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Osteoporosis has dramatically increased in the last few years and is a significant health problem. There is a growing recognition that osteoporosis is a disease that affects men and not only women.
Hip and vertebral fractures result in great morbidity and mortality for both men and women. Therefore, an increase awareness of risk factors for osteoporosis is vital to reduce the morbidity and mortality, along with early diagnosis and treatment.
This study was conducted to find out whether osteoporosis is a disease that affects men aswell as women and the prevalence of this disease amongst both genders. Studies focusing on risk factors for men and women and the cost that osteoporosis incurs were analysed.
It was found that the risk factors found in women were also apparent in men, and the prevalence of osteoporosis in women is higher than it is in men. This explains why it is under diagnosed and untreated, as most men are not screened for BMD testing as recommended by osteoporosis guidelines.
Osteoporosis is a disease of the bone that results in a higher risk of fracture. It is multifactorial, age-related (Agarwal et al, 2003), and is an asymptomatic condition (Baum & Peters, 2008). It is a clinically silent disease and is identified after fractures occur. The bone becomes diminished due to the loss of osteopenia. Deterioration of the bone tissue increases and disruption of bone architecture occurs. The bone then becomes weak that even a minor fall causes a fracture or vertebrae to collapse (Sunyeckz, 2008). The probability of fractures then increases. In osteoporosis, the anatomical bone volume is unchanged, but the bone shows cortical thinning. The trabeculae are also thinned and in certain areas they disappear. The complete aetiology of osteoporosis is not yet clearly understood (Blake et al, 1999).
Osteoporosis is becoming a major health problem, due to the aging population in the world. There are more than 200 million people are affected globally (Gardner et al, 2006) and it is the most widespread metabolic bone disease in the western world. The most important cause of morbidity and mortality are fractures. Over 3 million individuals suffer from osteoporosis in the UK (Prasad et al, 2006). In recent times, osteoporosis was seen as an unavoidable part of aging and was typically diagnosed only after a serious complication such as a fracture (Cummings et al, 2002). Many of the causes and vital one is postmenopausal osteoporosis. A hip fracture will occur in one in every six white women during their lifetime (Cummings et al, 2002). Epidemiologically, elderly white women have the highest incidence of osteoporotic fractures, whereas black women and all men are at a lower risk (Ray et al, 1997). However, many women are not conscious of this disease and therefore do not know that it is preventable (Stevenson et al, 2000).
Osteoporosis can be characterised as high turnover or low turnover. The osteoclastic activity increases in high turnover and the resorption lacunae are deeper. The osteoblasts are unsuccessful in forming bone during normal turnover in the low turnover variety. In perimenopausal women, the major form of osteoporosis that takes place is high turnover osteoporosis (Sutcliffe, 2006).
It has been acknowledged that osteoporosis in men is also a public health issue. The fracture correlated to an increased age that is seen in women is also seen in men (Adams & Lukert, 1999). Osteoporosis has mainly been focused on women as they are expected to develop osteoporosis more likely than men. Osteoporosis in men is under-recognised; therefore the majority of fractures are untreated (Gagnon et al, 2008). Men have a tendency to develop osteoporosis later on in life, by about a decade (Bilezikian, 1999). There are several aetiologies that include a deficiency of vitamin D, hyperparathyroidism, immobility and low serum sex hormone levels.
There are three types of osteoporosis. These are known as idiopathic osteoporosis, post-menopausal osteoporosis and senile osteoporosis. Idiopathic osteoporosis is rare and occurs in children and adults, with normal gonadal function. Postmenopausal osteoporosis is frequently seen and occurs in individuals among the ages of 50 and 75 years (Agarwal et al, 2003), and is characterised by the increase in bone turnover. In females, the occurrence is six times greater than in males (Agarwal et al, 2003). Senile osteoporosis frequently occurs in individuals older than 60 years. It is not accompanied by an increase in bone turnover; however, it leads to hip fracture. It is linked to aging and is characterised by the reduced number of osteoblasts.
Figure1 illustrates the common osteoporotic fracture sites (Taken from National Osteoporosis Society).
The vertebral, distal forearm and proximal femur are the main osteoporotic fractures. However, the humerus, pelvis and rib fractures are also common (Tuck et al, 2007). The frequency of these fractures increases sharply in both genders, as the age increases. The increase occurs in advance in women than it does in men.
