~ The Hidden Dangers of Male Osteoporosis

Most men think that osteoporosis — a condition characterized by decreased bone mass and density — is something that affects primarily women. Unfortunately for some 2 million American men, that is not the case.

While women do have more problems with osteoporosis partly because of hormonal changes that occur after menopause, the National Osteoporosis Foundation estimates that one in four men will have an osteoporosis-related fracture in his lifetime. More troubling, men are less likely to know that they have osteoporosis until the disease is highly progressed, and also are less likely to receive appropriate treatment once they are aware of their condition.

Osteoporosis is not a disease to ignore. Weak bones are responsible for almost 1.5 million fractures in the US each year, costing $10–15 billion annually in medical care. Most fractures occur in the spine, hip, or wrist, and research shows once you have experienced a fracture, you are at increased risk for future broken bones. The most devastating injuries are hip fractures—more than 300,000 Americans break their hips every year, often because of a fall. And fully one-fourth of patients with hip fractures die within a year of sustaining their injuries.

According to the National Inst-itutes of Health, as the population continues to age, osteoporosis in men will become a more-serious public health issue. In the US, the number of men over the age of 70 is expected to double in the next 50 years.1

Surprisingly, while 2 million American men have osteoporosis, very few of them are aware that they have brittle bones. "You see a preponderance of women coming in for a checkup before menopause because they have a family history of osteoporosis and know there is a link between menopause and osteoporosis," says Etah Kurland, assistant professor of clinical medicine at New York's Columbia University College of Physicians & Surgeons. "But because men do not go through a menopause, there is not a typical time when they have rapid bone loss." Kurland notes that even if a woman does not come in for a checkup, physicians usually raise the issue of bone loss with women who are reaching middle age. At this time, women will probably receive counseling on how to prevent bone loss through exercise, a calcium-rich diet, hormone modulation therapy, and drug strategies.

But for most men, the first sign that they have a problem is when they end up in the emergency room after a slip or fall.2

How Bones Are Built

Like a modern, bustling metro-polis, the human skeleton is in a constant state of construction. As soon as bone is built, it is quickly torn down to make way for the construction of new bone. This process continues in a constant cycle because the body has two different cells that form bone: osteoblasts and osteoclasts. Osteoblasts are the cells that make bone mineral, while osteoclasts are the cells that tear it down.

Most bone is formed during youth, when the body is growing and osteoblasts work overtime to lengthen bones. Bones stop lengthening when we reach our maximum height, which for women usually occurs in the teens but for some men may continue well into their twenties. Men's bones will continue to add mineral content until around age 30, increasing in density to provide strength. After this point, called peak bone mass, bones will slowly decline in strength. Throughout life, factors including heredity, hormones, diet, exercise, and certain medications affect bone density.

Because of their relatively larger body sizes, and possibly greater participation in physical activity, men tend to emerge from their twenties with a greater peak bone mass than women.3 This is thought to explain why men are at less risk for osteoporosis than women and why men are usually diagnosed with the condition later in life. Men simply have more bone to squander. Unfortunately, once bone loss occurs, there is no real way to build more bone. The best that can be done is to halt bone loss and preserve what the body created during youth.

Why Men Are Different

Men do not incur some of the bone-loss problems that women do once they reach middle age. Women entering menopause experience a drastic reduction in progesterone, estrogen, and other bone-protecting hormones. Proges-terone is important in maintaining healthy bones because as progesterone levels decrease, bones stop stimulating the osteoblasts to build more bone. Fortunately for men, their bodies have more bone reserves to compensate for whatever comes their way. Men attain greater bone mass for several reasons. First, their bones must be bigger to handle their relatively larger bodies. While men's bones are not necessarily denser than women's bones, they are of greater diameter.4 And thicker bones provide greater resistance to stress.

It is generally thought that hormonal changes that occur during puberty are responsible for giving men greater bone mass. In fact, studies have found that men with delayed puberty fail to reach peak bone mass.5 Male hormones certainly increase muscle mass, which in turn stimulates bone formation.

