help maintain BMD or they don`t, here is the literature to back either stand.

EDITOR

Jerome C. Donnelly
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