Men`s Osteoporosis Support Group
Volume II - Special Edition	May 1, 1998

Special Edition

Introduction

The Cooper Aerobics Center

Dr. Kenneth H. Cooper`s first book, Aerobics, popularized not only the term but the entire form of exercise. Before this book was written, about the only joggers or runners were on high school, college, or Olympic teams. Now, as we all know, joggers, and people doing all forms of aerobic exercise, are everywhere. Dr. Cooper founded The Cooper Aerobics Center in Dallas in 1970 as a way to carry on the knowledge he had gained while developing the Aerobics Point System while serving 13 years in the U.S. Air Force as a flight surgeon. The philosophy of the center is that it is easier to maintain good health through proper exercise, diet, and emotional balance than it is to regain it once it is lost. There are five major elements within The Cooper Aerobics Center that I will summarize from brochures available from The Cooper Aerobics Center.

The Cooper Clinic(R) provides the most up-to-date preventive medicine expertise in the world and helps thousands of individual and corporate patients each year. Clinic services include: Treadmill stress testing, comprehensive laboratory testing, body fat percentage testing, strength and flexibility testing, weight control and nutrition consultation, women`s preventive services, osteoporosis screening, FAA certification, sports injury therapy, mental health services, oral cancer screening, nuclear medicine/CAT scanning. The phone number of The Cooper Clinic(R) is 800-444-5764.

The Cooper Institute for Aerobics Research is known worldwide for its research and education programs. These include FITNESSGRAM: a fitness and physical activity testing program for children K-12, PALS: a personalized health and lifestyle assessment, corporate work site health promotion programs, training and certification programs for health, fitness, and medical professionals, and custom health/fitness newsletters and health education materials. The phone number is 800-635-7050 and this is the Web site for The Cooper Institue of Aerobics Research.

The Cooper Wellness Program(R) incorporates all elements of The Cooper Aerobics Center with a powerful, fast-track approach to optimal health. People taking the program will find a supportive, spa-like environment with programs custom designed to rejuvenate and educate participants while encouraging permanent, positive lifestyle changes. Weight management and smoking cessation assistance is available. The programs run from one day to two weeks. The phone number is 800-444-5192.

The Cooper Fitness Center(R) provides the finest in athletic/fitness facilities with a professional service-oriented staff available. For membership information, call 888-964-8875.

The Guest Lodge at the Cooper Aerobics Center is a 63-room European-style hotel. Individuals attending any of the facilities at The Cooper Aerobics Center can stay at The Guest Lodge during their visit. All the normal hotel amenities are available including health club privileges. Call 800-444-5187.

My visit to The Cooper Clinic(R)

In Volume 1, Issue 3 of this newsletter, I mentioned the Imatron Ultrafast CT(R) as a non-invasive test to detect and quantify calcium in the coronary arteries. Some Internet search engines actually store every word in the documents they search. This fact enabled Mr. Jerry Friede, Director Cooper Clinic(R) Preventive Imaging, to find that newsletter while searching for information using the word "Imatron." He wrote me an e-mail to explain that he didn`t realize that there was a men`s osteoporosis support group and thought we might be interested in his findings. The Cooper Clinic(R) had been using the Imatron Ultrafast CT(R) and was finding an unexpected number of men with low bone mineral density. I called the clinic to get more information and was invited to see what they were doing. I accepted the invitation without delay and scheduled an afternoon visit two days later.

I arrived at the clinic shortly before the 2:00 P.M. appointed time. It is located on Preston Road which is easily accessible from I-35, I-635, or the Central Expressway. The buildings fit well within the large grassy area that has many rubber-coated side walks for comfortable jogging. Many of the buildings and walks are tree-lined, making you forget your closeness to downtown Dallas. The Preventive Imaging department is upstairs in The Cooper Clinic(R) building where I was greeted by Carl, one of the technicians with whom I had spoken earlier in the week. He immediately invited me in to see the Ultrafast CT(R) scanner.

