With osteoporosis fractures increasing in prevalence worldwide, the prevention of fractures has become a major economic and social burden. In addition, nations with poorer health care systems in Asia, Africa, and Latin America are facing aging populations, making the development of affordable preventative therapy especially important.

Supplemental calcium, either alone or in combination with Vitamin D, has been suggested as an inexpensive treatment for the prevention of osteoporotic bone loss and fractures. Data from clinical trials have resulted in inconsistent results regarding the efficacy of this treatment in preventing bone loss and fracture. Tang et al. have synthesized a meta-analysis of randomized trials in which calcium, or calcium in combination with vitamin D, was used to prevent osteoporotic fracture and bone loss in adults over 50 years of age in an effort to offer a comprehensive review of all the relevant evidence.¹

Their findings supported the use of calcium and vitamin D supplementation. When data were pooled, it was revealed that supplementation had resulted in a reduction of 12% in bone fractures of all types (risk ratio 0.88, 95% CI 0.83-0.95; p=0.0004), and a 0.54% decrease in bone mineral density loss (0.35-0.73; p<0.0001) at the hip and 1.19% (0.76-1.61%; p<0.0001) in the spine.

The authors conclude that the evidence supports the use of calcium, or calcium in combination with vitamin D supplementation, as preventative therapy for osteoporosis in adults over 50 years of age. In addition, they suggest a minimum dosage of 1200 mg for calcium and 800 IU of vitamin D for optimal therapeutic effect.

Reference

1. Tang BM, Eslick GD, Nowson C, et al. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet 2007;370:657-66.

Lynne T. Shuster, MD, Women’s Health Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
Sharonne N. Hayes, MD, Women’s Heart Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
Mary L. Marnach, MD, Women’s Heart Clinic, Department of Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA.
Virginia M. Miller, PhD, Departments of Surgery and Physiology and Biomedical Enginering and Office of Women’s Health, Mayo Clinic College of Medicine, Rochester,MN,USA.

Women in the Western world may expect to spend a significant portion of their lives in postmenopause. After menopause, women are at increasing risk for several conditions associated with aging that may or may not be related to declining hormone levels. Caring for women seeking advice and treatment for menopausal concerns presents a golden opportunity to not only identify individuals at risk for early intervention but also to address prevention and screening strategies important to sustaining health.
Keywords: cancer, cardiovascular disease, menopause, osteoporosis, screening.

Karin H. Humphries, MBA, DSC, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC.
Janet McElhaney, MD, Department of Geriatrics, University of British Columbia, Vancouver, BC.

The growth in information about hormone replacement therapy (HRT) over the past few years has been impressive. This review summarizes the latest information on HRT and cardiovascular disease, osteoporotic fractures, and cognitive function. The risks of HRT (e.g., stroke, breast cancer, and venous thromboembolism) clearly outweigh the benefits (e.g., reduction in osteoporotic fractures). The use of HRT for primary or secondary prevention of coronary heart disease or to decrease the risk of cognitive dysfunction is also not supported. While the evidence in older adults is substantial, there is some controversy regarding the effectiveness of HRT initiated in women at the start of menopause.
Key words: hormone replacement therapy, cardiovascular disease, osteoporosis, cognitive function, dementia.

Rowena Ridout, MD, FRCPC, Toronto Western Hospital, Toronto, ON.

Osteoporosis is a significant cause of morbidity and mortality in the older population. Bone density testing is recommended for all men and women 65 or older. In postmenopausal women, and in men over the age of 50, testing is recommended for those at high risk for osteoporosis. Effective therapy is available for those at risk for fracture. Bone density testing combined with clinical risk factors, including age and fracture history, can be used to assess fracture risk and identify those individuals most likely to benefit from drug therapy.
Key words: osteoporosis, bone density, fracture, diagnosis.

Cathy R. Kessenich, DSN, ARNP, Professor, Department of Nursing, University of Tampa; Nurse Practitioner, Private Practice, Tampa, FL, USA.

Osteoporosis is a chronic, debilitating disease that is most distressing to patients and health care providers in the occurrence of fractures of the hip and spine. The lasting effects of vertebral and hip fractures can cause pain, deformity, and emotional distress. Various nonpharmacological modalities may be used adjunctively with prescribed agents to improve the quality of life of patients with fractures due to osteoporosis. Research evidence and clinical experience have determined that nutritional support, exercise and rehabilitation, pain management, orthopedic surgeries, fall prevention, alternative therapies, education, and social support may assist patients in coping with the pervasive effects of osteoporotic fractures. Clinicians need to be informed and encouraged about the use of nonpharmacological measures to assist patients at risk for experiencing the culminating event of this devastating disease.
Key words: osteoporosis, osteoporotic fracture, osteoporosis management.

Angela M. Cheung, MD, PhD, FRCP(C), CCD, Director, Osteoporosis Program, University Health Network and Mount Sinai Hospital; Associate Director, Women’s Health Program, University Health Network; Associate Professor, University of Toronto, Toronto,ON.

