Commentary: Male Osteoporosis—Policy Gaps in Prevention and Treatment

Osteoporosis is a disabling disease affecting 10 million Americans, leading to increased risk of fractures and poor functional ability. Although typically thought of as a women's disease, millions of men are diagnosed with osteoporosis or low bone mass, and the risk for osteoporotic fractures is increasing. To address undetected and untreated osteoporosis among men, public health education should be targeted to males. Insurance programs, including Medicare, should add the heel qualitative ultrasound (QUS) for age-eligible men with follow-up every 2 years. Policy changes should address funding of targeted education and prevention programs for aging males, including coverage of screening tests.     

Osteoporosis in the aging population: the male perspective

The importance of senile osteoporosis in men as a public health problem has long been underestimated. Elderly men are at substantial risk for fracture, and morbidity after osteoporotic fractures appears to be more serious and mortality more common in men than in women. Risk factors for osteoporotic fractures in men appear to be qualitatively similar to those in women, but there are quantitative differences. Low bone mineral density (BMD) is an important risk factor for fracture in men; however, further clarification of the relationship between BMD, bone geometry and fracture risk is needed before formulating definitive proposals on operational densitometric criteria for diagnosis of osteoporosis in men and the identification of men at high risk for fracture. Understanding of the mechanisms underlying senile bone loss and the pathogenesis of senile osteoporosis in men remains fragmentary with, in particular, the need for further clarification regarding the precise impact of hormonal status in elderly men on skeletal homeostasis. Recommendations on prevention and treatment of senile osteoporosis in men should focus on the minimization of known risk factors for bone loss and falls. Testosterone treatment may be useful in those men with initially low serum testosterone. As to other pharmacological treatment modalities, prospective trials specifically in elderly men, and preferably with fracture incidence as the primary clinical endpoint, are required.     

Osteoporosis: implications for risk reduction in the college setting.

Osteoporosis is often considered a chronic disease of older adulthood. As with many chronic diseases, lifestyle behaviors adopted during young adulthood are important risk factors for future development of osteoporosis. The college student population represents the age group in which optimal bone development is likely to occur and certain lifestyle behaviors are reinforced. Therefore, risk factors for osteoporosis, including nutritional insufficiency of calcium and vitamin D, smoking, alcohol abuse, excessive exercise, use of steroids, and high-protein diets, have special relevance for this target population. The authors examine risk factors for osteoporosis that are especially relevant to the college health setting and offer intervention strategies for college health professionals.     

Fitness and Mobility Exercise (FAME) Program for stroke

Given the potential of exercise to positively influence so many physical and psychosocial domains, the Fitness and Mobility Exercise (FAME) Program was developed to address the multiple impairments arising from the chronic health condition of stroke. We present the details of this exercise program and the evidence which has shown that the FAME Program can improve motor function (muscle strength, balance, walking), cardiovascular fitness, bone density, executive functions and memory. The FAME Program can help to improve the physical and cognitive abilities of people living with a stroke and reduce the risk of secondary complications such as falls, fractures and heart disease.     

The Health Belief Model and the Contraceptive Behavior of College Women: Implications for Health Education

Abstract

“The Incidence of Primary Cardiac Arrest During Vigorous Exercise,” David S. Siscovick, et al. To examine the risk of primary cardiac arrest during vigorous exercise, we interviewed the wives of 133 men without known prior heart disease who had had primary cardiac arrest. Cases were classified according to their activity at the time of cardiac arrest and the amount of their habitual vigorous activity. From interviews with wives of a random sample of healthy men, we estimated the amount of time members of the community spent in vigorous activity.

Among men with low levels of habitual activity, the relative risk of cardiac arrest during exercise compared with that of other times was 56 (95% confidence limits, 23 to 131). The risk during exercise among men at the highest level of habitual activity was also elevated, but only by a factor of 5 (95% confidence limits, 2 to 14). However, among the habitually vigorous men, the overall risk of cardiac arrest—i.e., during and not during vigorous activity—was only 40% that of the sedentary men (95% confidence limits, 0.23 to 0.67).

