Determinants of bone density in healthy older men with low testosterone levels

Mapping the extent of the literature and psychometric properties for the Physical Activity Scale for the Elderly (PASE) in community-dwelling older adults: a scoping review

BACKGROUND

Identifying valid and accessible tools for monitoring and improving physical activity levels is essential for promoting functional ability and healthy aging. The Physical Activity Scale for the Elderly (PASE) is a commonly used and recommended self-report measure of physical activity in older adults. The objective of this scoping review was to map the nature and extent to which the PASE has been used in the literature on community-dwelling older adults, including the evidence for its psychometric properties.

METHODS

Seven electronic databases (MEDLINE (Ovid), Embase (Ovid), AMED (Ovid), Emcare (Ovid), CINAHL (EBSCO), Ageline (EBSCO)) were searched from inception to January 25, 2023. Studies were included if physical activity was part of the aim(s) and measured using the PASE, participants had a mean age of 60 years or older and lived in the community, and papers were peer-reviewed journal articles published in English. Pairs of independent reviewers screened abstracts, full-texts, and extracted data. Where possible, weighted mean PASE scores were calculated for different subgroups based on age, sex, and clinical population.

RESULTS

From 4,124 studies screened, 232 articles from 35 countries met the inclusion criteria. Most studies were cross-sectional (60.78%), completed in high-income countries (86.4%) and in North America (49.57%). A variety of clinical conditions were included (n = 21), with the most common populations being osteoarthritis (n = 13), Parkinson's disease (n = 11), and cognitive impairment (n = 7). Psychometric properties of ten versions of the PASE were found. All versions demonstrated acceptable test-retest reliability. Evidence for construct validity showed moderate correlations with self-reported physical activity, fair to moderate with accelerometry derived activity and fair relationships with physical function and self-reported health. Pooled means were reported in graphs and forest plots for males, females, age groups, and several clinical populations.

CONCLUSION

The PASE was widely used in a variety of clinical populations and geographical locations. The PASE has been culturally adapted to several populations and evaluated for its reliability and convergent validity; however, further research is required to examine responsiveness and predictive validity. Researchers can use the weighted mean PASE scores presented in this study to help interpret PASE scores in similar populations. OSF REGISTRATION: osf.io/7bvhx.

Hemoglobin is associated with BMDs and risk of the 10-year probability of fractures in patients with type 2 diabetes mellitus

Purpose

This study aimed to investigate the associations between hemoglobin (HGB) levels and bone mineral density (BMD) and fracture risk in type 2 diabetes mellitus(T2DM) population of different ages.

Method

This cross-sectional study included 641 patients with T2DM (57.9% males). BMD of the femoral neck (FN), total hip (TH), and lumbar spine (LS) were measured using dual-energy X-ray absorptiometry. The 10-year probability of fracture was assessed using a fracture risk assessment tool (FRAX). HGB and other biochemical indices were measured in a certified laboratory at our hospital. Statistical analysis was performed using SPSS 26.0 and R language (R version 4.1.0). Generalized additive models (GAMs) were used to identify the associations between HGB and BMD and fracture risk.

Results

Patients with osteoporosis have lower HGB levels than the non-osteoporotic population and lower FN BMD in patients with anemia than in the non-anemic population. In patients with T2DM, there was sex- and age-related variability in the correlation between HGB levels and BMDs and fracture risk. In older men, HGB level was an independent determinant of BMD and was positively correlated with FN and TH BMD. In non-older women, HGB level was an independent determinant of BMD and fracture risk, positively associated with BMDs and negatively associated with 10-year probability of fracture risk. GAMs revealed a positive linear association between HGB level and BMDs in non-older female patients but not in older male patients.

Conclusion

Our study provides a new perspective on the association of HGB level and BMDs with fracture risk. Relatively high HGB levels are a protective factor for bone quality in patients with T2DM. However, the bone-protective effect of HGB is influenced by age and sex and persists only in older men and non-older women with T2DM.

Resveratrol Modulates Bone Mineral Density and Bone Mineral Content in A Rat Model of Male Hypogonadism

OBJECTIVE

To determine whether resveratrol (Res) can correct osteoporosis induced in a rat model of male hypogonadism.

