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
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
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,
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.
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.
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.
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
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
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.