The most common types of osteoporotic fracture are of the vertebral body. They are usually asymptomatic, therefore going unrecognised until recurrence or height loss occurs (Gronholz, 2008). The type of fracture that has the most serious consequence is the proximal femoral fracture (Baum & Peter, 2008). Mainly, vertebral fractures occur due to osteoporosis; however, peripheral fractures are the result of an inconsistent combination of endogenous and exogenous factors. The main significant causes of disability and premature death are due to hip fractures (Cummings et al, 2002). Hip fractures are responsible for the main causes of mortality, morbidity and costs that are associated with osteoporosis (Gardner et al, 2006).
Osteoporosis in men can be primary or secondary. Primary osteoporosis is separated into idiopathic and age-related based on the age of the diagnosis. Hypogonadism, oral steroid therapy and alcohol abuse are the most significant secondary factors of osteoporosis in men with vertebral fractures. Around 85% of cases of secondary osteoporosis in men are explained by these factors (Gagnon et al, 2008).
Hypogonadism is an important risk factor in men and women and in older men it is related with a BMD lower than normal and it is a cause that can be treated (Gardner et al, 2006). As men age, the serum testosterone decreases slowly, therefore, age-related hypogonadism is common in older men (Rochira et al, 2006). In young women, hypogonadism can be primary or secondary to conditions such as anorexia nervosa, chronic illness and gynaecological disorders (Kanis et al, 2002).
Osteoporosis is characterised by low bone mass and may be explained as a 'reduction in BMD of at least 2.5 standard deviations' (Henderson et al, 2000). By means of the World Health Organisation (WHO) guidelines, osteoporosis occurs if the BMD is 'more than 2.5 SD below the peak bone mass reference for young women' (Bilezikian, 1999). Figure 2 illustrates the WHO criteria.
World Health Organization bone mineral density (BMD) criteria
BMD T-score at -1.0 and above
Low bone mass
BMD T-score between âˆ’1 and âˆ’2.5.
BMD T-score at or below -2.5.
Women in this group with one or more fractures are considered to have severe osteoporosis
Notes: Based on BMD using DXA at the spine, hip, or wrist in white postmenopausal women.
BMD - bone mineral density
T-score - the number of standard deviations that a BMD measurement lies above or below the average value for young healthy women
Figure 2 illustrates the WHO BMD criteria (Taken & adapted from Vondracek et al, 2008).
Aging in the male is related to an enlargement of tubular and axial bone, as periosteal bone apposition is higher in the aging male skeleton than in the female (Bilezikian, 1999). The low bone mass is accompanied by an increase in fracture risk and microarchitectural deterioration of bone tissue (Agarwal et al, 2003). Reduction of bone mass and BMD is directly related to bone fractures and the bone loss, in both genders, is associated with aging. However, in women, the bone loss is accelerated, with the occurrence of menopause. 'Bone loss in postmenopausal year averages anywhere between 1-5% per year' (Agarwal et al, 2003). Men do not lose as much bone mass as woman, as they do not experience menopause equivalent (Bilezikian, 1999). Normal bone mass after growth has stopped is maintained by the stability between osteoblasts that are involved in bone formation and osteoclasts that play a part in bone resorption. Osteoclasts are efficient multinucleate cells that corrupt bone by connecting to a bone surface and secreting acids and enzymes into the mineralised bone surface (Sutcliffe, 2006).
The risk for osteoporotic fracture does not only depend on the bone mass. It also depends on the quality of the bone. The rate and efficiency of bone turnover impacts the bone architecture. The bone architecture is vital component of skeletal strength.
The difference in fracture occurrence between women and men is due to the type and the frequency of trauma that is experienced by men compared with women over life. Women tend to have a higher risk of fracture compared to men (Melton, 1989). Also, men are not as likely to fall as women (Bilezikian, 1999). Women have risks of hip and vertebrae fractures that are two to three times greater than those for men, later than the age of 50 years (Orwoll, 1999). Mortality statistics are much higher than those in women, when men do sustain a hip fracture (Bilezikian, 1999). Deaths are not caused by the fracture itself but to the conditions that are related with both the fracture and mortality, such as heart disease (Browner et al, 1996).
Figure 3 - shows the age and gender-specific incidence of fractures at any site between 5 million adults registered in the General Practice Research Database in the UK, 1988-1998 (Taken from Khosla et.al 2008).