Although the risk of primary cardiac arrest is transiently increased during vigorous exercise, habitual vigorous exercise is associated with an overall decreased risk of primary cardiac arrest. (New England Journal of Medicine 1984;311:874-7.)

“Osteoporosis in Women with Anorexia Nervosa,” Nancy A. Rigotti, et al. Because estrogen deficiency predisposes to osteoporosis, we assessed the skeletal mass of women with anorexia nervosa, using direct photon absorptiometry to measure radial bone density in 18 anorectic women and 28 normal controls. The patients with anorexia had significantly reduced mean bone density as compared with the controls (0.64 ±0.06 vs. 0.72 ±0.04 g per square centimeter, P < 0.001). Vertebral compression fractures developed in two patients, and bone biopsy in one of them demonstrated osteoporosis. Bone density in the patients was not related to the estradiol level (r = 0.02). Levels of parathyroid hormone, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D were normal despite low calcium intakes.

The patients with anorexia who reported a high physical activity level had a greater bone density than the patients who were less active (P < 0.001); this difference could not be accounted for by differences in age, relative weight, duration of illness, or serum estradiol levels. The bone density of physically active patients did not differ from that of active or sedentary controls.

We conclude that women with anorexia nervosa have a reduced bone mass due to osteoporosis, but that a high level of physical activity may protect their skeletons. (New England Journal of Medicine 1984;311:1601-6.)     

Trunk stabilization with sling training in osteoporosis patients—a randomized clinical trial

Fractures due to osteoporosis are one of the principal causes of functional limitations, chronic pain, and greater morbidity in advanced age. In addition to bone risk factors for osteoporotic fractures include extraosseous causes such as falls or reduced neuromuscular capacity. Muscle and coordination exercises enhance the patients’ abilities in daily life and prevent falls. In view of recent conclusions drawn from competitive sports, which stress the significance of the muscles of the trunk in respect of reducing back pain and optimizing posture, we used sling exercises to determine whether osteoporosis patients benefit from it and whether it is more advantageous than traditional physiotherapy. Fifty patients were randomized into two groups. Group A received traditional physiotherapy, while group B was given sling exercises, in each case twice a week for a period of 3 months. The results of treatment (pre-post) were analyzed in terms of pain levels, mobility, trunk strength, and the shape of the back. After a further 3 months with no specific exercise treatment, we retested all patients in order to draw conclusions about the long-term effects of the two types of exercise. Forty-four patients (88 %) completed the study. Patients were assigned to small groups (a maximum of five patients in each group) and, thus, received individual attention and motivation. Positive training effects were achieved in both groups. Significantly better results as regards improvement of mobility and reduction of falls were registered in the sling exercise group.     

Role of physical activity in the prevention of falls and their consequences in the elderly

This work aims to provide an inventory of the risk factors and consequences of falling in the elderly, namely fractures, and to identify strategies to prevent falls and minimise their effects. Falls in elderly people are a major cause of injuries, leading to a general fear of falling, poorer quality of life and even death. The increase in life expectancy brought by developments in the medical and health sciences has not always brought enhanced quality of life. More elderly people live with reduced functional capacities resulting in a higher prevalence of falls and associated problems for themselves and for society. Risk factors for falling, commonly resulting from normal aging processes, have already been identified through multiple studies. Exercise may play an important role in fall prevention and their consequences. Although, effective strategies are usually multi-disciplinary and focus simultaneously on several risk factors. However, only large-scale prevention programmes can have significant effective social impact. To minimise occurrence and consequences of falls, policies to systematically implement prevention programmes should be established.     

