April 2007–Flip on the television and you can see actress Sally Field speaking on behalf of a new medication designed to help prevent osteoporosis. But you won’t find any ads with Frankie Avalon or other men of Ms. Field’s generation explaining the benefits of preventing osteoporosis to men. That’s because most people consider osteoporosis to be a disease that only afflicts older women. The truth is osteoporosis is a serious condition that affects both men and women.

According to experts at the Mayo Clinic, a PinnacleCare Center of Excellence, osteoporosis and low bone mass (a precursor of full blown osteoporosis) are present in 44 million women and men in the U.S. age 50 and older. One in two women and one in five men will experience a fracture related to osteoporosis as they age. Even more worrisome, by 2010, the number of people affected by this disease is projected to jump to 52 million, and by 2020 the total will reach 61 million.

“Most of us think osteoporosis isn’t something we need to be concerned with now in our 30s, 40s, and 50s, but this is the time to ensure we are working to achieve optimal bone health and strength and making a real effort to cut risk factors,” says Miles J. Varn, PinnacleCare’s Executive Medical Director. “Young and older, male and female, there are steps we should all take to protect our bones.”

A real threat to health and independence
To those with no experience with the effects of osteoporosis, the disease may not seem like a serious health threat. But weak, brittle bones can irrevocably change your life. Each year, more than 1.5 million fractures of the hip, wrist, spine and other bones result from underlying, often undiagnosed osteoporosis. Those fractures can limit future mobility and result in the need to move to a nursing or continuing care facility.

In addition, vertebral compression fractures can cause a serious condition called kyphosis. The spine becomes bent and distorted causing pain, immobility, and, in the advanced stages of the disease, difficulty breathing and eating enough food to avoid malnutrition. There is also a very real threat to life. According to statistics gathered by the National Osteoporosis Foundation, more than 24 percent of people 50 and older who suffer a hip fracture die in the subsequent year.

What makes bones healthy?
To better understand osteoporosis, it helps to understand how bone is formed and broken down over the course of a life span. Bone is made up of a combination of collagen and calcium phosphate. The protein collagen provides a flexible framework which is strengthened and hardened by the calcium. Over time, old bone is removed through a process call resorption, while new bone is added through formation. Until about age 30, cells that build bone called osteoblasts are more abundant than those that break bone down (osteoclasts). After 30, the osteoclasts are more abundant, causing more bone to break down than there is new bone being added.

Bone becomes porous, thin and weak. This state puts bone at greater fracture risk from seemingly simply acts like lifting a pile of newspapers, sneezing or turning over in bed. Further complicating the diagnosis of osteoporosis is the fact that decreased bone density does not cause any symptoms or pain. In fact, even many vertebral compression fractures go unnoticed for the same reason.

Anorexia, breast cancer, depression—Unexpected risk factors
There is a wide range of factors which increase risk for osteoporosis. The more well known risk factors include:

Being female
Being thin with a small frame
Advanced age
Menopause-related estrogen deficiency
Fracture history in a first degree relative (parent, sibling, child)
Family history of osteoporosis
Low lifetime calcium intake
Vitamin D deficiency

In addition, there are many risk factors for osteoporosis that are virtually unknown by the public, including:

Anorexia nervosa
Teen motherhood (One study at Johns Hopkins, a PinnacleCare Center of Excellence, found that one-third of teen mothers studied between the ages of 13 and 18 had signs of bone loss after pregnancy.)
Early menopause, a history of abnormal menstrual periods, or removal of the ovaries without hormone replacement therapy before age 45
More than three weeks of use of glucocorticoid medications such as prednisone, cortisone and prednisolone which are used to treat conditions including asthma, psoriasis, lupus, multiple sclerosis, rheumatoid arthritis, Crohn’s disease and more
Use of the blood thinner heparin which is often prescribed after a stroke, to treat blood clots and is used during heart surgery
Use of some anti-convulsant medicines that prevent seizures including Dilantin
Hyperthyroidism
Use of some diuretic medications including furosemide (Lasix), bumetanide (Bumex), ethacrynic acid (Edecrin) and torsemide (Demadex)
Tobacco use
Alcohol abuse
Depression and the use of some anti-depressants such as Prozac and Paxil by people age 50 and up (A recent study found people with an average age of 65 who took these medications known as selective serotonin reuptake inhibitors (SSRIs) had twice the risk of fractures.)
Sedentary lifestyle (Experts at the Mayo Clinic note that an active lifestyle from childhood on helps build bone density and that jumping and hopping exercises are especially good for building healthy bones.)