Figure three shows a bimodal distribution for the fracture incidence in men. A peak begins in young adulthood and then arises again at an older age. Women have a higher prevalence of overall fractures compared to men after the age of 50 years, reversing the trend. In both genders, there is an increase in fracture occurrence following the age of 75 years (Khosla et al, 2008). In men, the BMD is predicted to be lost at a rate of up to '1% per year with advancing age' (Cooper et al, 1992). Also, approximately one in eight men aged 50 years and over will experience a fracture related to osteoporosis, in their lifetime'(Cooper et al, 1992).
Implementation of preventive measures such as falls prevention strategies, reasonable level of exercise and adequate levels of calcium and vitamin D intake is recommended to men and women (Gagnon et al, 2008). An effective way to prevent fractures is to prevent falls (Ashe & Khan, 2009).
Considerable risks have been reported in people of all ethnic backgrounds. Around, 20% and 7% of non-Hispanic Caucasian and Asian women and men aged 50 and older are estimated to have osteoporosis, respectively (NOF).
Diagnosis and treatment of osteoporosis has mainly focused on postmenopausal women (Cheng & Green, 2008), however, literature highlighting the occurrence and complications of osteoporosis in men is growing. The diagnostic approach to osteoporosis and bone loss includes a general examination, with a radiograph of the throacic and lumbar spin. BMD measurements have been used in the past to determine the need for treatment. However, there is an increase in recognition that these alone will not predict the absolute risk of fracture. DXA is currently the most widely used in clincial practice, and it generally accepted (Sutcliffe, 2006). The advantages of DXA are the good precision and short scan times. Also, it allows scanning of the spine and hips. These are observed as the vital measurement sites, as they are common types of osteoporotic fractures that result in morbidity and mortality. However, DXA does have limitations, as it is not able to measure bone structure and volumetric bone mineral distribution (Sutcliffe, 2006).
The treatment of osteoporosis is split into basic measures for fracture prevention and the pharmacotherapy. Fracture prevention and lifestyle include: smoking cessation, calcium intake (1200-1500 mg/day), physically active and optimised medications. Pharmacotherapy for osteoporosis is given for three to five years, and then the patient is re-evaluated (Baum & Peters, 2008). The NOF has proposed that drug therapy should be started in postmenopausal women and men that are aged 50 years and older that have: a hip or vertebral fracture, t-score of -2.5 or less at femoral neck or spine (after evaluation to eliminate secondary causes), low bone mass and 10-year probability of a hip fracture of 3% or more (Lewiecki 2009).
The aim of this study was to find out whether osteoporosis affects men and not only women and to look at the risk factors that affect both genders.
To determine if osteoporosis is a disease only affecting women
to look at the prevalence of osteoporosis and the fractures that occur the most within individuals
to look at figures indicating the cost of treating osteoporosis
Compare aetiology and risk factors for osteoporosis in both genders
compare the risk factors in women and men
consider if the risk factors associated with women differ with the risk factors associated with men
Recognition of osteoporosis in men has become noticeable until recently. Men are rarely treated for osteoporosis because the recognition of the problem is much more common in women than it is for men. Consequently, not many studies have been conducted on osteoporosis in men. Therefore, journals that have been published lately, potentially within the past ten years will be used. Journals will be used for the methodology as data on this subject is becoming ever more advanced. Journals will be obtained using databases and sources such as PubMed, Cochrane Library and Google Scholar. Data collected will be checked against criteria such as the relevance of the information and how it is related to the topic.
Along with the method of using journals, books will also be used to attain more information and accompany the research about osteoporosis in men as well as women. The risk factors in both genders will be compared against one another. A conclusion will be made with the data collected, on whether osteoporosis affects men and not only women.
Research will be conducted by; studying published information on osteoporosis in both men and women, the risk factors, obtaining information that relates to the prevalence of osteoporosis in both genders and comparing them.
The data collected from studies will be presented in the form of tables and graphs to analyse and compare. The data collected will be from over a period of time to give an improved view of the topic.
Key words that will be used in the search criteria box will be 'prevalence of osteoporosis in men, prevalence of osteoporosis in women, osteoporosis epidemiology, osteoporosis risk factors and costs related to osteoporosis.'
Questions which need to be addressed are; the differences in the occurrence of osteoporosis, in men and women, the most important risk factors and the costs related to this condition.
Researchers may publish data more than once in different journals; therefore checking for duplicate publications will be conducted. This will be done by checking the author list, research institute and any other factors.