Genetics also are important in reaching peak bone mass. Studies have found that a maternal hist-ory of hip fracture is major risk factor for osteoporosis in women.6 Scientists dispute which genes are involved in the formation of the human skeleton but believe that genetics account for about 50% in our reaching peak bone mass.7,8

Bone Loss in Men

Underlying factors usually cause bone loss in men. One major cause is the use of prescription steroids called glucocorticoids. "Going back just 10 years, there was very little appreciation of how glucocorticoids could affect bone health," says Kurland.

Doctors prescribe glucocorticoids for multiple reasons, including arthritic problems, asthma, and inflammatory bowel syndrome. Whether the prescription involves high doses for short periods or moderate doses for extended periods, it carries the risk of bone loss.

"If I see a patient who was treated with high doses of glucocorticoids or is currently taking them, I would want to screen this person for bone loss," says Kurland. "It was not that uncommon in the past for men to be taking these kinds of drugs."

Glucocorticoids inhibit the osteoblasts but stimulate the osteoclasts to eat up the bone. Kurland calls it "the worst situation, because as you decrease bone formation, you are increasing bone resorption."

The next most common reason men get brittle bones is from excessive alcohol consumption. While casual drinkers have nothing to fear, people with a known drinking problem should take note: alcohol will not only pickle your liver, but also poison the bone-forming cells.

The problem with drinking is defining the term "excessive." Kurland says the meaning of this word can change depending on cultural norms: "In France, for example, what is considered an average daily intake is actually on the high side in our country."

But it is not only current drinkers who have reason to be concerned. Kurland believes that people who have kicked an alcohol problem may already have done irreparable damage to their bones, especially if the excessive drinking occurred during frat house parties or a youthful stint in the military. After all, men in their early twenties are still accumulating bone mass. "I think it's really underappreciated as a risk factor," says Kurland.

Another cause of brittle bones in men is low levels of testosterone. Testosterone levels decline naturally as men age, but men with lower-than-normal levels of the male hormone can experience extreme bone loss. "Men might have low testosterone and never know it," says Kurland.

Clinical research has determined that testosterone is vitally important to bone health. A study of 403 healthy men aged 73-94 years examined the hypothesis that the decreases in muscle strength, bone mass, and body composition seen in aging males are related to falling testosterone levels.9 The researchers measured the men's hormonal levels and ran multiple tests to gauge their body composition, muscle strength, and bone mass. They found that muscle strength and bone mass were at optimal levels in men with the highest levels of free testosterone, and concluded that "a number of clinical problems present in older men may be related to androgen [testosterone] deficiency, including reduced muscle mass, changes in body composition, and loss of BMD [bone mass density]."

This hidden contributor to osteoporosis is why Life Extension urges middle-aged and elderly men to have their testosterone levels checked regularly through periodic blood testing. Optimal levels of free testosterone for most men are 18-26.5 pg/mL.10 If your testosterone levels are indeed low, then consider using supplemental testosterone or nutrients that naturally increase testosterone levels. From gels to patches or pills, there are many ways that men can increase their testosterone levels. A growing body of evidence lends credence to the idea of supplementing testosterone in older men. Testosterone supplementation can help reverse the potentially devastating effects of muscle loss and osteoporosis on an aging man's life. Supplemental testosterone has been shown to increase bone mass of the lumbar spine in elderly men.11

In still other situations, men experience bone loss for unknown reasons. Medication, certain diseases, or a combination of factors may have affected them. In such cases, according to Kurland, physicians still should try to determine the cause of bone loss, as brittle bones may be a sign of an underlying disease or condition. "It behooves the doctor to try to find the cause," she says.

Finally, as the body ages, the bone-forming cells simply tire out. Bone resorption probably does not increase, but the osteoblasts slowly begin to tire. While the age for this slowdown will vary, experts find that at around 70 years of age, men can expect their osteoblasts to begin slowing down.