METHODS

Thirty-two rats were randomly divided into 4 groups, 8 in each group; 1) a control sham group: underwent a similar surgical procedure for induction of orchiectomy (ORCD) without ligation of any arteries or veins or removal of the testis and epididymis; 2) a control + Res-treated group (Con+Res): underwent sham surgery similar to the control, but was then treated with Res, as described below; 3) an ORCD-induced group: bilateral ORCD surgery as described above, and 4) a ORCD+Res-treated group: bilateral ORCD surgery followed by Res treatment. Res treatment began 4 weeks after ORCD and continued for 12 weeks. After 12 weeks, bone mineral density (BMD) and bone mineral content (BMC) were measured in the tibia and femur of each rat's right hind leg. Blood levels of bone turnover indicators such as deoxypyridinoline (Dpd), N-telopeptide of type I collagen (NTX I), alkaline phosphatase (ALP), and osteocalcin (OC), as well as receptor activator of nuclear factor kappa B (RANK) and osteoprotegerin (OPG) were assessed.

RESULTS

ORCD significantly decreased BMD (P<0.01) and significantly increased bone resorption, manifested by increased RANK. In addition, it inhibited serum levels of OPG and OC. Res treatment after ORCD effectively increased serum levels of bone formation markers such as OPG and OC, compared with testisectomized rats (P<0.05).

CONCLUSION

Res could ameliorate bone loss induced by male hypogonadism, possible via restoration of the normal balance between RANK and OPG.

Endocrine sequelae of hematopoietic stem cell transplantation: Effects on mineral homeostasis and bone metabolism

Hematopoietic stem cell transplantation (HSCT) is an established therapeutic strategy for the treatment of malignant (leukemia and lymphoma) and non-malignant (thalassemia, anemia, and immunodeficiency) hematopoietic diseases. Thanks to the improvement in patient care and the development of more tolerable conditioning treatments, which has extended the applicability of therapy to the elderly, a growing number of patients have successfully benefited from HSCT therapy and, more importantly, HSCT transplant-related mortality has consistently reduced in recent years. However, concomitantly to long term patient survival, a growing incidence of late HSCT-related sequelae has been reported, being variably associated with negative effects on quality of life of patients and having a non-negligible impact on healthcare systems. The most predominantly observed HSCT-caused complications are chronic alterations of the endocrine system and metabolism, which endanger post-operative quality of life and increase morbidity and mortality of transplanted patients. Here, we specifically review the current knowledge on HSCT-derived side-effects on the perturbation of mineral metabolism; in particular, the homeostasis of calcium, focusing on current reports regarding osteoporosis and recurrent renal dysfunctions that have been observed in a percentage of HSC-transplanted patients. Possible secondary implications of conditioning treatments for HSCT on the physiology of the parathyroid glands and calcium homeostasis, alone or in association with HSCT-caused renal and bone defects, are critically discussed as well.

Bone health in ageing men

Osteoporosis does not only affect postmenopausal women, but also ageing men. The burden of disease is projected to increase with higher life expectancy both in females and males. Importantly, osteoporotic men remain more often undiagnosed and untreated compared to women. Sex steroid deficiency is associated with bone loss and increased fracture risk, and circulating sex steroid levels have been shown to be associated both with bone mineral density and fracture risk in elderly men. However, in contrast to postmenopausal osteoporosis, the contribution of relatively small decrease of circulating sex steroid concentrations in the ageing male to the development of osteoporosis and related fractures, is probably only minor. In this review we provide several clinical and preclinical arguments in favor of a 'bone threshold' for occurrence of hypogonadal osteoporosis, corresponding to a grade of sex steroid deficiency that in general will not occur in many elderly men. Testosterone replacement therapy has been shown to increase bone mineral density in men, however data in osteoporotic ageing males are scarce, and evidence on fracture risk reduction is lacking. We conclude that testosterone replacement therapy should not be used as a sole bone-specific treatment in osteoporotic elderly men.

Hemoglobin level and osteoporosis in Chinese elders with type 2 diabetes mellitus

Objectives

Several studies demonstrated a positive relationship between hemoglobin level and bone mineral density (BMD). Thus, the association between hemoglobin concentration and osteoporosis in elders with type 2 diabetes mellitus (T2DM) was explored in this study.

Methods

Totally, 573 elders with T2DM were included in the study. BMD was measured by dual-energy X-ray absorptiometry. Hemoglobin levels were tested. The association between the hemoglobin level and osteoporosis was subjected to logistic regression analysis.