5.0 Results & Discussion
5.1 - PREVALENCE OF OSTEOPOROSIS
As the population ages, osteoporotic fractures are progressively more recognised as a serious health problem. As mentioned earlier, the NOS have estimated that almost 3 million people in the UK have osteoporosis and each year and there are roughly 40,000 fractures within the UK. The combined annual occurrence of vertebral body, hip and distal forearm fractures is roughly 200,000 and the majority are associated with osteoporosis (Stevenson & Marsh, 2000). The NHS and social care expenses, in 2001, for a single hip fracture in the UK was approximately £20,000 (NOS).
Figure 4 - shows the age-specific incidence rates for hip, vertebral and distal forearm fractures in men and women. Data derived from population of Rochester, Minn. (Taken from Campion & Maricic, 2003).
From looking at the two graphs, one for fractures occuring in men and another for fractures occuring in women, it is clear to see that men present osteoporotic fracture years later than women. This reason being that they have greater bone mass. In women, bone loss has been well studied. The studies show at menopause bone loss occurs as a result of oestrogen deficiency and is characterised by increased bone turnover. However, in men, the aetiology of bone loss during aging is weakly defined (Scocapasa et al, 2002).
The most important factor that is used to conclude whether an individual will develop osteoporosis is the maximum peak bone density, the quantity that is attained and also the quantity that is lost. In both genders, peak bone mass is attained after skeletal growth ceases (Stevenson & Marsh, 2000). The bone mass at skeletal development varies amongst both genders, and it is 30-50% larger in men than in women. The most significant genetic factor controlling bone mass is gender (Cummings et al, 2002). The decade after menopause in women, an increase is experienced. This is a result of a decrease in circulating estradiol concentration. Among the ages of 35 and 40 years, bone loss starts in both men and women. There is a variation in the maximum bone mass achieved early in life (Cummings et al, 2002).
The prevalence of hip fractures, in both genders increases rapidly around the age of 75 years. Age-related bone loss takes place in both the corticol and trabecular bone. It is correlated to an increased bone turnover and a difference in the remodelling cycle. Age-related bone loss is the consequence of an increased bone breakdown caused by the osteoclasts, and a decline in bone formation by osteoblats (Poole, 2006).
Hip fracture mortality in men one year after fracture is 31% compared to a rate of 17% in women (Campion & Maricic, 2003). A case-control study conducted in the UK found that male patients had an 8-fold increase in mortality after hip fractures. Hip fractures are related to a fall in survival of 10-20% and it is within the first six months of fracture most deaths take place (Schuit et al, 2004).
The risk of pneumonia and death is increased in individuals that have multiple vertebral fractures. Ioannidis et al (2009) showed in their study that vertebral fractures were an independent predictor of death. Other frequent factors are depression, apprehension and withdrawal (Gardner et al, 2006). Mortality following clinical verterbal fractures has been described to be increased for up to 10 years in women and 3 years in men, in a case-control study (Bliuc et al, 2009). The study conducted by Bliuc et al (2009), highlights the premature mortality related to all types of fractures. It is demonstrated that mortality risk was highest in the first 5 years following all fractures types. Also, non-hip and non-vertebral fractures that are usually not considered in these types of studies were related with 29% of the premature mortality. They also found that mortality risk decreased with time.
Ioannidis et al (2009) also conducted a study that involved a populace of unselected Canadian patients, and it was found in their results that individuals 50 years and older that had hip or vertebral body fractures were expected to die during the 5 years of follow-up, in contrast to individuals with no fractures. Patients with these fractures have a 3-fold increase risk of death compared with individuals who have not had a fracture (Ashe & Khan, 2009).
Colle's fracture is most common among elderly white people. Colle's fracture is explained by a fall onto an outstretched arm. These fractures are more common in women as it is seen in figure 4, with an increase in occurrence among the ages of 40 and 65 years. From looking at the graph, in men there is no clear increase in incidence of wrist fracture with age, remaining constant between 20 and 80 years (Sutcliffe, 2006). The occurrence of wrist fractures varies with geographical site. Also, time of the year is a factor, as the number of falls might increase due to falls outside on icy surfaces (Sutcliffe, 2006).
Nguyen et al (2001) have suggested in their study, that research has shown that in the last three decades, attention has been on determining the causes for hip fractures in aging women. Yet, hip fractures are only accountable for one third of the total occurrence of fractures in the elderly people. An equivalent percentage of fractures occur at the humerus, forearm and wrist. However, according to Ioannidis et al (2009), it was found that hip fractures have long-term consequences, therefore, signifying that they are important. A patient with hip fracture has one in four chance of dying in the 12 months after the fracture. The NOS has predicted that the rate of hip fractures in the UK may increase to approximately 117,000 in the year 2016 (NOS). The cause of humerus, forearm and wrist fractures is not as recognised, compared to the thorough research into the cause for hip fractures.
