First, thanks to all the men who mailed, called, or e-mailed with comments or articles to bring to
my attention. I always appreciate the feedback very much.
Calcitonin red or yellow flag. Larry Schindler sent some information from the Prostate
Forum Newsletter, a Rivanna Health Publication Newsletter, P.O. Box 6696, Charlottesville, VA 22906-6696. Phone number (804) 974-1303. The editor is Charles E. Myers, Jr. M.D., who is the Director of
the Cancer Center, University of Virginia at Charlottesville. Larry suggests Dr. Myers` comments
concerning calcitonin should be a red or yellow flag for men taking that medication for osteoporosis. As
you all know, calcitonin is one of the currently accepted medications to treat osteoporosis that works by
inhibiting the action of osteoclasts to break down bone. Dr. Myers states, "However, laboratory studies
show calcitonin can also stimulate the growth of prostate cancer cells. For this reason, I am reluctant to
recommend its use."
I did a Medline search to see if I could find literature to back up Dr. Myers` concerns. There was
one nonclinical study using human prostate carcinoma cell lines and then testing the effects of
parathyroid hormone (PTH) or calcitonin (CT) on cell proliferation and chemotaxis (cell movement).
This article by Ritchie CK, and others, was published in 1997 in Prostate Feb 15;30(3):183-7, Medline UI
97247274. The authors state, "The calciotrophic hormones, PTH and CT, may play an integral role in the
regulation of prostate cell growth and metastases." Additionally, I found an article by Sim SJ, and others,
Ann Clinc Lab Sci 1996 Nov-Dec;26(6):487-95, Medline UI 97064768, Serum calcitonin in small cell
carcinoma of the prostate. This study found 56% of the cases (9/16) had elevated serum CT. They
concluded, "Future studies are needed for further evaluation of serum CT as a disease monitor and
prognostic marker in SCC (small cell carcinoma) of the prostate, which often is not diagnosed until the
advanced stage."
Based upon my findings, it appears there is no clinical evidence for any effect of calcitonin on
prostate cancer at this time. There does appear to be some laboratory data implicating calcitonin as a
growth stimulator of prostate cancer cells. Therefore, I would suggest that men taking calcitonin discuss
this situation with their physicians to see if either the patient or doctor would be more comfortable using
Fosamax to treat the osteoporosis. There is no evidence of anything negative as concerns Fosamax to
treat osteoporosis in prostate cancer patients.
Calcium, vitamin D, and prostate cancer risk revisited. Larry Schindler also sent a copy of Dr.
Myers` newsletter that included a discussion on the study by Giovannucci E, and others, Calcium and
Fructose Intake in Relation to Risk of Prostate Cancer. Cancer Research 58:442-447, 1998, Medline UI:
98117291. I have discussed this study in previous newsletters. In summary, the Giovannucci study
looked at the calcium and fructose intakes of more than 50,000 men in the Health Professional Follow-Up
Study. The theory was that excess calcium intake might decrease serum vitamin D levels. Since
circulating vitamin D has been found to inhibit prostate cancer, if calcium reduced the level of vitamin D,
there might be an increase in prostate cancer in those study participants taking large doses of calcium.
Additionally, circulating fructose reduces the level of circulating phosphorus. Through a complex cycle
of events, this could help raise vitamin D levels, which should decrease prostate cancer risk.
Giovannucci and others found exactly this to be the case: Increased calcium-especially more than 1000
mg/day-was associated with increased prostate cancer rates while increased fructose consumption was
associated with lower rates of prostate cancer. LunarNews discussed this article and thus suggested that
men consider taking 1000 mg or less of calcium daily to decrease prostate cancer risk and I reported this
recommendation to you. Dr. Myers points out that adequate calcium intake could be extremely important
for males-especially those with osteoporosis. He suggested that rather than restricting calcium intakes,
men concentrate on maintaining adequate serum vitamin D levels. He says, "While the paper by
Giovannucci did not measure calcitriol levels, other studies directly measured the link between calcitriol
blood levels and the risk of prostate cancer. These studies consistently report that blood levels in the
range of 40 picograms per milliliter or higher are associated with a low risk and levels below 30
picograms per milliliter with high risk of this cancer." He also says, "If you stop taking calcium, your
bones will weaken and break. The better solution is to take calcitriol." Bottom line: Men should be
tested to verify that their calcitriol level is 40 picograms per ml or more. If not, take some form of
vitamin D (including calcitriol itself, if necessary) to obtain an adequate calcitriol level rather than
reducing calcium intake below recommended ideal amounts. I`m sorry if Dr. Myers`
recommendations appear in conflict with previous information in this newsletter. The Giovannucci
article is complex and it takes someone of Dr. Myers` background, talents, and interest in prostate cancer,
to point out the importance of vitamin D levels vs. calcium intake. When I researched the recommended
calcium intake for both men and women, there are recommendations from both the National Academy of
Sciences (1997) and National Institutes of Health (1994). The highest recommended dosage for either
sex is 1500 mg daily for men and women over age 65. Otherwise, the recommended dose for men is
1000 mg daily. So, men should calculate their daily consumption of both dietary and supplemental
calcium to keep it at either 1000 or 1500 mg, according to their age, for maximum bone health. They
should also talk to their physicians about monitoring their serum calcitriol levels to keep them at 40
picograms per ml or greater to assure prostate health. It would appear to be relatively unimportant that
your calcium intake exceeds recommended allowances, at least up to 2500 mg daily, as long as your
calcitriol levels remain in the 40 picograms per ml range. Also, note how this fits in with the review of
the Heaney article on calcium practical considerations in this same issue. Thanks again to Larry
Schindler for sending me this newsletter.