Diagnosing Bone Loss

Because men rarely receive counseling for osteoporosis, they are usually diagnosed with the condition only after suffering enough bone loss to result in a fracture. Bones can be expected to break during violent collisions, but if you happen to slip and break your wrist when hitting the ground, you should get a bone scan. Lower back pain and a noticeable loss in height also may be signs of porous bones.

Tests to check for bone density — called bone mineral density tests or bone density scans — are easy to obtain and cost around $100, depending on where the exam is performed. Scanners check lumbar spine density as well as hip density. More-sophisticated models also test the forearms.

Different areas of the body are examined because humans have two types of bone: spongy bone and the more-compact cortical bone, which makes up most of the skeleton.

The spine contains spongy bone and is an important area for fractures, and thus always is examined. The hip contains a mix of spongy and cortical bone, but is always assessed because broken hips are the most deadly type of fracture. Incorporating a scan of the forearm is important to evaluate total cortical bone health. "When you look at the forearm, you're able to get a glimpse at the cortical bone throughout the body," according to Kurland.

Once osteoporosis is diagnosed, the likelihood of regaining bone mass is very low. Most therapies are designed to prevent further loss and save the remaining bone.

Two kinds of drug used to treat bone loss are bisphosphonates (brand name: Fosamax®; generic name: alendronate) and the recedrinates (brand name: Actonel®; generic name: risedronate sodium). Taken once a week, these drugs are absorbed and stored by the bone, and inhibit the bone resorption cells until they slow and almost stop the process of breaking down bone. Meanwhile, the bone-forming cells continue to build bone mineral.

Keeping the Bone You Have

Quite apart from taking prescription drugs, there are several ways to keep bones strong. These aspects of bone health also are important in preventing osteoporosis, as studies have found that once men begin having problems with their bones, they are likely to continue having trouble. In part, this is because even after men have been diagnosed with osteoporosis, they are unlikely to receive proper treatment.

In a study of close to 200 patients who had had apparent osteoporosis-related hip fractures, scientists found that fewer men than women received treatment for osteoporosis.12 Men also were less likely than women to have bone scans to detect osteoporosis. The study authors concluded that osteoporosis was highly under-diagnosed in men, even though conflicting studies had found that men are more likely than women to die following a hip fracture.

One of the most important things men can do to increase bone mass is to maintain an active lifestyle that incorporates weight-bearing activity. The term "weight bearing" refers to activities that make the skeleton bear the body's weight. Certain cells located at the joints and different parts of the bone sense motion and stress, and respond by stimulating bone-forming cells to create stronger bone.

"People hear 'weight bearing' and go to the gym and start lifting barbells," says Kurland. "Now this will certainly help the arms, but it does nothing for the hips and spine." For best results, Kurland advises moderate exercise such as walking or jogging, or playing tennis or basketball. Swimming, she adds, is not a weight-bearing exercise, because the body is kept afloat by water.

Supplementation Is Critical

Because bone comprises a great deal of calcium, men also need to ensure they have enough of this mineral in their diet. Getting adequate vitamin D likewise is critical, as vitamin D is crucial in absorbing calcium. The National Osteoporosis Foundation recommends a daily intake of 1200 mg of calcium, along with about 400 IU of vitamin D, an amount sufficient to absorb the calcium.

Boron is involved in bone metabolism and has long been known to promote healthy bone density.13 Boron acts an integrator to support the functions of calcium, magnesium, and vitamin D. Calcium and magnesium are important building blocks of healthy bone; however, in instances of adequate calcium supply but deficient magnesium supply, boron appears to substitute for magnesium in the process of bone formation. Under such conditions, boron's concentration in bone tissue increases. Boron's effect on bone appears to be mediated by its ability to reduce the urinary excretion of both calcium and magnesium. Where adequate boron intake prevails, the net effect of boron is to raise ionized calcium levels. Boron, in effect, acts to preserve calcium and magnesium in situations of nutritional stress that would otherwise adversely affect metabolic processes involved with these substances.14