Results

For men, the hemoglobin levels were significantly lower in osteoporosis group than that in non-osteoporosis group (135.98 ± 16.20 vs. 142.84 ± 13.78 g/L, P = 0.002). Hemoglobin levels were positively related with BMD of total hip and femoral neck in men (r = 0.170, P = 0.004; r = 0.148, P = 0.012, respectively). After adjusting for age, body mass index (BMI), hemoglobin A1c (HbA1c), estimated glomerular filtration rate (eGFR) and 25-hydroxyvitamin D₃ [25(OH) D₃], the hemoglobin level was related with a 0.97-fold lower risk of osteoporosis (odds ratio (OR): 0.97; 95% confidence interval (CI): 0.95–0.99; P = 0.004) in men, but no such association was found in women.

Conclusion

Higher levels of hemoglobin play a protective role against osteoporosis in older men with T2DM.

The Role of Testosterone in the Elderly: What Do We Know?

Testosterone is the most important hormone in male health. Aging is characterized by testosterone deficiency due to decreasing testosterone levels associated with low testicular production, genetic factors, adiposity, and illness. Low testosterone levels in men are associated with sexual dysfunction (low sexual desire, erectile dysfunction), reduced skeletal muscle mass and strength, decreased bone mineral density, increased cardiovascular risk and alterations of the glycometabolic profile. Testosterone replacement therapy (TRT) shows several therapeutic effects while maintaining a good safety profile in hypogonadal men. TRT restores normal levels of serum testosterone in men, increasing libido and energy level and producing beneficial effects on bone density, strength and muscle as well as yielding cardioprotective effects. Nevertheless, TRT could be contraindicated in men with untreated prostate cancer, although poor findings are reported in the literature. In addition, different potential side effects, such as polycythemia, cardiac events and obstructive sleep apnea, should be monitored. The aim of our review is to provide an updated background regarding the pros and cons of TRT, evaluating its role and its clinical applicability in different domains.

The Role of Testosterone in the Elderly: What Do We Know?

Testosterone is the most important hormone in male health. Aging is characterized by testosterone deficiency due to decreasing testosterone levels associated with low testicular production, genetic factors, adiposity, and illness. Low testosterone levels in men are associated with sexual dysfunction (low sexual desire, erectile dysfunction), reduced skeletal muscle mass and strength, decreased bone mineral density, increased cardiovascular risk and alterations of the glycometabolic profile. Testosterone replacement therapy (TRT) shows several therapeutic effects while maintaining a good safety profile in hypogonadal men. TRT restores normal levels of serum testosterone in men, increasing libido and energy level and producing beneficial effects on bone density, strength and muscle as well as yielding cardioprotective effects. Nevertheless, TRT could be contraindicated in men with untreated prostate cancer, although poor findings are reported in the literature. In addition, different potential side effects, such as polycythemia, cardiac events and obstructive sleep apnea, should be monitored. The aim of our review is to provide an updated background regarding the pros and cons of TRT, evaluating its role and its clinical applicability in different domains.

Role of sex steroids hormones in the regulation of bone metabolism in men: Evidence from clinical studies

Sex steroids regulate bone metabolism in young men during growth and consolidation. Their deficit during growth compromises longitudinal and radial growth of bones and has a negative impact on body height, bone width, peak areal bone mineral density (aBMD) and bone microarchitecture. In older men, the deficit of sex steroid hormones (mainly 17β-oestradiol) contributes to high bone turnover rate, low aBMD, poor bone microarchitecture, low estimated bone strength, accelerated bone loss and rapid decline of bone microarchitecture. The role of 17β-oestradiol is confirmed by the case of men with congenital oestrogen receptor deficit and with congenital aromatase deficiency. 17β-oestradiol inhibits bone resoption, whereas both hormones regulate bone formation. However, the associations are weak. Prospective data on the utility of blood 17β-oestradiol or testosterone for fracture risk assessment are inconsistent. Men with hypogonadism have decreased aBMD and poor bone microarchitecture. In men with hypogonadism, testosterone replacement therapy increases aBMD and improves bone microarchitecture. In men with prostate cancer, androgen deprivation therapy (gonadoliberin analogues) induces rapid bone loss and severe deterioration of bone microarchitecture.