Note that keeping track of calcium intake can be somewhat tricky. I noted the other day that the
fat-free, no sugar added ice cream that I normally eat had 45% of the recommended daily allowance of
calcium for a half-cup single serving. If you like ice cream or yogurt like I do, you probably don`t restrict
yourself to a half-cup serving size. This means that two one-cup servings of this ice cream daily would be
almost my entire need for calcium. If you like this kind of food, it probably makes routine calcitriol level
testing even more important since it is hard to keep calcium ingestion to 1000-1500 mg daily.
A suggestion for prostate relief from a member. Thanks to Denis Neumann for sending several
e-mails with comments and recommendations. Along the lines of men`s health, but not an osteoporosis
issue, Denis mentioned the book The Prostate Cure by Harry G. Preuss, M.D. and Brenda Adderly, MHA,
published in 1998. The focus of the book is on a compound derived from pollen called Cernitin which is
widely used in Europe to reduce or eliminate the symptoms of an enlarged prostate. A Medline search
turned up one article by Yasumoto R, and others, Clin Ther 1995 Jan-Feb;17(1):82-7, Medline UI
95277792, Clinical evaluation of long-term treatment using Cernitin pollen extract in patients with
benign prostatic hyperplasia. This study compared several parameters of benign prostatic hyperplasia
(BPH) both at baseline and after periods of from 12 weeks to one year after taking Cernitin pollen extract
in a dose of two 63 mg tablets three times daily. The study involved 79 patients, none had any adverse
effects, and several parameters were found to have significant improvement after therapy. Please note
that this was not a double-blinded study, which is the gold standard for drug studies. The product is sold
under the name of Rexall Sundown, and is available on the Internet from other companies. I have no
experience with this product, am not affiliated with any company selling it, and can`t vouch for its
effectiveness. It is mentioned in hopes it might be helpful to older men with osteoporosis and BPH.
Update on last month`s question for readers. Last month I asked for input from anyone reading
the newsletter who had significant childhood illness such as pneumonia, meningitis, etc. I only got one e-mail from a person who stated he had viral meningitis in his mid-twenties. So, there appears to be no
correlation between these illnesses and osteoporosis among men reading the newsletter.
Rate of bone renewal. I ran across an interesting figure recently in a very good review paper
called Osteoporosis and Bone Densitometry by Katherine Ott, published in Radiologic Technology,
(1998) (2):129-48, Medline UI: 99056707. She stated that, "In the mature adult, approximately 25% of
the cancellous bone and about 3% of the cortical bone are renewed annually." As you can see, it is only a
small percentage of bone that is actually undergoing change even on a yearly basis. You only have, e.g.,
Fosamax working on (at most) 25% of the total trabecular bone for an entire year. So you can`t expect too
much rebuilding from such a slow process. That now makes 3-5% annual BMD increase sound even
better to me than it did before. Incidently, this article would be an excellent reference article for anyone
wanting a review of osteoporosis and the various bone densitometry tests used to diagnose it.
What`s old but noteworthy?
Most often you`ll notice that this newsletter`s emphasis is on the latest research findings
about osteoporosis. But, occasionally when checking the literature, I find older articles
that are filled with useful information that I want to pass on to the readers. Calcium
Supplements: Practical Considerations, By R. P. Heaney, published in Osteoporosis International,
1999;1-65-71, is one of those articles with a lot of practical information that is still applicable to those
with osteoporosis, or wishing to prevent it. The Medline UI for this article is
UI: 92163645 . Remember
when using Medline, you don`t enter the letters, only the numbers to bring up the correct article.