Osteoporosis is common in postmenopausal women and older men. There are various efficacious therapies for the treatment of osteoporosis and the prevention of osteoporotic fractures in Canada. First-line therapies include alendronate, risedronate and raloxifene; all of these are oral antiresorptive therapies. In this article, we review new drug therapies currently or soon to be available in Canada, such as bone formation therapies (parathyroid hormone and strontium ranelate) and intravenous infusions (such as zoledronic acid), and compare them to existing therapies.
Key words: osteoporosis, osteoporotic fractures, parathyroid hormone, strontium, zoledronic acid.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Susan J. Whiting, PhD, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK.
Hassanali Vatanparast, MD, College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK.

This review describes the current state of knowledge in nutritional interventions in osteoporosis, using the Osteoporosis Society of Canada’s (OSC) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis as a basis. Nutrients important for osteoporosis are calcium, vitamin D, protein, sodium, caffeine, and isoflavones. These recommendations are updated and other nutrients and food components, not covered in the OSC 2002 report, are described. As a single nutrient approach is no longer warranted, we discuss how the Dietary Approaches to Stop Hypertension (DASH) diet can be used to provide appropriate intakes of many key nutrients for persons with, or at risk of, osteoporosis.
Key words: DASH diet, calcium, vitamin D, protein, osteoporosis.

Our focus this issue is on osteoporosis, a topic that is finally starting to get the respect it deserves. During my residency days in the 1970s, those physicians who were interested in osteoporosis and its treatments were considered to be working outside of mainstream medical practice. Now we know that they were in fact pioneers, if not visionaries. We recognize today that men as well as women are affected by osteoporosis, and that the consequences of this disease are dramatic, causing impaired quality of life and, in some cases, premature death. Yet we still have a long way to go both in recognition of the disorder and in its management. It has long been recognized that osteoporosis is not a disease of old age per se, but rather a disease of young life with manifestations in old age. In fact, one of the first major articles pointing out that peak bone mass in early adult life was a major predictor for late-life osteoporosis and fractures was by a geriatrician, Norman Exton-Smith. Population-based strategies for prevention of osteoporotic fractures will thus have to be based on ways of building bone mass in early life.

In her article, Dr. Rowena Ridout outlines the process of “Osteoporosis Screening and Diagnosis.” Dr. Panagiota Klentrou reviews the role of “Physical Activity for the Prevention and Treatment of Osteoporosis,” while Drs. Susan Whiting and Hassanali Vatanparast write about “Nutritional Interventions in Osteoporosis.” Cathy Kessenich reviews the “Nonpharmacologic Prevention and Management of Osteoporosis,” while the noted scientist in osteoporosis research, Dr. Angela Cheung, informs us about “New Drug Therapies in Osteoporosis.”

In our cardiovascular column Drs. Julian Jarman and Tom Wong review the “Modern Management of Arrhythmias in the Older Population.” Drs. Gordon Searles and Joseph Coffey review “Malignant Photo Damage” in their skin column; be wary when you go south on your winter vacation! A spin-off from the Women’s Health Initiative has been the question of managing symptomatic menopause. In her women’s health column, “Symptomatic Menopause--What are the Safe and Effective Options?”, Dr. Jerilynn Prior answers this query. Finally, our case study this month is “A Case of Iron Deficiency Anemia” by Dr. Anna Monias with commentary by Dr. Duane Sheppard.

Enjoy this issue.
Barry Goldlist

L. Giangregorio, PhD, Lyndhurst Centre, Toronto Rehabilitation Institute, Toronto, ON.
A. Papaioannou, MD, Department of Medicine, McMaster University, Hamilton, ON.
J.D. Adachi, MD, Department of Medicine, McMaster University, Hamilton, ON.

Osteoporosis is characterized by compromised bone strength, predisposing a person to an increased risk of fracture. The wrist, hip, and spine are the most common sites for fractures associated with osteoporosis. The economic and human costs of osteoporosis-related fractures are considerable. Although it is often considered a woman’s disease, osteoporosis is a significant source of morbidity and mortality in men. Available pharmacological treatments for osteoporosis include bisphosphonates, selective estrogen receptor modulators, calcitonin, parathyroid hormone, and hormone replacement therapy. Non-pharmacological interventions, such as nutritional counselling, exercise, and fall prevention, should also be considered in a fracture prevention plan.
Key words: osteoporosis, fragility fracture, bone, skeleton, bone density.

Wojciech P.Olszynski, MD, PhD, FRCPC, Clinical Professor of Medicine,University of Saskatchewan, Director, Saskatoon Osteoporosis Centre, Saskatoon, SK.

Though osteoporosis occurs less frequently in men than in women, it is nonetheless a significant medical problem. Osteoporotic vertebral fractures in particular are as common for men as for women, and about one-third of all hip fractures occur in men. As a consequence of fragility fractures, the associated morbidity and mortality are higher in men than women, particularly after fracture of the hip. Idiopathic osteoporosis is common; however, secondary causes are found in about 50% of cases. Bone density measurements should be advised for every man over 65 years of age and for younger men in the presence of osteoporosis risk factors. For practical purposes, the use of T-score <= 2.5 for men over age 65 should be used for the diagnosis of osteoporosis.

Key words: osteoporosis, men, fracture, diagnosis, treatment

Epidemiology
Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.