Hormonal and Metabolic Changes of Aging and the Influence of Lifestyle Modifications

Increased life expectancy combined with the aging baby boomer generation has resulted in an unprecedented global expansion of the elderly population. The growing population of older adults and increased rate of age-related chronic illness has caused a substantial socioeconomic burden. The gradual and progressive age-related decline in hormone production and action has a detrimental impact on human health by increasing risk for chronic disease and reducing life span. This article reviews the age-related decline in hormone production, as well as age-related biochemical and body composition changes that reduce the bioavailability and actions of some hormones. The impact of hormonal changes on various chronic conditions including frailty, diabetes, cardiovascular disease, and dementia are also discussed. Hormone replacement therapy has been attempted in many clinical trials to reverse and/or prevent the hormonal decline in aging to combat the progression of age-related diseases. Unfortunately, hormone replacement therapy is not a panacea, as it often results in various adverse events that outweigh its potential health benefits. Therefore, except in some specific individual cases, hormone replacement is not recommended. Rather, positive lifestyle modifications such as regular aerobic and resistance exercise programs and/or healthy calorically restricted diet can favorably affect endocrine and metabolic functions and act as countermeasures to various age-related diseases. We provide a critical review of the available data and offer recommendations that hopefully will form the groundwork for physicians/scientists to develop and optimize new endocrine-targeted therapies and lifestyle modifications that can better address age-related decline in heath.

Testosterone and Bone Health in Men: A Narrative Review

Bone fracture due to osteoporosis is an important issue in decreasing the quality of life for elderly men in the current aging society. Thus, osteoporosis and bone fracture prevention is a clinical concern for many clinicians. Moreover, testosterone has an important role in maintaining bone mineral density (BMD) among men. Some testosterone molecular mechanisms on bone metabolism have been currently established by many experimental data. Concurrent with a decrease in testosterone with age, various clinical symptoms and signs associated with testosterone decline, including decreased BMD, are known to occur in elderly men. However, the relationship between testosterone levels and osteoporosis development has been conflicting in human epidemiological studies. Thus, testosterone replacement therapy (TRT) is a useful tool for managing clinical symptoms caused by hypogonadism. Many recent studies support the benefit of TRT on BMD, especially in hypogonadal men with osteopenia and osteoporosis, although a few studies failed to demonstrate its effects. However, no evidence supporting the hypothesis that TRT can prevent the incidence of bone fracture exists. Currently, TRT should be considered as one of the treatment options to improve hypogonadal symptoms and BMD simultaneously in symptomatic hypogonadal men with osteopenia.

Factors Associated with Low Bone Density in Opioid Substitution Therapy Patients: A Systematic Review

Background: Long-term opioid therapy is a risk factor for low bone mineral density (BMD). However, other factors may also contribute to low BMD. Several studies have examined the variables that might contribute to low BMD in patients receiving opioid replacement therapy (OST). However, to our knowledge, there was no systemic review conducted to address this particular issue. Thus, we reviewed the articles on the factors associated with low BMD in the population of opioid use disorder receiving substitution therapy. Methods: The articles that examined correlates or risk factors of low BMD in OST population were retrieved from OVID, SCOPUS, and PUBMED from inception until July 2020 by two independent investigators. Results: A total of 429 articles from three databases were retrieved initially. After screening based on eligibility criteria, five articles were included in the final analysis. The risk factors or correlates found to be significantly associated with low BMD in the OST population include male gender, low body mass index, low testosterone level, methadone or heroin use, and longer duration of heavy alcohol use. The review limitations include small sample sizes and inconsistent definition of variables. Conclusion: OST patients should be screened for BMD and its associated factors. Guidelines and training of practitioners involving in the OST service should be provided to increase the detection of low BMD in the OST population.

Impact of Dehydroepiandrosterone (DHEA) on Bone Mineral Density and Bone Mineral Content in a Rat Model of Male Hypogonadism

Objectives: The present study examined the effect DHEA (dehydroepiandrosterone) on bone mineral content (BMC) and bone mineral density (BMD) and biomarkers of bone remodeling in orchidectomized male rats. Material and Methods: A total of 32 male rats were divided equally into four groups (n = 8): (i) control group (C), (ii) control treated with DHEA (Control + DHEA), (iii) orchidectomized (ORCH) group that underwent bilateral orchidectomy and (iv) orchidectomized (ORCH) rats treated with DHEA (ORCH+DHEA). DHEA treatment started 4 weeks after orchidectomy and continued for 12 weeks. After 12 weeks the bone mineral density (BMD) and bone mineral content (BMC) were assayed in the tibia and femur of the right hind limb of each rat. We also measured the serum levels of the bone turnover markers deoxypyridinoline (Dpd), N-telopeptide of type I collagen (NTx), alkaline phosphatase (ALP), tartrate-resistant acid phosphatase 5b (TRAP-5b) and osteocalcin (OC) as well as receptor activator of nuclear factor kappa B (RANK) and osteoprotegerin (OPG). Results: Orchidectomy in rats caused significant reduction in BMD, BMC, serum levels of testosterone, PTH (parathyroid hormone), OPG, OC and ALP with significant rise in serum levels of TRAP-5B, RANK, Dpd and NTx1 (p < 0.05). On the other hand, DHEA therapy for 12 weeks caused significant improvement in all studied parameters except NTx1 (p < 0.05). Conclusions: DHEA corrected hypogonadism-induced osteoporosis in male rats probably via inhibiting osteoclastogenesis, stimulating the activity of osteoblasts and stimulating the secretion of PTH and testosterone.