Breast cancer survivors, especially those who underwent chemotherapy or treatment with aromatase inhibitors that suppress the production of estrogen are also at an increased risk. Similarly, men who have been treated for prostate cancer and have low testosterone levels have a higher risk for osteoporosis.

Surgery to remove a part of the stomach, gastric bypass and digestive disorders like Crohn’s disease which inhibit the body’s ability to absorb an adequate amount of calcium are additional risk factors.

Even a seemingly low risk behavior, consuming large amounts of caffeinated soda, can boost your chance of developing osteoporosis. In addition to taking the place of calcium-rich beverages like milk, caffeine may interfere with the absorption of calcium and excess intake of phosphoric acid could also contribute to bone loss. A study conducted by researchers at Tufts University found that both men and women who drank three or more cola-based sodas each day had a four percent lower bone mineral density in their hip.

Change your lifestyle, protect your bones Experts at PinnacleCare Center of Excellence The Cleveland Clinic outline five basic steps to help protect the health of your bones and prevent osteoporosis.

Take part in regular weight-bearing exercise to build muscle, prevent bone loss and increase your balance to minimize the risk of falling.
Eat a diet high in calcium from childhood on. The U.S. recommended daily allowance of calcium for adults is 1,000 mg per day. If you are at high risk for developing osteoporosis, the RDA increases to 1,500 mg per day. You can find that calcium in a number of sources beyond dairy foods including dark green leafy vegetables, canned fish with bones like salmon and sardines, calcium-added orange juice and baked good with calcium enriched flour.
Get an adequate amount of Vitamin D, which aids the absorption of calcium, in your diet from foods (eggs, fatty fish, vitamin D fortified milk and cereal) and from time spent in the sun (about 20 minutes per day is recommended, but remember to use adequate sun screen to protect your skin).
Limit alcohol consumption and do not smoke. Smoking dampens the production of estrogen.
Open a dialog with your physician. Discuss family history, concerns, the need for osteoporosis testing like bone densitometry (DEXA), the value of supplements and medications.

Men don’t get osteoporosis and other myths exposed
Though men start life with denser bone, they are also at risk for developing low bone mass and osteoporosis. Two million men currently have osteoporosis and an additional 12 million are at risk for developing the condition.

For men, there is an additional risk factor—lack of education. A recent Duke University study found that only one in six men with spine and hip fractures are tested and treated for osteoporosis. A negligible 1.1 percent of men who end up in the hospital as the result of a serious fracture receive a bone density test, the gold standard for osteoporosis screening and risk evaluation. Noted Duke’s Dr. Thomas J. Weber, Assistant Professor of Medicine, “Doctors don’t hesitate to do that (test) for a woman, but it seems we just don’t think of it in terms of men.”

Men face other serious hurdles dealing with osteoporosis as well. Their death rate after suffering a fracture is one in three versus one in five for women. Experts believe that underlying conditions including heart disease may boost that statistic. In addition, there are fewer medications approved for the prevention and treatment of osteoporosis in men. Only alondrenate (Fosamax) is approved for use in men, though risedronate (Actonel) is also approved for use in men with steroid-induced osteoporosis. Teraparatide is also approved for use in men at an increased risk for fractures. Testosterone supplementation may also provide bone health benefits. A study is underway to further assess the benefits and risks of this approach.

Other osteoporosis myths include the belief that osteoporosis is simply an inevitable part of the aging process and that if you had the condition, you would be aware of it. As mentioned previously, osteoporosis usually has no symptoms until a fracture occurs. While bone loss is part of the aging process, most of it can be slowed or even prevented with medications.

Treatments attack the problem from different angles
In addition to ensuring you get adequate calcium and Vitamin D in your diet and take part in regular weight bearing exercise, there are several medications currently approved for prevention and treatment of osteoporosis.

While once considered the top choice for prevention and treatment of osteoporosis in women, estrogen and hormone replacement therapy have been found to pose several serious risks including an increase in heart attacks, blood clots, strokes and breast cancer.