Figure 5 - shows the age- and gender-specific occurrence of fractures at selected sites among 5 million men and women registered in the General Practice Research Database, 1988-1998 (Taken from Schuit et al 2004).
Figure five shows the incidences for various fracture locations by age and sex. Group A illustrates the fractures with a distinct increase in occurrence with aging. Above the age of 50 years, the fracture incidence is greater among women than men, for most of the fracture sites. Group B illustrates the fractures that show no apparent increase or decrease in occurrence, with aging. Skull, carpus, feet and distal lower extremity fractures do not show to increase with age. Consequently, they are considered less likely to be related to osteoporosis.
The factor that is the most obvious for fractures of the radius/ulna is sexual dimorphism. With increasing age in women, the rates escalated; yet no such trend was seen amongst men. The pattern of fracture occurrence with increased age was quite diverse for this group. With young men, the carpus occurrence was the highest, and no increase was significantly seen with increasing age. Among all fractures, those that increased with aging in men included fractures of the femur/hip, vertebra, humerus, clavicle, scapula, ribs and pelvis (Van staa et al, 2001). In a study of fracture incidence conducted by the Royal Infirmary of Edinburgh, fractures of the femur, humerus and clavicle usually occured in elderly men (Schuit et al, 2006).
The observed lower absolute incidence in osteoporotic fratures in older men compared with women may also be due to the fact that with aging, women have an increased frequency of falls, relative to men (Winner at al, 1989). Studies have found that that injuries related to sports activities were the most important source of limb fractures in males. Football injuries being the single most important cause (Khosla et al, 2008). Fractures in the workplace for men most commonly involved the hands and feet (Islam et al, 2001).
Figure 6 - summarises the estimated lifetime and 10 year risks of fracture among men and women at various ages.
Current age (years)
10 year risk
Data taken and adapted from Nguyen et al (2001).
Using the data in the table above, two graphs have been drawn up to illustrate the approximate lifetime and 10 year risks of fracture, amongst men and women at different ages and at different fracture sites.
Figure 7 - the estimated lifetime risk of fracture among men and women at various ages
The graphs indicate the fracture sites that have been estimated for fractures of the radius/ulna, femur/hip and vertebral body. Firstly, looking at the lifetime risk for women at the age of 50 years, the percentage at any fracture sites was 53.2%, and at the age of 80 years it declined to 28.6%. Looking at the fractures for men at any sites the percentage at the age of 50 years was 20.7% and at 80 years, 9.6%. Thus, the risk was much higher for women than for men.
Figure 8 - the estimated 10 year risk of fracture among men and women at various ages
The ten year risk of a fracture at the age of 50 years for women, at any fracture sites was 9.8% and increased to 21.7% at the age of 80 years. Yet, in men, the possibility of fracture at the age of 50 years, at any site was 7.1% and increased to 8.0%. The increase for men was not a great increase compared to women. For women, there was an increase of 11.9% compared to an increase of 0.9% for men.
It is evident to see that some fractures were to some extent more frequent in women than in men. Hip and vertebrae fractures were related with an excess mortality up to 5 years in both men and women and radius/ulna fractures were related to an excess mortality in only men. Generally the fracture occurrence in women at the age of 35 years and beyond increased sharply as the bone density declined, with several fractures such as the hip and distal forearm occurring twice as normal in women as in men. In women, the age adjusted occurrence of forearm fractures increased gradually following the perimenopausal period. The prevalence in men was lower and more constant until the age of 75 years and above. In extreme old age, occurrence rates of several fractures become constant or started to decrease.
5.2 - COST OF OSTEOPOROSIS
Osteoporotic fractures have huge personal costs and cause substantial costs to the NHS. The cost of health care is continuing to rise. Osteoporosis costs the NHS and the government approximately £2.3 billion a year and it will increase as the years go by. This shows that the financial implications are daunting. It has been estimated that 14,000 people die each year after a hip fracture in the UK. More than 1150 premature deaths occur every month as a result of hip fractures (NOS). Johnell and Kanis (2006), estimated that 9 million osteoporotic fractures occured worldwide in the year 2000, 39% of which were in men. They used data that was published from different sources around the world (Johnell et al, 2006). As the years have gone by, this number is most likely to have increased.
