Men's Osteoporosis Support Group

Answers to an emailer's questions

I received an email from a visitor to the Men's Osteoporosis site who noted that I had posed questions in one of the early Newsletters that I hoped one of our experts would be able to answer. This fellow wondered if I had answers for those questions, and I do. I was able to answer them with information I've gleaned doing this Website and with searches of PubMed.

1. Several dietary risk factors exist for osteoporosis, excess wheat bran intake, excess soda pop ingestion, excess animal protein ingestion, and excess alcohol use. How significant are these either alone or all together?

Answer: See the last question for the wheat bran answer.

Excess animal protein intake is subject to some debate, with the book I recently reviewed "Building Bone Vitality," leading the way as saying that excess animal protein is a negative factor on bone density. See: http://maleosteoporosis.citywebshop.com/maleosteo/3609_bbv.htm. This topic is discussed in several articles on the Men's Osteoporosis Website, so search FreeFind for "PRAL" for more details. My personal opinion at this point is that any diet that raises the urinary pH level, makes it more alkaline, which would be one that is low in animal protein, should be beneficial for the skeleton.

Excess alcohol use is a strong predictor of osteoporosis risk. However, low to moderate alcohol consumption can be positive for bone health: http://www.ncbi.nlm.nih.gov/pubmed/16923313 and http://www.ncbi.nlm.nih.gov/pubmed/18456037. Alcoholism as a risk factor for osteoporosis: http://www.ncbi.nlm.nih.gov/pubmed/16272272. Here is an interesting example of a young, college athlete who was diagnosed with osteoporosis due to binge drinking, an apparently somewhat common finding. I suspect that alcoholic osteoporosis is related to the direct effects of the excess alcohol, but also the fact that alcoholics are commonly very undernourished. I don't think that researchers have uncovered all the facts regarding this area. Particularly, the exact level where alcohol consumption is beneficial and where it becomes harmful hasn't been clarified yet. So anyone prone to alcoholism would best avoid it to be on the safe side.

Here is a recent study which showed a negative effect in lab rats when they were fed colas compared to controls: http://www.ncbi.nlm.nih.gov/pubmed/17448120. The damage was attributed to kidney damage caused by the cola. This abstract from the Framingham Osteoporosis Study showed that colas, but not other sodas, had a negative effect on bone density of women: http://www.ncbi.nlm.nih.gov/pubmed/17023723. This study found a negative effect, particularly increased markers of bone resorption, from adding cola to a diet that previously had milk as the calcium source: http://www.ncbi.nlm.nih.gov/pubmed/15886860. Here is another study showing that heavy cola drinking negatively impacted bone health: http://www.ncbi.nlm.nih.gov/pubmed/11068076.

There is a need for more research in this area, but it appears that colas, in particular, are not beneficial to bone health. There is little research to confirm that regarding other soda products.

2. Have any patients been brought up to standard bone mineral density by taking Fosamax? If so, is there a different maintenance dosage for them?

Answer: Many people have returned to normal bone mineral density, including me. There is no recommended maintenance dose that I'm aware of. However, my endocrinologist placed me on 35 mg Fosamax once-weekly when my BMD got in the normal range. We have watched it now for a couple of years with no significant drop. If your BMD returns to normal you might want to ask your care provider about a lower dose of your medication. But you should monitor your BMD regularly to be sure it remains stable.

3. Fosamax is only taken in the A.M., why? Would A.M. and P.M. dosages provide increased bone mineral density?

Answer: Fosamax is taken in the A.M. because it must be taken on an empty stomach. It is very sensitive to having anything else ingested along with it, so this is critical. For an excellent discussion of this topic see http://www.ncbi.nlm.nih.gov/pubmed/8298197. There are now bisphosphonates that can be given once-monthly or even once-yearly with the same effectiveness as taking it once daily. Thus there would be no reason to take it twice a day.

4. An inexpensive and quick bone mineral density test would be ideal. What research is being done to develop such a test?

Answer: The quantitative ultrasound (QUS) is the most inexpensive bone density test of which I'm aware. The results on its effectiveness are mixed, and to my knowledge the dual-energy X-ray absorptiometry (DXA) bone density test is still the gold standard. For a recent review of QUS with free online full text see: http://www.ncbi.nlm.nih.gov/pubmed/19287890.

A recent article showed that the sit-to-stand strength of people was significantly related to bone mineral density and multiple other parameters of bone health. Whether this might become a viable alternative to DXA or QUS is questionable. But further research might find specific populations that could use this simple strength test as a proxy for DXA. See: http://www.ncbi.nlm.nih.gov/pubmed/19219383.