Never having seen a CT scanner before, I didn`t know what to expect. I have had several MRIs and assumed the Ultrafast CT(R) would be similar. It was, but it did not have the large tomblike cover that you slide into when having an MRI. Instead, it was a metal ring with some reinforcing structures around it, that gave me a comfortable open feeling compared to viewing the MRI machine. This scanner is about ten times faster than the fastest of conventional CT scanners. This speed is necessary to "freeze" cardiac motion. The radiation for a test is similar to a standard X-ray film of the abdomen. Carl showed me the supporting equipment that isn`t normally seen by patients and it was impressive. It included cooling equipment and the control boxes that looked very expensive and complex. We walked back from the control equipment area and Carl said, "Lift your shirt up, we`ll put some cardiac leads on your chest and we`ll give you a scan." I wasn`t expecting such a first-hand view of exactly what the machine did, but I agreed readily because I knew it would be highly educational.

As mentioned, you don`t take any clothes off and, at most, just empty your pockets of metallic items before lying down on the platform that slides under the ring. Carl showed me the phantom, a metallic sheet that acts as a density reference when finding bone mineral density. This is placed on the table under your body and will show up on a scan under your spine, more on this later. He had me lie flat with my arms over my head holding a plastic bar in somewhat of a chin-up position. This comfortably keeps the arms out of the way during the scan. He went out of the room and talked to me through a microphone during the procedure. First he had me hold my breath for about 20-30 seconds as I moved through the ring from the level of my shoulders to about the lower tip of my sternum. I then had a few moments to catch my breath before the next scan which was from the last position to my lower abdomen. The machine repositioned itself while I gained my breath before I held my breath one more time while it scanned my heart. Carl had explained that the slower the heart beat, the longer you have to hold your breath since the computer times the exposures when the cardiac leads indicate the heart is resting. This gives an image like a still frame of the heart and vessels when viewed later. This was the first time I was sorry about doing aerobic exercise for so long because the time to take the scan had me happy to take a nice deep breath of air at the end. But, even that was not really uncomfortable, making the overall procedure as simple as could be expected. The entire scan time was probably just more than a minute, and the entire time on the table was approximately five minutes. The extra time was taken by setting up the computer with my name and other information, I presume.

After the scan, I met Mr. Jerry Friede who sat me right down at a large computer monitor and proceeded to show me what the inside of my upper body looked like. This was fascinating to watch and very educational. First he showed me the scans of my heart while pointing out the areas where the various arteries were located. I was happy to say that I saw nothing where he was pointing. Jerry confirmed my happiness by telling me that my coronary calcification score was zero-as good as it gets. I was subconsciously thanking myself for almost thirty years of following Dr. Cooper`s exercise and diet tips. Jerry showed me age-matched tables that would explain the risk of an ischemic coronary event for that person according to the calcification score they received. For instance, at age 50 if you were in the zero range, your risk was as low as possible, if you were over about 1,200 your risk was very high. Those numbers in between would have less risk in accordance with the size of the number. Jerry showed me scans of people who had coronary artery calcification so I could see what it looked like. The view was impressive and would certainly get your attention as you watched the computer monitor. He explained that this was a powerful way to enforce the importance of the need for diet, exercise, medications, and other means to lower heart attack risk. People who view the image of their own arterial calcification take the matter seriously. Jerry pointed out that the personal look at my results was not something special for me, in fact, every person who is scanned at the clinic gets to look at the results of the scan.

How important is coronary artery calcification in contributing to heart attacks? A recent multi- center study led by John J. Mahmarian, M.D. of the Baylor College of Medicine in Houston, Texas found that 94% of people experiencing a first heart attack had coronary artery calcification which could have been detected by the Ultrafast CT(R) scanner. Furthermore, a majority of these individuals had relatively low calcium scores which suggest that they could not have been detected by other tests such as treadmills or stress nuclear imaging. The authors concluded that "A lack of coronary calcification therefore identifies a population at very low risk for coronary artery disease and subsequent cardiac events."

The Ultrafast CT(R) was originally used by The Cooper Clinic(R) and, is apparently being used elsewhere, solely as a coronary vessel calcification scanner. That means those people only receive(d) the last scan that I had where scanning was done between beats of the heart. The cost of the multiple scan as done at The Cooper Clinic(R) is $595. That done elsewhere, consisting of only the heart scan, costs about $450-495. Jerry Friede noticed that doing only the heart scan limited the usefulness of the results because so much additional information is available with the two quick additional scans of the chest and abdomen. Thus, the added scans have been done at The Cooper Clinic(R) for the last couple of years while they have accumulated data about what has been gained with those scans. From my view, that extra information is incredibly exciting and I can`t wait for the published results to see exactly what they found. The next two areas of my scan that we viewed cover that extra information gained by the other two scans.