By the year 2020, it has been estimated that the cost of treating all osteoporotic fractures will increase to more than £2.1 billion, in postmenopausal women. Hip fractures are accountable for the majority of medical costs associated with osteoporosis which is approximately 75% of the costs. Five percent to 20% of patients will die in the year after the hip fracture (Cummings et al, 2002). Death rates are mostly high after hip fracture for men and black women. Also, hip fractures can result in long-lasting stays in treatment hospitals or even nursing homes a while after acute care (Sutcliffe, 2006). There is an increasing financial impact occurring from inpatient treatment for hip fractures that may relate to long-lasting stays in hospitals. Fractures of the hip sustain the greatest morbidity; therefore they are a serious economic stress to the inadequate health service resources. Fractures at skeletal sites other than the hip receive much less attention, even though they can also cause substantial disability. There are more than 40,000 Colle's fractures occuring annually in the UK and it has been predicted that the annual expenditure of each Colle's fracture is about £468 (Sutcliffe, 2006). Due to the escalating healthcare expenditure and the escalating number of fractures occurring, the costs are predicted to increase (Lawrence et al, 2005).
Figure 9 illustrates that fractures can result in extra consultations with the GP in the year following injury (Taken from the National Osteoporosis Society).
From looking at the figure above it is clear to see that the most common fractures that resulted in consultations with the GP are vertebral fractures, at 14.69 visits per year. The least common fractures for consultation were of the forearm, at 5.36 visits per year. Expenses that result from hospitalisation of hip fracture add up to approximately £730 million annually (Lawrence et al, 2005). This is established on the number of 60,000 hip fractures occurring annually in the UK (Lawrence et al, 2005). The quantity of hip fractures occurring worldwide is growing by 1-3% annually (Lawrence et al, 2005). Also, by 2015 it has been predicted that approximately 66,300 hip fractures will occur annually, in the UK (Lawrence et al, 2005).
5.3 - AETIOLOGY AND RISK FACTORS IN WOMEN AND MEN
Several factors are responsible for the progress of hip fractures including BMD, bone architecture, previous fracture history and other factors related to physical weakness and an increased risk of falls. In both genders, the probability of hip fracture is increased by prior fractures at any location. Apart from the risk factors such as age, sex, and geographical location, other risk factors include use of glucocorticoids and low BMI (Sutcliffe, 2006). The significance of these risk factors differs as some act independently and other dependently.
Figure 10 - Risk factors for osteoporosis in men (Taken from Campion et al, 2003).
Figure 11 - Risk factors (besides low bone mass) for osteoporotic fracture in postmenopausal women (Taken from Vondracek et al, 2008).
Above, the two figures indicate the risk factors for men and women. There are some similar risk factors that occur in both genders such as family history, smoking, alcohol, personal fracture and use of glucocorticoids.
Ageing and genetic factors are related to the progress of osteoporosis in men. Around, 30-60% of cases of osteoporosis are linked with one or more secondary causes (Campion et al, 2003). An example of a high-risk cause is glucocorticoid therapy, especially long term oral glucocorticoid therapy. It is responsible for one in six cases of male osteoporosis (Campion et al, 2003). Hypogonadism is also a well-known high risk factor in men and it is a condition that is caused by the deficiency of androgens or their action (Stanworth & Jones, 2008). It has been reported to occur in up to '20% of men with vertebral crush fractures and 50% of elderly men with hip fractures' (Sutcliffe, 2006). Defects resulting frm hypogonadism may be treated with testosterone and then lead to an increase in BMD. The diagnosis of hypogonadism may not always be clinically apparent in males that have osteoporosis, therefore, regular measurement of serum testosterone and gonadotrophins is important.
An example of medium-risk cause is anticonvulsant medication. Using this medication could contribute to osteoporosis (Campion et al, 2003). This is achieved through several effects on calcium metabolism. Declining intestinal calcium absorption is the result of anticonvulsant drugs increasing the hepatic metabolism of vitamin D and 25-hydroxyvitamin D (Campion et al, 2003).In the kidney, 25-hydroxyvitamin D changes into the active form, which is 1,25 hyrodxyvitamin D. This active form assists in controlling blood levels of calcium and phosphate.