5. A thorough report of the toxicity of Vitamin D is needed.

Answer: A recent Update with information provided by Heaney shows that vitamin D toxicity is not the issue that some have made it out to be. See: http://maleosteoporosis.citywebshop.com/maleosteo/0609_d3.htm. Heaney points out that the ideal serum level of 25(OH)D is 80 nmol/L or higher with toxicity occurring at 500 nmol/L or higher. Thus showing the safety factor involved with normal supplement dosing or sunlight exposure. He notes we would have to take in excess of 20,000 IU/day to reach this toxic level. For more details here is an article on the Vitamin D Council website regarding vitamin D toxicity: http://www.vitamindcouncil.org/vitaminDToxicity.shtml. For a recent discussion of vitamin D and sunscreen, and other topics, see this: http://www.skintherapyletter.com/2008/13.5/1.html. Note that this dermatologist disagrees with the new suggested higher levels of serum vitamin D as the standard to attain.

6. How does one interpret a bone densitometry chart? Are there true bone mineral density norms for males or are they just a conjecture from those developed from females?

Answer: Here is an excellent step-by-step explanation of how to interpret the bone densitometry chart from Dr. Susan Ott's website: http://courses.washington.edu/bonephys/opDEXA1.html. There are indeed normal profiles for both men and women for the charts. That is, men are compared to men and women are compared to women. However, there are differences among certain races and ethnicities that may not be accounted for by using the two standard gender-specific charts. This abstract discusses some of these issues in men: http://www.ncbi.nlm.nih.gov/pubmed/17340219, and this one does the same for women: http://www.ncbi.nlm.nih.gov/pubmed/16910903. Also you can read the related articles if you are interested.

7. Is anything being done to have insurance companies pay for male bone density testing?

Answer: I've not heard this as an issue for years now, mainly since Fosamax was approved for use in men. So I think this is no longer a problem in general, although specific insurance companies may be problematic. Check with your company to get specifics if you are in doubt.

8. What are the safety concerns with testosterone injection or patch therapy? How great is the risk of prostate or other cancer, for example?

Answer: The main concern usually expressed is fear of prostate cancer. However, it has been shown that testosterone therapy doesn't cause cancer. It does, however, exacerbate it if present. Thus before starting testosterone therapy a thorough prostate cancer screening exam should be done to include PSA tests, digital rectal exam, etc. And prostate status should be monitored closely for the first year of therapy to rule out previously undetected prostate cancer. See this update: http://www.maleosteoporosis.org/maleosteo/andropause.htm. For information regarding adverse effects go to the product website and look up the prescribing information. For instance, see this page regarding the Androderm patch: http://www.androderm.com/p/hcp_info/index.asp.

9. Are there studies showing any ethnic or geographic populations being relatively immune to osteoporosis? If so, are there any plausible reasons?

Answer: Here is a study which looked at the hip fracture rates in 33 countries and compared it to protein intake: http://biomed.gerontologyjournals.org/cgi/content/full/55/10/M585. Here is a table showing the results for all 33 countries: http://biomed.gerontologyjournals.org/cgi/content/full/55/10/M585/T1. Obviously this study concluded that excess protein intake is related to hip fracture. It is possible to think that other factors could be involved too. Perhaps those living in low-fracture-rate countries have increased sun/vitamin D levels, have shorter statures with concomitantly reduced chance of fracturing if they fall. Perhaps there are other factors in these countries that reduce the chance of falling: they don't use throw rugs, they don't climb stairs, etc.

10. What are the experts recommending concerning DHEA or other natural osteoporosis treatments?

Answer: There appears to be little evidence that DHEA does anything for osteoporosis, and its positive effects are questionable in most other areas, other than for adrenal insufficiency. See: http://www.ncbi.nlm.nih.gov/pubmed/12163230.

11. What is the current state of calcitonin for treatment of osteoporosis. When and for whom is it recommended? Why would it be used along with or in lieu of Fosamax?

Answer: There are several articles on the Men's Osteoporosis Website regarding Miacalcin, intranasal salmon calcitonin spray. In general it has been shown effective at reducing the acute pain of vertebral fracture, so is a good choice for the first medication to use in such individuals, male or female. After the acute phase it can be replaced with another FDA-approved medication, if desired. See: http://www.maleosteoporosis.org/maleosteo/b12.htm. There is a potential issue of a relationship between calcitonin and prostate cancer, but I've never seen any literature to back that up with actual case reports of that occurring in men using calcitonin for osteoporosis. This Update showed calcitonin had the worst record for fracture reduction compared to Actonel and Fosamax: http://www.maleosteoporosis.org/maleosteo/3studies.htm. Fracture reduction is the key parameter that any osteoporosis medication is after. Bone mineral density is a hopeful feature, but studies show it isn't always correlated to decrease fracture risk.

Note that there is current research into an oral calcitonin medication: http://www.ncbi.nlm.nih.gov/pubmed/19055791. This study showed that nasal calcitonin greatly improved vertebral bone density in a one-year trial: http://www.ncbi.nlm.nih.gov/pubmed/11874243. Fracture rates were not tested in this small study.

The bottom line that I can determine is that Miacalcin has taken a back seat to other FDA-approved medications. This may be related to the fact that hip fracture reduction hasn't been very impressive. But the side effects appear to be minimal, so future studies, should they find the oral medication is effective and safe, might be worth following. They could show that calcitonin is a good replacement for one of the bisphosphonates with fewer side effects.