We proceeded to view the internal organs, bones, and other structures that had been scanned. Try to imagine a hot dog setting on a plate at eye level, and you are viewing its end. You are cutting it into thin slices and taking a video shot of the hotdog after each slice. Then later you play back the video to see what was contained within each part of the hot dog. This is roughly what you see of the image of your body`s insides as you watch the computer monitor. You can start at the tips of your lungs, work to the middle, and then lower ends. Using the mouse to scroll the information, you can move slowly or as fast as you want. You see the airways and structure that you associate with normal lung tissue. Then you follow the esophagus through the lower lung segments and can actually look for hiatal hernias or similar problems. We also looked at the images of the liver, spleen, pancreas, kidneys, adrenal glands, and other organs, all with no apparent abnormalities. Jerry explained that using this technique, they had found dozens of early cancers in the people tested. So far, all of these have led to successful treatment because the tumors were found before spreading to other parts of the body. Jerry also showed me the lung scan of a 53-year-old woman smoker. He explained that as she watched the scan she immediately stated that she was now an ex-smoker. There were no reference images of normal lungs and no one pointed out the damage to her to help her make that decision. It was purely the power of the images of her own badly damaged lungs that convinced her.

The last thing we checked was my bone density. As you recall, there was a reference phantom placed on the table under me while I was scanned. This metallic image was now visible as we found my lumbar spine. Jerry could actually take a "cut" right through the middle of the vertebra so we were checking the density of the inner trabecular bone, the most important to evaluate for osteoporosis. Using our hot dog reference above, it was as though the skin of the hot dog was the thick cortical bone and the inside of it was the trabecular bone. He then drew out a reference box using the mouse, compared that to one on the phantom, and the computerized results were matched to give a percent of bone loss. My results showed 83% of normal BMD and my most recent DEXA showed 86% of normal. According to Jerry, this is to be expected since this is a more sensitive test of bone mineral density. The DEXA is a posterior-anterior x-ray that must include all the cortical bone, arthritic bone, abnormal soft tissue calcifications, etc. These should lead to a slightly greater appearing bone density than the test on my spine that only included trabecular bone.

The addition of the bone density test to the Ultrafast CT(R) scan results at The Cooper Clinic(R) has shown an unexpected high rate of low bone mineral density in the "normal" males that have been tested so far. The exact results will be published later, but some general figures are available now. From tests of about 5,000 men, in those aged 55-59, about 25% have low bone density and half of those have density below the fracture range. By ages 65-69 that number doubles: 50% have low bone density and half of those have readings below the fracture range. Jerry says that, although hormonal abnormalities and steroidal anti-inflammatory drug use account for some of the cases, the vast majority of cases appear related to calcium deficiency, physical inactivity, and (sometimes) smoking. They have often found that many general medical practitioners don`t accept the idea that their male patients have osteoporosis and don`t adequately treat the condition. They recommend that men seek out an endocrinologist or other physician specializing in osteoporosis if their physician does not take the finding seriously. It was pointed out that several men have been treated with Fosamax and have shown significant increases in bone mineral density in a one-year follow-up test.

We were viewing my results in the back of the lab near the scanner. Jerry took me to the front where people normally see their scans in a nicely appointed room that also has the large computer monitor and comfortable chairs to sit in while viewing the results. There are several pamphlets with diagrams and charts to explain the results and risks at each step of the explanation. They have found that compliance with recommendations for diet and exercise modification are excellent and feel that this is largely attributable to the first-hand viewing of the data rather than sending written results as is often done after x-rays, MRIs, or CT scans. I know that I found viewing my results both fascinating and powerful. Had coronary calcifications been present, it would have gotten my attention without a doubt.