Clinical effects of growth hormone on bone: a review

Growth hormone (GH) stimulates bone turnover. Deficiency of GH due to hypopituitarism is related to low bone mineral density and increased fracture risk. GH substitution increases and thus normalizes bone mineral density in these patients, which is one of a number of arguments for GH substitution in hypopituitarism. In contrast, a possible therapeutic use of GH in idiopathic osteoporosis and glucocorticoid-induced osteoporosis is speculative and not established. Reduction of osteoporosis risk is an argument brought up for a use of GH in healthy elderly persons (anti-aging medicine). However, since only very limited data are available yet, this cannot be based on scientific evidence, and there are important concerns about the safety of use of GH in healthy elderly persons.     

Overview of the physiological changes and optimal diet in the golden age generation over 50

Basically, our lifespan is determined genetically. However, several other parameters such as the environment, lifestyle and diet have a high impact on living in the best of health. Many older persons suffer from various diseases, which often cannot be avoided; however, their development can be postponed and symptoms can be mitigated by a balanced diet, moderate physical activity as well as a healthy lifestyle. These diseases are, for example, sarcopenia (degenerative loss of muscle mass), osteoporosis (decomposition of bone structure), digestive restrictions, sensory impairment, water imbalance or a compromised immune system. Psychological modifications, obesity and loss of weight also commonly occur in older adults. To define an adequate diet for elderly between the ages 50 and 80 is difficult, even impossible, because the nutritional requirements differ between the dynamic quinquagenarian and the frailer eighty-year-old. However, several studies have shown that sufficient consumption of high-quality proteins, calcium, vitamin D, anti-oxidative food compounds, water as well as adapted energy values and nourishment with high-nutrient density in combination with physical activity especially help one to remain healthy to a great age. The cornerstone of healthy ageing is the maintenance of normal bodyweight in order to prevent the development of diseases such as osteoporosis, coronary heart disease or diabetes type 2. This publication will review the physiological changes that occur with advanced age and consequential nutritional recommendations for elderly persons.     

LOH–pitfalls of an ambiguous abbreviation

Osteoporosis in elderly men is becoming an important health issue with the aging society. Elderly men with androgen deficiency are exposed to osteoporosis and can be treated with testosterone replacement. In this study, Eurycoma longifolia (EL), a plant with androgenic effects, was supplemented to an androgen-deficient osteoporotic aged rat as alternative to testosterone. Aged 12 months old Sprague-Dawley rats were divided into groups of normal control (NC), sham-operated (SO), orchidectomised-control (OrxC), orchidectomised and supplemented with EL (Orx?+?El) and orchidectomised and given testosterone (Orx?+?T). After 6 weeks of treatment, serum osteocalcin, serum terminal C-telopeptide Type 1 collagen (CTX) and the fourth lumbar bone calcium were measured. There were no significant differences in the osteocalcin levels before and after treatment in all the groups. The CTX levels were also similar for all the groups before treatment. However, after treatment, orchidectomy had caused significant elevation of CTX compared to normal control rats. Testosterone replacements in orchidectomised rats were able to prevent the rise of CTX. Orchidectomy had also reduced the bone calcium level compared to normal control rats. Both testosterone replacement and EL supplementation to orchidectomised rats were able to maintain the bone calcium level, with the former showing better effects. As a conclusion, EL prevented bone calcium loss in orchidectomised rats and therefore has the potential to be used as an alternative treatment for androgen deficient osteoporosis.     

Can balance exercise programmes improve balance and related physical performance measures in people with dementia? A systematic review

This review presents the physical performance outcomes of randomised trials investigating exercise programmes that included balance exercise for older people with dementia. A systematic literature search through five computerised bibliographic databases until February 2009 was carried out. Of 1,038 potentially relevant published articles, only seven met the inclusion criteria and were extracted. Findings from the review for a total of 632 participants showed that almost all of the included studies addressed exercise or physical activities as the main intervention; however, only two of the studies focused on balance exercise. The effect size values varied from no effect (0.00) to a large effect (3.29) of the interventions for a range of physical performance outcome measures. Findings also suggest that it is feasible to conduct exercise programmes with older people with dementia. However, further studies with more specific exercise designed to improve balance performance in order to prevent falls are required for older people with dementia.     