Anemia and Risk of Fractures in Older Korean Adults: A Nationwide Population-Based Study

Anemia is a common health problem in older adults and is associated with risk factors for fracture such as low physical function and low bone mass. The aim of this study was to examine the relationship between anemia and fracture risk in older adults. We conducted a retrospective cohort study from 2003 to 2013. The participants were community-dwelling Korean adults aged 65 years and older who participated in the National Health Screening Program (n = 72,131) between 2003 and 2008. Anemia (<12 g/dL for women and <13 g/dL for men) and severity of anemia (mild: 11 g/dL ≤ Hb < 12 g/dL; moderate to severe: Hb < 11 g/dL) were defined by World Health Organization (WHO) criteria. The incidence of any fractures, vertebral fractures, and femur fractures was identified using ICD-10 codes. Cox proportional hazard regression models were used to assess risk of fracture according to anemia. Anemia was associated with increased risk of fracture in men (any: adjusted hazard ratio [aHR] = 1.29, 95% confidence interval [CI] 1.18-1.41; vertebral: aHR = 1.20, 95% CI 1.03-1.40; femur: aHR = 1.71, 95% CI 1.44-2.04), and less strongly but still significantly in women (any: aHR = 1.10, 95% CI 1.11-1.41; vertebral: aHR = 1.11, 95% CI 1.03-1.20; femur: aHR = 1.37, 95% CI 1.25-1.52). Higher risk was observed in subjects with moderate-to-severe anemia in both sexes. Considering the high prevalence of anemia in older adults, it is important that health professionals recognize increased fracture risk in older adults with anemia. © 2019 American Society for Bone and Mineral Research.

Contribution of bone turnover markers to the variation in bone mineral density: a study in Vietnamese men and women

The present cross-sectional study constructed reference ranges for bone resorption marker beta isomerized form of C-terminal crosslinking telopeptides of type I collagen (beta-CTX) and bone formation marker procollagen type 1 N-terminal propeptide (PINP) for the Vietnamese population. We have further shown that for a given age and weight, higher levels of beta-CTX were significantly associated with bone mineral density in men and women.

INTRODUCTION

Normal bone is constantly renewed by two opposing processes of resorption and formation which can be reflected by bone turnover markers (BTMs). This study sought to define the contribution of BTMs to the variation in bone mineral density (BMD) in normal individuals.

METHODS

The study involved 205 men and 432 women aged between 18 and 87, who were randomly selected from various districts within Ho Chi Minh City, Vietnam. Fasting serum levels of PINP and beta-CTX were determined by electrochemiluminescence (Roche, ECLIA). BMD at the lumbar spine (LS) and femoral neck (FN) was measured by dual-energy x-ray absorptiometry (Hologic, Waltham, MA, USA).

RESULTS

Among those aged < 50 years, women had lower PINP and beta-CTX levels than men, but among those aged > 50 years, women had higher PINP and beta-CTX levels than men. In the multiple linear regression analysis, beta-CTX-but not PINP-was significantly associated with both femoral neck (P = 0.008) and lumbar spine BMD (P = 0.008) and the association was independent of gender, age, and body weight. The proportion of variance in BMD attributable to beta-CTX was 1% for femoral neck BMD and 2% for lumbar spine BMD.

CONCLUSION

The elevation in bone formation marker PINP and bone resorption marker beta-CTX in postmenopausal women was greater than in elderly men. However, only beta-CTX was modestly but significantly associated with BMD.