Medline`s URL is http://www.ncbi.nlm.nih.gov/PubMed/.
Absorbability. Calcium absorption from either food or calcium supplements is generally
inefficient. And, the important thing to remember is that the absorption fraction varies inversely with
intake, and averages about 30% for mixed food intakes. At low calcium intakes, absorption occurs via
both active transport, with vitamin D helping out, and by passive diffusion across the various intestinal
membranes where absorption occurs. The most efficient area of the intestine for absorption is the
duodenum. But, food is only here a short while, thus reducing the degree of absorption at that site. At
high intakes, active transport probably has little effect on total absorbed calcium. If food is eaten with the
calcium-containing food or a calcium supplement, there is about 20-25% improvement in absorption
compared to taking it on an empty stomach. This is apparently because the food is digested and emptied
into the duodenum in multiple small squirts. This optimizes duodenal calcium absorption compared to
putting the entire contents of a supplement into the duodenum at once.
The most reliable method of measuring calcium absorption is the isotopic labeling method. Using
this method shows that calcium carbonate and citrate, two commonly used formulations, are about
midrange in all the tested compounds. About 30% of each formulation is absorbed under test conditions.
Dr. Heaney points out that the formulation of the tablet is more important than the intrinsic absorbability.
That is, if a tablet does not dissolve under simulated gastric conditions, it would not be absorbed at all in
the body. He is very wary of generic calcium supplements, and suggests brand names or
chewable/effervescent preparations where break down is assured. He points out that TumsŪ, a calcium
carbonate product, has been tested and found to show good absorbability.
Dosage Regimen. "Calcium absorption efficiency varies inversely as the logarithm of the size of
the load." Accordingly, if rather than taking a 1000-mg dose of calcium, it was divided into two doses of
500 mg each, 30% additional calcium would be absorbed. Or, if this 1000-mg dose was divided into four
doses of 250 mg each, then 60% more calcium would be absorbed. There are other considerations: <
1. Patient compliance. If the patients won`t follow the four-daily dose regimen, they are probably
better off with the larger dose taken less frequently.
2. Timing of the dose is important as mentioned previously with meal times being best.
3. Large calcium loads can interfere with iron absorption both from food or medicines. Anyone
with an iron deficiency should probably take the calcium-citrate-malate (CCM) that is found as a fortifier
in citrus juices since it does not affect iron absorption.
4. One of the four daily calcium doses taken at bedtime has much to offer. It is during the fasting
state that most parathyroid hormone-mediated bone breakdown occurs. Calcium should help avoid some
fasting bone breakdown.
Calcium Supplements, Calcium Solubility, and Gastric Acidity. Dr. Heaney points out that the
solubility of the calcium compound is irrelevant, even though this is generally thought to be an important
attribute. Even in older individuals with achlorhydria (lack of stomach acid), it has been shown that
calcium carbonate, which is relatively insoluble, can be absorbed adequately if taken with meals. This is
one more reason to take the calcium supplements with meals if you have normal stomach acid or not.
Choosing Dosage. Individuals typically vary in their ability to absorb calcium at high intakes in
the range of 6-20%-a factor of three. There are tests available to evaluate a person`s absorption of
calcium. Someone not reaching expectations on osteoporosis therapy, might want to look into having one
of these tests done to be sure they are adequately absorbing ingested calcium.
Safety. Dr. Heaney indicates that calcium intakes up to 2500 mg daily are safe. In Masai in East
Africa, people ingest in excess of 6000 mg of calcium daily with no apparent ill effects. He also states
that kidney stones should not be a concern unless the person has absorptive hypercalciuria. This person
has no need for a high calcium intake both because their bodies don`t need the extra calcium, and it can
increase the risk of kidney stones.
< Summary. <
1. If you are going to supplement your calcium intake, use a brand-name product.
2. To maximize absorption of calcium in food or supplements, divide the day`s total dose into at
least four smaller doses to be taken with food.
3. Take one supplement dose at bedtime with a snack or eat a snack containing calcium in it.
4. If you have iron deficiency, use a juice with the CCM form of calcium.
5. Lack of gastric acidity is not important as long as calcium is taken with meals.
6. Doses up to 2500 mg daily appear to be completely safe except for persons with absorptive
hypercalciuria. [Editor`s note: Recent research has raised some doubt on this figure for men, suggesting
1000 mg daily as a safer target. But, as long as calcitriol levels are monitored and remain in the 40
picograms range, excess calcium intake should not be a problem even for men. If you can`t or won`t
monitor serum calcitriol, then it should be wise to keep calcium intake to about 1000 mg per day or less if
your physician agrees.]