Falls recall��limitations of the most used inclusion criteria

The demographic changes in the industrialized countries place new and important challenges to health care providers, politicians, and modern society. Many older persons wish to maintain independence and mobility as long as possible. Falls and their consequences constitute a serious threat to these most important goals of the older person, and they do occur frequently in the community-dwelling cohort of people aged 65 years and older. This article discusses the limitations of one of the most important independent risk factors to predict future falls: a positive fall history. Several issues arise with assessing fall history in an older population. Firstly, several studies indicated that self-reported recall of falls may lead to underreporting and that older persons perceive a fall differently compared to health professionals and researchers. Secondly, falls can be reported retrospectively or prospectively. In general, a prospective design is favored by researchers with “daily fall calendar” considered the golden standard. Thirdly, different research has been conducted to find the most reliable time frame for self-recorded falls in the past. Self-reported recall of falls by older persons may lead to underreporting due to older persons not recognizing (the severity of) a fall or not remembering a fall and due to different interpretation of “a fall”. Data on fall history should be expanded with questions about trips, slips, and self-perceived problems in balance, gait or mobility and preferably fear of falling or a quick physical assessment. In general, a prospective design is favored by researchers with “daily fall calendar” considered the golden standard. Computerized interactive response technology may be of additional value to prospectively monitoring falls in older persons. The best time frame for obtaining self-reported falls seems a period of 12 months, ruling out any seasonal influence.     

National Osteoporosis Society's Position statement on hormone replacement therapy in the prevention and treatment of osteoporosis

Hormone replacement therapy (HRT) has been shown to increase bone density, reduce the risk of fracture and can successfully relieve menopausal symptoms. From a time when HRT was the major therapeutic option for the management of osteoporosis, women and their clinicians now have a range of treatments available. Following the publication of the Women's Health Initiative (WHI) and the Million Women Study highlighting potential side-effects, such as breast cancer, heart disease and stroke, many doctors and women are now reluctant to use HRT. The National Osteoporosis Society felt that the role of HRT in the management of osteoporosis needed to be clarified. Using the Charity's expert clinical and scientific advisers, and through public consultation with members and key stakeholders, a Position Statement has been published. We conclude that HRT has a role to play in the management of osteoporosis in postmenopausal women below the age of 60 years. The key recommendations of the Position Statement are presented in this paper.     

Prevention and treatment of osteoporosis in women

Osteoporosis affects one in three women. There has been some confusion among women and health professionals about the management of osteoporosis since the publication of the Women's Health Initiative and Million Women studies. This guidance regarding estrogen-based and non-estrogen-based treatments for osteoporosis responds to the controversies about the benefits and risks of individual agents. Treatment choice should be based on up-to-date evidence and targeted to individual women's needs.     

Balance dysfunction and falls in people with lower limb arthritis: factors contributing to risk and effectiveness of exercise interventions

Chronic musculoskeletal conditions in the lower extremities, particularly arthritis, and the chronic pain associated with them, are independent risk factors for falls, with approximately 50% of people with arthritis reporting one or more falls. Despite this, few studies have specifically addressed balance dysfunction, falls risk and falls incidence in people with arthritis. This review aimed to identify potential factors contributing to the increased risk of falls in people with lower limb osteoarthritis or rheumatoid arthritis and to summarise the evidence base for effective exercise interventions targeted to reduce their risk of falls. A systematic search of the literature was conducted in February 2010 and included the following databases: MEDLINE (Ovid), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, Cochrane Library and PsycINFO. Only three studies that investigated exercise programmes for people with lower limb arthritis met all inclusion criteria, but none used falls as an outcome measure. To broaden the review, systematic reviews that assessed the effectiveness of exercise interventions for fall prevention in older people were also included. The presence of any form of lower limb arthritis and the associated consequences including pain, balance impairment, reduced muscle strength and reduced function are all associated with increased risk of falling. Due to the link between musculoskeletal pain and the increased risk of falls, further research needs to investigate which type of exercise programme will be effective in reducing the risk of falls in populations with arthritis in the lower limbs.     