The effect of boron intake was analyzed in a study involving 12 post-menopausal women not on estrogen replacement therapy.15 Patients were first given a boron-deficient diet for 119 days, followed by a 48-day period in which they received boron supplementation. Patients also were studied during periods of adequate magnesium intake versus magnesium deficiency. Deprivation of boron or magnesium caused changes similar to those seen in women with post-menopausal osteoporosis, including increased loss of urinary calcium. In women receiving boron supplements, however, urinary losses of both calcium and magnesium were significantly diminished, especially if dietary magnesium was low. Boron manifests similar integrative effects on bone metabolism in its actions relating to vitamin D, which enhances calcium absorption through the stomach and small intestine. This integrative effect of boron with vitamin D, as with boron's interaction with magnesium, appears to be more profound in settings of vitamin D deficiency.

Men also are advised to increase their intake of vitamin K. Research has identified a link between vitamin K intake and the incidence of hip fracture. One study examined 900 elderly patients to determine whether vitamin K intake had any influence on hip fractures or low bone density.16 The researchers found that those with the highest vitamin K intake had the lowest level of hip fracture; no association was found between vitamin K intake and bone mineral density.

The study authors concluded that vitamin K helps keep bones healthy. (Those taking Coumadin® or other anticoagulant medication should not take vitamin K.)

Two recent studies reported in the journal Bone provide evidence that silicon plays a role in promoting bone formation. The first, a survey of 3,000 people, found that dietary silicon was associated with greater bone mineral density,17 except for postmenopausal women. The second study found that silicon has a stimulatory effect on collagen in the osteoblast cells that form bone.18 The study authors concluded that silicon is more important in forming bone that in preventing bone loss.

In men whose bone loss is the product of low testosterone levels, testosterone replacement therapy is vital. Testosterone works by improving bone thickness, especially in the small bones of the spine. Spinal fractures are much more common in men than in women. Moreover, men with low testosterone are twice as likely as women to suffer a hip fracture. After taking testosterone, men often report increased energy. (Men with prostate cancer, however, should not take testosterone.)

Testosterone therapy can take many forms. An injection can be given every two to three weeks. Patches are available that release the hormone at night, as is a cream form that can be applied to the skin. Additionally, a variety of natural supplements can be taken to increase testosterone levels.

As the population continues to age, more and more men will discover — unfortunately too late — that they are suffering the consequences of osteoporosis. Now is the time to be proactive with your physician and request a bone density test.

The two types of bone density tests are DEXA (dual x-ray absorptiomethyl) and QCT (quantitative computed tomography). DEXA is the most common bone mineral density test, but the QCT test is clearly superior. In a paper published by Smith, et al, investigators compared DEXA and QCT bone mineral density testing in the same patients. A significantly greater percentage of men were found to have osteoporosis using the QCT methodology than the DEXA approach. QCT technology picked up abnormalities in bone density in 95% of men compared to only 34% of the same men using DEXA.

Because most physicians are not readily familiar with QCT technology, it is important that patients and their partners share these new findings and seek out radiology facilities that have QCT equipment. Two references for sources of QCT testing are Mindways, Inc., and Image Analysis. To contact Mindways, call 1-877-646-3929 or log on to www.qct.com. To contact Image Analysis, call 1-800-548-4849, or log on to www.image-analysis.com. With proper supplementation, exercise, and lifestyle changes, you can avoid the crippling effects of this insidious disease.
Bone Mass: Lost in Space?

Space exploration has produced interesting insights into many subjects, including bone loss.

NASA research has found that during space flight, the body does not encounter the full force of gravity. This gravity-supplied stress on the bones is critically important. The cells that normally stimulate bone growth are not stimulated in a weightless environment, and as a result, astronauts lose around 1-2% of their bone mass a month. Upon returning to Earth, some space travelers have lost up to 20% of their bone strength during six-month stays at the International Space Station. This is of profound concern to NASA, as any long-duration space flight (for example, a trip to Mars) could result in severe weakening of the skeleton.