Book review
The Osteoporosis Book, A guide for Patients and their Families,
ISBN 019511602X, by Nancy E. Lane, M.D., is an
excellent reference source for anyone wanting information about osteoporosis. The book was
published by Oxford University Press in 1999 and I was able to purchase in on line at
www.amazon.com. Dr. Lane uses case studies of people to explain osteoporosis-related
problems and give them a realistic connotation. Each chapter has a complete list of references used in
writing it in the back of the book to further your knowledge if you want to go to the source. To give you
an idea of how comprehensive the coverage of osteoporosis is, note the following chapter outline:
Part I - Understanding Osteoporosis
Who Is At Risk of Developing Osteoporosis?
How Do We Diagnosis Osteoporosis?
Bone Fractures and Osteoporosis
Do Men Get Osteoporosis?
Part II - Prevention and Treatment of Osteoporosis
Prevention of Osteoporosis and Management of menopause with Hormone Replacement Therapy
Medications Other Than Hormones to Prevent and Treat Osteoporosis
The Role of Vitamin D
Exercise, Bone Health, and Osteoporosis
Bone-Building Agents: Are There Any "Magic Bullets?"
Prevention and Treatment of Secondary Osteoporosis
Treating the Pains and Problems of Osteoporosis
Dr. Lane is Associate Professor at the University of California, San Francisco, and co-director of
Clinical Rheumatology at San Francisco General Hospital. A quick check of Medline with the terms
"Lane NE" will produce abstracts of over 50 articles that she has written or co-authored indicating her
strong background in medical research. After reading the book, you will realize that this research
background has given her a unique ability to express in easily understandable terms the various
complexities of osteoporosis diagnosis, prevention, and treatment.
Make no mistake about it, this book is primarily directed to women who either have, or may get
osteoporosis. This is how it should be since more women develop osteoporosis and generally at a
younger age than men. There is, however, a chapter on men with osteoporosis. But after reading it you
will think that only men aged 80 or older have any significant risk of osteoporosis. Tell that to the 34-year-old man who recently e-mailed me, or the others in their 30s, 40s, or 50s in our group with
osteoporosis. The weaknesses in the chapter on men notwithstanding, the rest of the book is loaded with
timely accurate information. Both men and women should gain a tremendous understanding of
osteoporosis, especially those just finding they have the disease and needing a lot of information quickly.
It would take you weeks of reading the information gleaned from searching Medline`s abstracts to find
information that you`ll read in minutes in this book.
Here are some interesting findings or especially noteworthy sections.
Steroids: In the discussion of steroid-induced bone loss, p.29, Dr. Lane notes that, "At a dose of
7.5 milligrams a day for 6-12 months, prednisone results in a loss of 10 to 20 percent of spinal trabecular
bone." Unbelievably, the 34-year-old with osteoporosis that I mentioned earlier had never been warned
of any possible bone problems due to the long-term use of steroids to treat his asthma and sinusitis.
Certainly if you are on steroid therapy for asthma, rheumatoid arthritis, or other auto-immune diseases,
you need preventive measures against this rapid loss of trabecular bone.
Diuretics: Diuretics are often prescribed to prevent excess loss of calcium in the urine and thus
increase bone mass. Dr. Lane states (p. 31), "However, although thiazides may prevent bone loss, a
woman must take them for over 10 years to achieve this effect." Don`t expect a quick fix from diuretics.
Antacids: Dr. Lane notes that aluminum-containing antacids, especially if combined with other
osteoporosis risk factors, could be quite deleterious to bone mineral density since they increase calcium
loss in the urine. She says, ". . .neither men nor women should take aluminum-containing antacids unless
they are prescribed by a physician.
DXA clinical interpretation: The entire section of bone densitometry on pages 43-46 is
excellent. There are very good photos, diagrams, and explanations of the complexities of understanding
DXA results including the spine, hip, and forearm. Questions about DXA results are common for people
who first find they have osteoporosis. This section alone will provide a lot of answers for those striving
to understand what the DXA means.
Vertebral fractures: Vertebral compression fractures are common findings in people with
osteoporosis and I`ve had them myself. But, I have to admit I didn`t really understand what they are. The
diagram and explanation on page 54 very simply and clearly shows exactly what the three types of
vertebral fractures are and how they affect the spine.
In summary, Dr. Lane`s book is one that anyone, especially when newly diagnosed with
osteoporosis, should buy to get an excellent overview of the diagnosis, prevention, and treatment of
osteoporosis. It will serve as a good source of initial information, and as a reference later if questions
develop about osteoporosis-related issues.
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.
EDITOR