Calcium and vitamin D--for whom and when

The basis of 'nutritional' interventions for the prevention of postmenopausal osteoporosis and osteoporotic fracture is a large topic with much genetic and biochemical evidence, as well as the results of randomized controlled trials, to guide the investigator and clinician. The efficacy of treatment with calcium and vitamin D was once controversial, but with the advent of controlled clinical trials using bone mineral density as an endpoint it has become clear that calcium with or without vitamin D therapy can lead to reductions in the rate of bone loss in postmenopausal women of all ages. Furthermore, with certain caveats, calcium with vitamin D therapy in the older postmenopausal woman can lead to useful reductions in fracture rates and falls, especially in populations with reduced exposure to sunlight, which is potentially the majority of postmenopausal women in both developed and developing countries. However, estrogen, selective estrogen receptor modulators (SERMs) and bisphosphonates (especially when given in combination with calcium and vitamin D) are more efficacious in preventing fracture, particularly in postmenopausal patients with impaired bone structure.     

The predictive role of bone turnover markers for BMD in middle-aged men

Measurement of bone turnover markers has been proposed as a potentially valuable clinical laboratory aid in osteoporosis risk assessment. These markers may allow quantitative evaluation of rates of bone loss, and thereby identify persons at risk for osteoporosis at an earlier stage. As far as we know, this is the longest longitudinal study on bone turnover markers conducted in adult men. The objectives of this study were to determine whether markers of bone formation (type I procollagen amino-terminal propeptide, PINP, and carboxy-terminal propeptide, PICP), and of bone resorption (type I collagen carboxy-terminal telopeptide, ICTP), are predictive of changes in lumbar spine and femoral neck BMD over a 5-year period, and to determine the ability of the bone resorption marker urine amino-terminal telopeptide (NTx) to explain the variance in BMD change over the past 5 years in a group of men 35–69 years old. In this group, NTx was the only marker to correlate significantly with BMD changes at the femoral neck (r = ?0.21), but not at the spine. The use of the biochemical markers studied to predict change in bone density in adult men in middle-aged years is of very limited value.     

Optimal health and function among the elderly: lessening severity of ADL disability

Despite mounting evidence implicating sedentary behavior as a significant risk factor among the elderly, there is a limited amount of information on the type and amount of activity needed to promote optimal health and function in older people. Overall muscle strength and mass decline 30–50% between the ages of 30 and 80. The loss of muscle mass accounts for most of the observed loss of strength. The loss of muscle tissue is due to a decrease in the number of muscle fibers and to atrophy of the type II muscle fibers. The declining strength reduces the capacity to carry out basic activities of daily life and puts people at risk for falls and dependence on others. The objective of the present review is to examine the role of exercise training as a primary tool for increasing cardiopulmonary and muscular fitness in order to lessen the severity of disability in activities of daily living and to attain optimal health and functioning among the elderly.     

How to help the aging male? Current approaches to hypogonadism in primary care

Hypogonadism is a common condition which occurs more frequently in older men. It is characterized by low testosterone (T) and is associated with symptoms which are often nonspecific. A key symptom is low libido, but it can also be associated with erectile dysfunction, reduced muscle mass and strength, increased body fat, reduced bone mineral density and osteoporosis, reduced vitality, and depressed mood. Hypogonadism is linked with a variety of comorbid conditions including erectile dysfunction, metabolic syndrome, diabetes, obesity, and osteoporosis. However, the condition is often underdiagnosed. T supplementation in hypogonadism is associated with a range of benefits including improved sexual function, increased lean body mass and/or reduced fat mass, and improved bone mineral density. A variety of T supplementation formulations are available. Although there is no evidence of increased risk of initiating prostate cancer with T supplementation, it is contraindicated in men with prostate cancer. It is important that primary care physicians are aware of both the signs and symptoms of hypogonadism, the monitoring and testing that is required and the merits and advantages of the various T preparations to ensure optimal management of the condition with a treatment approach that best suits patients’ needs.