The Effects of Quassinoid-Rich Eurycoma longifolia Extract on Bone Turnover and Histomorphometry Indices in the Androgen-Deficient Osteoporosis Rat Model

Male osteoporosis is associated with higher rates of disability and mortality. Hence the search for suitable intervention and treatment to prevent the degeneration of skeletal health in men is necessary. Eurycoma longifolia (EL), a traditional plant with aphrodisiac potential may be used to treat and prevent male osteoporosis. The skeletal protective effect of quassinoid-rich EL extract, which has a high content of eurycomanone, has not been studied. This study aimed to determine whether EL could prevent skeletal deteriorations in gonadal hormone-deficient male rats. Ninety-six male Sprague⁻Dawley rats were randomly assigned to baseline, sham-operated (Sham), orchidectomised or chemically castrated groups. Chemical castration was achieved via subcutaneous injection of degarelix at 2 mg/kg. The orchidectomised and degarelix-castrated rats were then divided into negative control groups (ORX, DGX), testosterone-treated groups (intramuscular injection at 7 mg/kg weekly) (ORX + TES, DGX + TES), and EL-supplemented groups receiving daily oral gavages at doses of 25 mg/kg (ORX + EL25, DGX + EL25), 50 mg/kg (ORX + EL50, DGX + EL50), and 100 mg/kg (ORX + EL100, DGX + EL100). Following 10 weeks of treatment, the rats were euthanized and their blood and femora were collected. Bone biochemical markers, serum testosterone, osteoprotegerin (OPG), and receptor activator of nuclear factor kappa β-ligand (RANKL) levels and histomorphometric indices were evaluated. Quassinoid-rich EL supplementation was found to reduce degenerative changes of trabecular structure by improving bone volume, trabecular number, and separation. A reduction in the percentage of osteoclast and increase in percentage of osteoblast on bone surface were also seen with EL supplementation. Dynamic histomorphometric analysis showed that the single-labeled surface was significantly decreased while the double-labeled surface was significantly increased with EL supplementations. There was a marginal but significant increase in serum testosterone levels in the ORX + EL25, DGX + EL50, and DGX + EL100 groups compared to their negative control groups. Quassinoid-rich EL extract was effective in reducing skeletal deteriorations in the androgen-deficient osteoporosis rat model.

Associated Factors of Bone Mineral Density and Osteoporosis in Elderly Males

BACKGROUND

Low bone mineral density and osteoporosis is prevalent in elderly subjects. This study aimed to determine the associated factors of bone mineral density and osteoporosis in elderly males.

METHODS

All participants of the Amirkola health and ageing project cohort aged 60 years and older entered the study. Bone mineral density at femoral neck and lumbar spine was assessed by the dual energy X-ray absorptiometry (DXA) method. Osteoporosis was diagnosed by the international society for clinical densitometry criteria and the association of bone mineral density and osteoporosis with several clinical, demographic and biochemical parameters. Multiple logistic regression analysis was used to determine independent associations.

RESULTS

A total of 553 patients were studied and 90 patients (16.2%) had osteoporosis at either femoral neck or lumbar spine. Diabetes, obesity, metabolic syndrome, overweight, and quadriceps muscle strength > 30 kg, metabolic syndrome, abdominal obesity and education level were associated with higher bone mineral density and lower prevalence of osteoporosis, whereas age, anemia, inhaled corticosteroids and fracture history were associated with lower bone mineral density and higher prevalence of osteoporosis (P = 0.001). After adjustment for all covariates, osteoporosis was negatively associated only with diabetes, obesity, overweight, and QMS > 30 kg and positively associated with anemia and fracture history. The association of osteoporosis with other parameters did not reach a statistical level.

CONCLUSIONS

The findings of the study indicate that in elderly males, diabetes, obesity and higher muscle strength was associated with lower prevalence of osteoporosis and anemia, and prior fracture with higher risk of osteoporosis. This issue needs further longitudinal studies.

Prostate Cancer: Is It a Battle Lost to Age?

Age is often considered an important non-modifiable risk factor for a number of diseases, including prostate cancer. Some prominent risk factors of prostate cancer include familial history, ethnicity and age. In this review, various genetic and physiological characteristics affected due to advancing age will be analysed and correlated with their direct effect on prostate cancer.

Building healthy bones throughout life: an evidence-informed strategy to prevent osteoporosis in Australia