The class of drugs known as bisphosphonates, which includes the brand names Fosamax, Actonel and Boniva are approved for post-menopausal women. These pills slow bone loss and cut fracture risk. There are also IV forms of bisphosphonates. IV Boniva is FDA-approved for osteoporosis management, but two other medications Zometa and Aredia have not yet been approved. IV formulations of this type of drug have recently been linked to a condition called osteonecrosis which results in permanent damage of the jaw bone. This side effect has been primarily noted in patients receiving high doses of IV bisphosphonates as part of cancer treatment and the risk to people who use these IV formulations for osteoporosis appears low to date.

Treatment with a hormone manufactured from the thyroid gland is another option. Sold under the brand names Calcimar and Miacalcin, calcitonin is delivered as a nasal spray or injection and can not only help slow bone loss, it can lessen the likelihood of vertebral fractures.

The selective estrogen receptor modulator (SERM) raloxifene (Evista) promotes bone health by imitating estrogen’s effect without the side effects associated with estrogen replacement such as an increase in breast cancer risk.

Teriparatide (Forteo) is a type of parathyroid hormone. The injection has been shown to stimulate the growth of new bone. It may not be an appropriate treatment for those who have undergone radiation or who have high parathyroid hormone levels. Another parathyroid hormone-based treatment, Preos, is currently in clinical trials.

New treatments inspired by molecules and astronauts
From monoclonal antibodies to mechanical treatments developed as a by-product of NASA research, there are a wealth of promising new approaches to osteoporosis in development.

One treatment already in use in Europe but not yet approved in the U.S. is strontium ranelate, sold as Protelos. The powder, which is dissolved in water and taken daily, has been shown to reduce fracture risk. Notes Mayo Clinic endocrinologist B. Lawrence Riggs, M.D., biologically the drug is different than other treatments because "the new data suggests it stimulates bone formation and inhibits bone resorption. It is well-tolerated, especially in older people, where the bisphosphonates sometimes cause gastrointestinal defects and may not be well-tolerated."

Denosumab, an investigational fully human monoclonal anti-body, has also shown promise. The first osteoporosis treatment that targets RANK Ligand, a protein that affects the activity of the osteoclasts which break down bone, denosumab trials have shown a 6.69 percent increase in the cortical thickness at the femoral shaft versus a 1.82 percent increase for people treated with alendronate (Fosamax). "Increasing thickness at highly cortical sites is an effective way to improve bone strength and mechanical integrity of the skeleton," explains Thomas Beck, ScD, associate professor at The Johns Hopkins University. "These observations support the potential of targeting RANK Ligand to improve bone structural strength."

Another new drug in trial, Reclast, is delivered in a single annual IV infusion. Reclast is a biphosphenate, but its dosing may make it a better choice for those who do not want to manage a more frequent dosing schedule. Trials have shown that women who received the drug had a 70 percent lower risk of spine fractures and a 40 percent lower risk of hip fractures.

In Europe, a nitric-oxide donating compound, HCT 1026, which was being studied as an Alzheimer’s treatment was found to reduce the number of molecular markers for bone resorption. From Sweden comes research on a compound known as MIV-701 which inhibits the enzyme cathepsin K, a substance that breaks bone down.

Other scientists are approaching osteoporosis prevention from a nutrition focus. Researchers from Penn State have found that plant-based omega-3 polyunsaturated fatty acids in foods like walnuts and flaxseed oil may protect bone health. At Tufts University, PhD Katherine Tucker has uncovered a positive association between Vitamin B12 and bone health which has led her to describe B12 deficiency as a modifiable osteoporosis risk factor.

NASA is the source for a seemingly low tech prevention tool. Known as whole body vibration, the technique was developed as a method to help astronauts in space avoid bone loss while weightless. The osteoporosis study looked at 70 post-menopausal women who did knee exercises on a vibrating plate for 10 to 20 minutes a day. Their bone mineral density at the hip increased significantly compared to women who exercised on the ground.

Make a plan for lifetime bone health
PinnacleCare Members can turn to their Advocate to help map out a complete plan to protect the health of their family’s bones. From nutrition and exercise plans to help children and teens build a foundation of strong bone to prevention and treatment strategies, information on the latest developments and fast access to the best practitioners in the field, Advocates work to develop the plan that fits your needs precisely.