The article by Skedros et al. in this issue of The Journal raises awareness of a critical and generally underrecognized issue—namely, that osteoporosis is not just a woman's disease1. Men are at high risk for osteoporosis and its sequela, fragility fracture. Moreover, Skedros and colleagues advocate using the simple-to-use Osteoporosis Self-Assessment Screening Tool (OST)2 to screen both male and female patients.
Historically, most clinicians have not been concerned about the risk of osteoporosis or bone fracture in men. They have been complacent because, compared with women, men achieve higher peak bone mass, have slower rates of bone loss during aging, do not become hypogonadal, fall less frequently, and have shorter life expectancies. But clinicians have failed to recognize that men who have passed the age of sixty-five or seventy years of age begin to lose bone mass at the same rate as women do; in addition, if a man does have osteoporosis, his risk of having a secondary medical condition that contributes to bone loss is 40% to 60%3.
The risk of osteoporosis for both men and women is too high, and the consequences are unacceptable. As the average life span of both men and women increases, we need to ensure that all seniors remain healthy and independent for as long as possible.
Unfortunately, we don't yet know a lot about what influences bone health in men, because most research has been focused on women. But what we do know is worrisome. For example, the lifetime risk for the occurrence of a hip fracture at fifty years of age is indeed substantially lower for men than for women (6% to 11% and 17% to 22%, respectively)4,5. However, a man who does fracture a hip is, on the average, younger than a woman who fractures a hip, and he also has more comorbidities and is at a higher risk of sustaining a refracture6.
That's not the end of the tale. Of the approximately 90,000 men who are sixty-five years of age or older and who suffer a hip fracture in any one year, one in three will die within the first year after fracture6,7. That means that, in the United States, more men die of hip fracture each year than of prostate cancer8.
And if a man who is sixty-five years of age or older sustains a hip fracture and survives, he will achieve a lower level of postfracture function than would a woman under similar circumstances6. He will be much less likely to receive preventive care9. Fragility fractures may be less common in men than in women, but woe unto the man who suffers one!
The dearth of information about osteoporosis in men has serious public policy implications. The nursery rhyme that begins, "For want of a nail, a shoe was lost," describes the osteoporosis story. Because so little research has been done in men, there are no evidence-based guidelines for osteoporosis prevention, diagnosis, and treatment in men. Existing guidelines have been based on the accumulated data from the prevention and treatment of osteoporosis in white women10.
Furthermore, because of the lack of evidence-based guidelines, osteoporosis screening for men is not approved for reimbursement by the Centers for Medicare and Medicaid Services (CMS) under many circumstances. CMS pays for bone-density testing only for an estrogen-deficient woman who has been clinically identified as being at risk for the development of osteoporosis; for an individual with radiographically demonstrated vertebral abnormalities indicative of osteoporosis, low bone mass, or vertebral fracture; for an individual who is receiving long-term glucocorticoid (steroid) therapy; for an individual with primary hyperparathyroidism; or for an individual being monitored to assess the response to or efficacy of a Food and Drug Administration-approved osteoporosis drug therapy11. A review of the new CMS 2007 Physician Voluntary Reporting Program Measure Specifications indicates that, although bone-density measurement is urged after a fracture in all patients, such testing is encouraged as a screening tool only in women who are older than sixty-five years12.
The OST holds great promise, but its potential cannot be realized if public policy and CMS reimbursement guidelines remain behind the curve. As an orthopaedic surgeon, I concur with Skedros et al. that the OST should be applied to women who are older than forty-five years and to men who are older than fifty-five years; however, it is not clear that health insurers will agree.
Fortunately, help is on the way. The National Institutes of Health (NIH) is wrapping up "Mr. OS," its seven-year, multi-site study of more than 5700 men, age sixty-five years or older13. The purpose of the study is to determine whether fracture risk in men is related to bone mass as it is in women. The study is also looking at the role of other potential risk factors (e.g., bone structure, lifestyle, and tendency to fall) on bone mass and fracture rates in men. When these data are analyzed, it will be possible to develop an evidence-based guideline for men that can drive the public policy and reimbursement agenda.
As we evaluate the results of the NIH study, however, we will need to remember one ironic outcome of the National Osteoporosis Risk Assessment (NORA) study: most women who suffered a fragility fracture in that study did not, in fact, have osteoporosis14. In other words, there is more to bone quality than bone density. Bone quality research has the potential to improve the quality of life of millions of Americans. It must become a federal research priority.
In the meantime, as orthopaedic surgeons, we must do what we can to ensure optimum bone health in our older patients. Because of lack of training, many orthopaedic surgeons are reluctant to take on the responsibilities of diagnosing secondary causes of osteoporosis and providing pharmacotherapy. However, all orthopaedic surgeons are qualified—and should feel obligated—to discuss bone health with their patients. Osteoporosis prevention needs to be a patient-education priority. We need to ensure that the public is better informed of the importance of getting enough dietary calcium and vitamin D as well as regular exercise.
Skedros et al. have given us a remarkable tool. With only a calculator and measurements of age and weight (data required by the Joint Commission on Accreditation of Healthcare Organizations), we can alert some of our most vulnerable patients (and their primary care physicians) of a major health risk. We owe it to America's seniors to begin.
*The author did not receive any outside funding or grants in support of their research for or preparation of this work. The author or a member of her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Merck, for lectures on fragility fractures). Also, a commercial entity (Merck, for a research grant unrelated to this work) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.
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8. American Cancer Society. Cancer facts and figures 2006. Accessed 2007 Mar 12.
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10. National Osteoporosis Foundation. Physician's guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation; 2003.
11. National Osteoporosis Foundation. Reimbursement of bone mineral density tests. Accessed 2007 Mar 12.
12. Centers for Medicare and Medicaid Services. 2007 Physician Voluntary Reporting Program Measure Specifications. Accessed 2007 Mar 12.
13. National Institutes on Health. Word on Health. Men can get osteoporosis too. Accessed 2007 Mar 12.
14. Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, Wehren LE, Abbott TA, Berger ML, Santora AC, Sherwood LM. Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment. JAMA. 2001;286:2815-22.