Some observations

One interesting observation that Jerry noted was that so far in their tests serious weight lifters do not show osteoporosis. These men tested generally use moderate to heavy weights at least three times a week. There have been many T-scores (age-matched bone density) that are +1-2 standard deviations above normal. He points out that weight lifting must be done properly to avoid injury or degenerative changes and those with back problems should be cleared by a physician and learn proper technique from a certified trainer (most are not certified). Those with severe osteoporosis should take care not to over lift as that may cause vertebral compression fractures. Slowly increasing the weight used while strengthening bones with calcium, Vitamin D, and often Fosamax would be reasonable. Anyone with chest pains or existing heart disease should obviously not take up new exercise until cleared by a physician and anyone with high blood pressure should have that condition controlled first.

I was concerned about insurance coverage of the test. Jerry says that many insurance companies do cover the test. Usually there needs to be a diagnosis for insurance to cover, i.e., chest pain or discomfort, shortness of breath, osteoporosis, abdominal pain, back pain, etc. Most insurance companies also require a physician`s referral.

In the people tested so far, there appears to be a definite correlation between patients with osteoporosis and coronary atherosclerosis. There are, however, many exceptions and the relationship most probably reflects the fact that many people who develop both conditions have a propensity toward poor diet and exercise habits.

I had wondered about the use of the Ultrafast CT(R) to also scan for carotid artery calcifications in the neck as an additional scan. Jerry said that ultrasound does such a good job of carotid artery imaging that it is felt to be the method of choice. They do often recommend the carotid ultrasound when there is substantial coronary and/or aortic calcification that shows up in the scan.

An interesting aspect of the tests is that after coronary calcifications are found, subsequent annual tests can be done to monitor results. The great part of this monitoring is that the test is non-invasive and objective, and the person can actually view the changes or lack thereof in arterial calcification and/or bone density. Jerry says they expect to see increased bone mineral density at follow-up on patients that start therapy after being diagnosed with osteopenia or osteoporosis. They, however, really do not expect to see regression in calcified plaque, but what they look for is a lack of progression (stability). Their data shows that patients with above normal calcification for their age will progress quite rapidly without treatment. When treatment to lower LDL cholesterol is implemented, progression slows dramatically and sometimes stops completely.

The published results of all the details contained in the data from thousands of scans at The Cooper Clinic(R) should have interesting ramifications. It is hoped they will give guidance as to who would benefit most from a scan with the Ultrafast CT(R) using The Cooper Clinic(R) method. If the results are dramatic enough, it may cause other testing facilities to add the two additional scans to a normal test rather than only doing the heart scan. Additionally, it would be important to have objective data describing the importance of needed follow-up examinations, perhaps based upon age and conditions diagnosed in the original scan. Of course, the final picture of the rates of osteopenia and osteoporosis in the sample of men should be very interesting. The men who attend The Cooper Clinic(R) undergo a very thorough physical and provide a detailed personal history, including diet, exercise, and other factors that might be important to elucidating the source of the low bone mineral density in the men tested. If testosterone levels are tested, that might provide further information as to the cause of the men`s low bone mineral density. If these factors can be correlated with the causes of low bone mineral density in tested men, there should be additional information available to help men prevent osteoporosis, obviously more desirable than treating it after it occurs.

Summary

The Ultrafast CT(R), as used at The Cooper Clinic(R), appears to have tremendous potential to diagnosis multiple serious problems with a thorough, quick, and non-invasive test. As pointed out, there is strong evidence that the finding of coronary artery calcification identifies that person as someone at risk for heart attack. Realizing that heart attack risk is present, that individual can then take advantage of all that is known to reduce their risk by diet, exercise, and medications. Annual heart scans thereafter will attest to the effectiveness of therapy. The importance of the other scans would be readily agreed upon by all in whom early cancers and low bone mineral density were detected by those scans. The significance of the findings on the percentage of "normal" men with low bone mineral density who have taken the test is yet to be fully described. The future publication of the results appears to have the potential to change the view that males are generally not expected to be candidates for osteopenia or osteoporosis, that being solely the worry of women. As soon as these final results are available, I will summarize them in this newsletter.

Disclaimer

Diagnosis and treatment of osteoporosis are the responsibility of the patient and his or her physician. Nothing in this newsletter is to be interpreted as a recommendation for treatment or to change treatment that your physician has prescribed. Although we attempt to assure that information in this newsletter is factual, errors will occur. It is the responsibility of the reader to verify that information they are acting on is factual. There is no relationship between this newsletter and any national osteoporosis group, including the National Osteoporosis Foundation. All references to any such groups are for informational purposes only.