Osteoporosis imposes a tremendous burden on Australia: 1.2 million Australians have osteoporosis and 6.3 million have osteopenia. In the 2007–08 financial year, 82 000 Australians suffered fragility fractures, of which > 17 000 were hip fractures. In the 2000–01 financial year, direct costs were estimated at $1.9 billion per year and an additional $5.6 billion on indirect costs. Osteoporosis was designated a National Health Priority Area in 2002; however, implementation of national plans has not yet matched the rhetoric in terms of urgency. Building healthy bones throughout life, the Osteoporosis Australia strategy to prevent osteoporosis throughout the life cycle, presents an evidence-informed set of recommendations for consumers, health care professionals and policymakers. The strategy was adopted by consensus at the Osteoporosis Australia Summit in Sydney, 20 October 2011. Primary objectives throughout the life cycle are: to maximise peak bone mass during childhood and adolescence to prevent premature bone loss and improve or maintain muscle mass, strength and functional capacity in healthy adults to prevent and treat osteoporosis in order to minimise the risk of suffering fragility fractures, and reduce falls risk, in older people. The recommendations focus on three affordable and important interventions — to ensure people have adequate calcium intake, vitamin D levels and appropriate physical activity throughout their lives. Recommendations relevant to all stages of life include: daily dietary calcium intakes should be consistent with Australian and New Zealand guidelines serum levels of vitamin D in the general population should be above 50nmol/L in winter or early spring for optimal bone health regular weight-bearing physical activity, muscle strengthening exercises and challenging balance/mobility activities should be conducted in a safe environment.

Multivariate analysis of lifestyle, constitutive and body composition factors influencing bone health in community-dwelling older adults from Madeira, Portugal

This study describes the association between habitual physical activity (PA), other lifestyle/constitutive factors, body composition, and bone health/strength in a large sample of older adults from Madeira, Portugal. This cross-sectional study included 401 males and 401 females aged 60-79 years old. Femoral strength index (FSI) and bone mineral density (BMD) of the whole body, lumbar spine (LS), femoral neck (FN), and total lean tissue mass (TLTM) and total fat mass (TFM) were determined by dual-energy X-ray absorptiometry-DXA. PA was assessed during face-to-face interviews using the Baecke questionnaire and for a sub-sample by Tritrac accelerometer. Demographic and health history information were obtained by telephone interview through questionnaire. The relationship between habitual PA variables and bone health/strength indicators (whole body BMD, FNBMD, LSBMD, and FSI) investigated using Pearson product-moment correlation coefficient was similar for females (0.098≤r≤0.189) and males (0.104≤r≤0.105). Results from standard multiple regression analysis indicated that the primary and most significant predictors for FNBMD in both sexes were age, TLTM, and TFM. For LSBMD, the most significant predictor was TFM in men and TFM, age, and TLTM in females. Our regression model explained 8.3-14.2% and 14.8-29.6% of the total variance in LSBMD and FNBMD for males and females, respectively. This study suggests that habitual PA is minimally but positively associated with BMD and FSI among older adult males and females and that body composition factors like TLTM and TFM are the strongest determinants of BMD and FSI in this population.

The relationship between body mass index and physical activity levels in relation to bone mineral density in premenopausal and postmenopausal women

We prospectively analyzed 283 women to evaluate the effects of body mass index (BMI) and physical activity levels on bone mineral density (BMD) progression in pre- and postmenopausal women over 2 years. In postmenopausal women, lower BMI was linked with worsening BMD, and moderate activity levels were associated with a lower likelihood of worsening BMD at 2 years.

PURPOSE

The aim of our study is to evaluate the effects of BMI and physical activity levels on BMD progression in pre- and postmenopausal Asian women over 2 years.

METHODS

We prospectively analyzed 283 women from 2006 to 2009. They were divided into two groups (159 pre- and 124 postmenopausal) and analyzed separately to avoid confounding by age and menopausal hormonal status. The mean follow-up period was 771 days. Demographic data was obtained, including medical history, calcium supplementation, BMI, and physical activity levels (IPAQ scale). Bilateral femoral neck BMD was determined at the time of recruitment, 1 year, and after 2 years. Generalized linear modeling was used to evaluate the effects of BMI and physical activity levels on BMD progression over a 2-year period.

RESULTS

Amongst premenopausal women, lower initial femoral neck BMD scores were linked to worsening BMD (p = 0.048). In postmenopausal women, lower BMI was linked with worsening BMD (p = 0.012). Postmenopausal patients with moderate activity levels had a lower likelihood of worsening BMD at 2 years (p = 0.038). High physical activity levels were linked to a lower risk of BMD worsening (p = 0.066).

CONCLUSIONS

Higher BMI scores are protective for osteoporosis in postmenopausal women. Moderate levels of physical activity are beneficial for bone health in postmenopausal women, while low physical activity levels are not helpful. We recommend that, in the secondary prevention of osteoporosis, postmenopausal women should be encouraged to participate regularly in moderate physical activities. A practical approach would be walking 30 min a day for at least 5 days per week.