Low levels of androgens are also a risk factor for osteoporosis, as androgens are essential for developing peak bone mass, and also maintaining bone mass (Sutfliffe, 2006). Testosterone levels steadily decline with increasing age. However, low levels in elderly men are associated with low bone density. Refering to Stanworth & Jones (2008), the overall testosterone levels decrease at an average of 1.6% per year, whereas 'free and bioavailable levels fall by 2-3% per year' (Stanworth & Jones, 2008). Low levels of oestrogen in men are associated with declining bone density than are declining testosterone levels. These low levels of oestrogen may contribute to age-related bone loss in men (Sutcliffe, 2006). Gonadal hormones are the most significant causes of skeletal mass in women. The deficiency of oestrogen has a serious consequence on the female skeleton. The loss of oestrogen is the most vital factor in the advancement of postmenopausal bone loss and osteopororisis. This loss could be natural or due to surgical menopause.
Higher bone mass at maturity is related to the use of oral contraceptives than in women who do not use them. Within five years of menopause, bone loss is lost quickly, with a gradual rate of bone loss in postmenopausal years (Sutcliffe, 2006). Overall, oestrogen and testosterone are vital for normal growth and protection. The deficiency of these sex hormones is associated with osteoporosis. There is information demonstrating that testosterone treatment increases BMD in elderly men. However, this treatment is limited to hypogonadal men (Stanworth & Jones, 2008). There are no studies up till now to confirm that the progress in bone density with testosterone treatment actually decreases fractures in men. This is an essential area for research to be done in the future.
Another common risk factor that occurs in both genders is rheumatoid arthritis, however, this attacks more women than men. The onset of the disease can occur at any age. It is more prevalent among individuals aged 30-60 years old (Sundel, 1998). The disease is systemic autoimmune in which the immune systems attack articular cells, cartilage and bone. The use of glucocorticoids relieve symptoms of rheumatoid arthritis due to their anti-flammatory effects.
Smoking and excessive alcohol consumption in all societies is more prevalent in men. Smoking related bone mass is associated to the duration and quantity. In men who smoke, bone loss is higher than it is in female smokers and this could be a result of men's higher exposure to cigarette smoking (Sutcliffe, 2006). The mechanism could be a combination of reduced body weight, reduced calcium absorption, reduced estradiol levels and a direct toxic effect on bone metabolism (Campion et al, 2003). Women who smoke tend to have an earlier menopause, therefore signifying the development of oestrogen breakdown (Sutcliffe, 2006). Data taken from a twin study propose that women who smoke atleast 20 cigarettes a day during adulthood will by the time of menopause have a typical BMD deficit of 5-10% compared with non-smokers (Stevenson & Marsh, 2000).
Alcohol affects calcium metabolism and this may result in the reduction of bone density. The ethanol has a direct toxic effect on osteoblasts therefore affecting the osteoblastic function (Campion et al, 2003). Excessive consumption of alcohol is related to a fall in bone density and increase in the risk of fracture, poor nutrition and a decline in physical activity. Although it has been suggested that modest alcohol consumption has a protective consequence on bone density, the quantity still remains uncertain (Sutcliffe, 2006).
A signficiant risk factor for women is low body weight. Body weight is an essential independent determinant of BMD (Adam & Lukert, 1999). Conditions such as anorexia nervosa and bulimia affect 5-10% of women (Sutcliffe, 2006). The media is considered to be moderately responsible for eating disorders, especially in adolescents. They do this by bombarding and influencing young girls with pictures showing slim celebrities. In developed countries there is a value placed on being thin, which encourages extreme dieting and weight control (Treasure, 2009). The onset is at any time from adolescence during the fourth decade of life. These eating disorders result in considerable morbidity and mortality as they are resistant to treatment. However, eating disorders do affect 10% of males also (NHS). Metabolic disorders associated with anorexia nervosa that may adversely affect the skeleton. These include oestrogen deficiency, protein-energy malnutrition and secondary hyperparathyroidism caused by low dietary calcium intake or vitamin D deficiency (Treasure, 2009).
Sufficient nutrition is vital, as it is a widespread prevention measure (Gardner et al, 2006). Low BMD and skeletal fragility is becoming more prevalent in the aging society (Adam & Lukert, 1999). In western societies the average age is predicted to reach 85 years within the next 20 years (Adam & Lukert, 1999). Calcium is essential for several functions in the body and more than 99% of the calcium is stored in bone. The intake of calcium and vitamin D can help in preventing fractures in elderly women, as the deficiency of vitamin D is frequent in elderly people (Sutcliffe, 2006). However, some studies have revealed that calcium and vitamin D are inadequate for preventing fractures in patients when taken alone. Thus, whether these are taken alone or together, they must not be considered sufficient for the reduction of fracture risk in patients with osteoporosis, although they are beneficial for bone health (Gardner et al, 2006). Other studies also suggest that women whose intake of calcium was below the RDA during childhood or adolescence have clinically lower BMD (Adam & Lukert, 1999). The table below indicates the recommended amount of calcium and vitamin D intake. Women around the ages of 19-30 are recommended to take 1000 mg/day of calcium and 200 IU/day vitamin D. However, unfortunately, 90% of women may not be getting adequate calcium. Around 50% of women treated for bone loss have insufficient levels of vitamin D.