12. What forms of exercise are most recommended to prevent and treat osteoporosis?

Answer: The forms of exercise that are weight bearing, which include: walking, jogging, running, hiking, weight lifting and other strength training, dancing, racket sports, etc. Exercise that improves balance would include Tai Chi, yoga, and anything that improves lower body strength.

The important factors on this topic are exactly what exercise can do and what osteoporosis is. Is osteoporosis the loss of bone mineral density or some change in bone quality? Is it a fracture or something different? This is a deep philosophical topic, but I think it is generally accepted that BMD is a proxy for fracture risk--albeit not a perfect one. The risk of falling is equally as important as BMD since that is how we suffer most fractures. That is, with decreased BMD or quality a minor fall would be able to cause a fracture. So with exercise we should have two goals: improve BMD (and presumably bone quality) and reduce the risk of falls. To that end only weight bearing exercise can increase BMD, and thus is important for that purpose. Almost any exercise can increase muscle strength, improve balance, etc., and thus is also important. In short, we should all be exercising. If possible, do exercises that are proven to increase BMD and improve balance. Interestingly, it has also been shown that aerobic exercise is beneficial as in this review, http://www.ncbi.nlm.nih.gov/pubmed/12137611, and this clinical trial: http://www.ncbi.nlm.nih.gov/pubmed/19280097. Here is a study showing the relationship between physical activity and hip fracture with a 62% reduction in fractures in those doing the most physical activity: http://archinte.ama-assn.org/cgi/content/full/160/5/705. Note that several of the references, particularly 1-7, refer to other articles on this topic. Many have free full text so you can just click on them from this one article to get a lot of information on this topic. In short, it has been shown that exercise can help prevent hip fracture.

13. What is the current state of the art concerning electrostimulus for healing broken bones?

Answer: There is some evidence of benefit from both electrostimulation and ultrasound for healing in lab animals: http://www.ncbi.nlm.nih.gov/pubmed/9798836. There is a 2008 review article on electromagnetic stimulation to repair non-healing fractures that concludes: "There is a consensus that electromagnetic stimulation is an effective adjunct to conventional therapy when used in the management of non-union of long bone fractures." See this abstract in Injury, 2008 by Griffin XL and others: http://www.ncbi.nlm.nih.gov/pubmed/18321512. Here is a link to an orthopedic website where the authors say they use three different types of electrostimulation daily to hasten bone healing: http://www.orthopodsurgeon.com/elecstim.html. PubMed is harder to track good studies on this topic, so I'd have to go with the medical provider in this case.

14. What is the exact relationship between wheat bran ingestion and lack of calcium absorption? How much bran would be needed to completely prevent absorption of a 500 mg calcium supplement?

Answer: This 2000 study by Kennefick S, Cashman KD. in the Eur J Nutri, http://www.ncbi.nlm.nih.gov/pubmed/10900553, was very interesting and informative on this topic. It showed that the phytate is the problem in wheat fiber, not the fiber itself. It also showed that barley fiber doesn't have the same effect because it is 3.2 times lower in phytate than wheat, so if you are concerned, eat more barley to reduce the effects of phytate. The wheat phytate could reduce calcium uptake by about 20-25%. Presumably wheat phytate would only have effects when it is eaten along with calcium. So this effect would be completely avoidable if ingesting calcium or calcium-containing foods without also eating phytate-containing foods.

This study showed approximately 40% reduction in calcium absorption on a high fiber diet: http://www.ncbi.nlm.nih.gov/pubmed/8263606. For the short duration of the study it had no apparent negative effect on calcium balance since the body had compensatory mechanisms to deal with the lower calcium absorption. Calcium absorption wasn't affected during the fasting state when fiber was not present.

None of these studies tried to completely negate the absorption of calcium with fiber, if that is possible, so I can't answer that question. It looks like high fiber diets that most people would consume might lead to about a 25-40% reduction in calcium absorption, which the body could handle for short periods. Or which wouldn't be an issue if calcium ingestion is high enough to overcome the phytate effect. As shown by Heaney, what happens with a lower dose of calcium is that the body is more effective at absorbing more because the absorption fraction varies inversely with intake, and averages about 30% for mixed food intakes. So that would be a compensatory mechanism for the effect of the phytate. See http://www.maleosteoporosis.org/base.asp?HID=464&ACT=1&INO=38141&SD=F660860C-5B20-4F89-8C0E-41CA5AC2B584.

My interpretation of this topic is that about the only way that someone could cause real problems would be to eat a very low calcium diet combined with a very high phytate/fiber diet wherein the calcium was always eaten along with the phytate/fiber. Since to a great extent phytate is in cereal grains, consuming a variable diet, not primarily comprised of cereal grains, would eliminate the risk of low calcium levels due to fiber/phytate. Also eating foods that have moderate or high calcium content throughout the day would help alleviate the risk of phytate/fiber reducing calcium or other mineral absorption.

Return to Home