One interesting therapy NASA is examining involves placing astronauts on vibrating plates. The vibrations are barely detectable and astronauts strap themselves on to the plates while working on other tasks. The therapy appears to work, and scientists believe that the gentle vibrations help stimulate bone-forming cells.
References

1. Osteoporosis Prevention, Diagnosis, and Therapy. NIH Consensus Development Conference Statement 2000 March 27-29; 7(1):1-36.

2. Bilezikian JP, Kurland ES, Rosen CJ. Male skeletal health and osteoporosis. Trends Endocrinol Metab 1999 Aug;10(6):244-50.

3. Orwoll ES, Klein RF. Osteoporosis in men. Endocr Rev 1995 Feb;16(1), 87-116.

4. Gilansz V, Boechat MI, Roe TF, Loro ML, Sayre JW, Goodman WG. Gender differences in vertebral body sizes in children and adolescents. Radiology 1994 Mar;190(3):673-7.

5. Finkelstein JS, Klibanski A, Neer RM. A longitudi- nal evaluation of bone mineral density in adult men with histories of delayed puberty. J Clin Endocrinol Metab 1996 Mar;81(3):1152-5.

6. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med 1995 Mar 23;332(12):767-73.

7. Econs MJ, Speer MC. Genetic studies of complex diseases: let the reader beware. J Bone Miner Res 1996 Dec;11(12):1835-40.

8. Krall EA, Dawson-Hughes B. Heritable and life- style determinants of bone mineral density. J Bone Miner Res. 1993 Jan;8(1):1-9.

9. van den Beld AW, de Jong FH, Grobbee DE, Pols HA, Lamberts SW. Measures of bioavailable serum testosterone and estradiol and their relationships with muscle strength, bone density, and body com- position in elderly men. Clin Endocrinol Metab. 2000 Sep;85(9):3276-82.

10. Male hormone modulation therapy. Segala M, ed. Life Extension Disease Prevention and Treatment. 4th ed. Life Extension Media;2003:1043.

11. Snyder PJ, Peachey H, Hannoush P, et al. Effect of testosterone treatment on bone mineral density in men over 65 years of age. J Clin Endocrinol Metab. 1999 Jun;84(6):1966-72.

12. Kiebzak GM, Beinart GA, Perser K, Ambrose CG, Siff SJ, Heggeness MH. Undertreatment of osteo porosis in men with hip fracture. Arch Intern Med 2002 Oct 28;162(19):2217-22.

13. Strum S. Boron maintains bones, joints, neurons, and may reduce prostate cancer risk. Life Extension. Nov 2003:27-31.

14. Nielsen FH. Studies on the relationship between boron and magnesium which possibly affects the for mation and maintenance of bones. Magnes Trace Elem. 1990;9(2):61-9.

15. Nielsen FH, Hunt CD, Mullen LM, Hunt JR. Effect of dietary boron on mineral, estrogen, and testos- terone metabolism in postmenopausal women. FASEB J. 1987 Nov;1(5):394-7.

16. Booth SL, Broe KE, Gagnon DR, et al. Vitamin K intake and bone mineral density in women and men. Am J Clin Nutr. 2003 Feb;77(2):512-6.

17. Jugdaohsingh R, Tucker KL, Kiel DP, Qiao N, Powell JJ. Silicone intake is a major dietary determi- nant of bone mineral density in men and pre menopasual women of the Framingham offspring cohort. Bone. 2003 May;32(5)S192 (abstract only— presented at the 1st Joint Meeting of the International Bone and Mineral Society and the Japanese Society for Bone and Mineral Research; Osaka, Japan; 2003 June 3-7).

18. Reffitt DM, Ogston N, Jugdaohsingh R, et al. Orthosilicic acid stimulates collagen type 1 synthesis and osteoblastic differentiation in human osteoblast-like cells in vitro. Bone 2003 Feb;32(2):127-35.


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