IU - international units
Mg - milligram
Figure 12 illustrates the recommended dietary intake of calcium and vitamin D. (Taken from Sunyecz, 2008).
Obtaining the RDA of calcium and vitamin D during adolescence ensures peak bone mass development. Low calcium intake causes secondary hyperparathyroidism, as calcium homeostasis in blood should be kept stable. The resorption of calcium from the bone occurs with bone loss and an increased risk of fracture resulting (Cho et al, 2008). However, there are a lack of studies on calcium intake in patients with hip fractures.
The risk of future fractures are increased due to prior fractures, despite bone density. Individuals with hip fractures are more prone have at least one vertebral fracture. They are also twice as likely to have sustained a distal radius fracture aswell (Gardner et al, 2006).
Physical activity plays an important role in achieving peak bone mass (Adam & Lukert, 1999). Activities such as weight-bearing provide the mechanical stimulus significant for the protection and improvement of bone health (Sutcliffe, 2006) and also stimulate bone growth. Optimal physical activity produces adequate tension to maintain bone strength. However, the activity needs to be within safe limits. Exercise during growth leads to a high peak BMD and higher muscle strength. Extreme physical activity may result in hypothalamic induced hypoestrogenism, which leads to a reduced BMD (Stevenson & Marsh, 2000).
Another risk factor in both genders is primary hyperparathyroidism. It is usually asymptomatic and is the third most frequent endocrine disorder. It is most common in postmenopausal women (Fraser, 2009). The hormone responsible for maintaining calcium homeostasis is parathyroid hormone, through its action on target cells in the bone and kidney. Parathyroid hormone controls the level of calcium (Gunn, 2007). In primary hyperparathyroidsim, the parathyroid cell loses its usual sensitivity to calcium, which leads to a decline in the feedback control of PTH by extracellular calcium (Sutcliffe, 2006).
The figure below indicates the changing clinical presentation of primary hyperparathyroidism. Looking at the years 1970-2000 for overt skeletal disease, it is clear to see that it is rare; however, osteoporosis with related fracture is increasing. As patients with primary hyperparathyroidism have no clear signs and symptoms of the disease, it is usually detected by incidental finding of hypercalcaemia.
Figure 13 - illustrating changing clinical presentation of primary hyperparathyroidism (Taken from Fraser, 2009).
The aim of this study was to determine whether osteoporosis is a disease that also affects men aswell as women and to establish the risk factors that do affect both genders. From looking at the evidence provided from this study, it is clear to see that osteoporosis does affect men also.
This study has found that osteoporosis has increased dramatically in the last few years. There are over 200 million individuals affected by osteoporosis worldwide and costs the NHS and the government around £2.3 billion a year. This figure is most likely to increase as the years go by.
A deficiency of calcium intake was found to be considered a major risk factor for osteoporosis. Excluding genetic factors, the four most important primary determinants of skeletal mineralisation included sexual maturation, calcium intake, body weight and physical activity. Other risk factors for osteoporosis included advanced age and history of previous fractures.
Men experience significant rates of morbidity and mortality after osteoporotic fracture, like women. Both hip and vertebral fractures are related to an increased mortality in men. However, unlike women, who are diagnosed with osteoporosis through BMD screening, men are normally diagnosed when they present with fractures (Cheng & Green, 2008). Also, men are less likely than women to receive post fracture treatment for osteoporosis, regardless of the occurrence of osteoporosis in men; men are under diagnosed and untreated. This is due to the lack of knowledge concerning the prevalence of osteoporosis among men (Gronholz, 2008). Evan once men have had fractures, they are less likely than women to be diagnosed and treated.
To conclude, I believe that physicians need to increase their awareness of the prevalence of osteoporosis in men, the importance of the consequences and of the indications for screening and treatment. This is the way that osteoporosis in men will be much more recognised as it is with women. The main reason for insufficient osteoporosis care in our society is the constant failure to recognise the importance of the problem. One recommendation that would help guide physicians in the management of osteoporosis is future studies of barriers to screening and treatment, mainly of male individuals and the research on the benefits of treating men with osteoporosis.