Prevalence of osteoporosis in otherwise healthy Indian males aged 50 years and above

Bone mineral density was studied in 200 healthy Indian men above 50 years age, without fractures or osteoporosis. Mean vitamin D was 18.96 ng/ml; other biochemical evaluations were normal. Bone density (femur neck) decreased with age; there was osteoporosis in 8.5 %, osteopenia in 42 %, while 49.5 % were normal. Vitamin D deficiency may have caused osteoporosis.

PURPOSE

Osteoporosis is recognized as the disease of females; however, males are also affected and have serious consequences thereof. The present study aimed at studying the prevalence of osteoporosis in otherwise healthy Indian males aged 50 years or more and studying the factors affecting bone mineral density (BMD).

METHODS

With informed consent, 200 healthy males aged 50 years or more without the history of fractures or diseases affecting the BMD were evaluated clinically (including anthropometry) and biochemically (serum calcium, phosphate, alkaline phosphatase, creatinine, albumin, 25-OH Vitamin D, intact parathyroid hormone (iPTH), and testosterone). The BMD was measured by single observer on Lunar DPX-NT at right proximal femur for least effects of artifacts. Calculation of T score and categorization as osteoporosis, osteopenia, and normal BMD was done as per WHO classification.

RESULTS

The mean age was 62.61 ± 7.64 years, and BMI was 23.90 ± 3.73 kg/m(2). The testosterone levels were normal in 84 % subjects. The mean 25-OH vitamin D level was 18.96 ± 10.23 ng/ml; only 13.5 % subjects had normal levels. The mean iPTH level was 72.60 ± 43.77 pg/ml; 57 % subjects had normal iPTH (12-72 pg/ml). The other parameters studied were normal. The osteoporosis and osteopenia were more prevalent when BMD was evaluated at neck of femur (osteoporosis 8.5 vs 8 % at trochanter and 7.5 % at total right hip; osteopenia 42 vs 37 % at trochanter and 41 % at total right hip). The BMD deteriorated with age.

CONCLUSION

The osteoporosis affects 8.5 % of otherwise healthy males aged 50 years and above. Vitamin D deficiency is common in such group and maybe responsible for osteoporosis.

Eurycoma longifolia upregulates osteoprotegerin gene expression in androgen- deficient osteoporosis rat model

BACKGROUND

Eurycoma longifolia (EL) has been shown recently to protect against bone calcium loss in orchidectomised rats, the model for androgen-deficient osteoporosis. The mechanism behind this is unclear but it may be related to its ability to elevate testosterone levels or it may directly affect bone remodeling. The aim of this study is to determine the mechanism involved by investigating the effects of EL extract on serum testosterone levels, bone biomarkers, biomechanical strength and gene expression of Receptor Activator of Nuclear Factor kappa-B ligand (RANKL), Osteoprotegerin (OPG) and Macrophage-Colony Stimulating Factor (MCSF) in orchidectomised rats.

METHODS

Thirty-two male Sprague-Dawley rats were divided into: Sham-operated group (SHAM); orchidectomised-control group (ORX); orchidectomised and given 15 mg/kg EL extract (ORX + EL) and orchidectomised and given 8 mg/kg testosterone (ORX + T). The rats were treated for 6 weeks. The serum levels of testosterone, osteocalcin and C-terminal telopeptide of type I collagen (CTX) were measured using the ELISA technique. The femoral bones were subjected to biomechanical testing. The tibial bone gene expressions of RANKL, OPG and MCSF were measured using the branch DNA technique.

RESULTS

The post-treatment level of testosterone was found to be significantly reduced by orchiectomy (p < 0.05). Both ORX + EL and ORX + T groups have significantly higher post-treatment testosterone levels compared to their pre-treatment levels (p < 0.05). The bone resorption marker (CTx) was elevated after orchiectomy but was suppressed after treatment in the ORX + EL and ORX + T groups (p < 0.05). There was no significant finding for the femoral biomechanical parameters. The tibial OPG gene expression in the ORX group was significantly lower compared to the SHAM and ORX + EL groups (p < 0.05).

CONCLUSION

Supplementation with EL extract elevated the testosterone levels, reduced the bone resorption marker and upregulated OPG gene expression of the orchidectomised rats. These actions may be responsible for the protective effects of EL extract against bone resorption due to androgen deficiency.

Severe osteopenia and osteoporosis, sarcopenia, and frailty status in community-dwelling older women: results from the Women's Health and Aging Study (WHAS) II

OBJECTIVES

The goal of this study was to examine the associations between severe osteopenia and osteoporosis and/or sarcopenia on frailty status, a major geriatric syndrome in community-dwelling older women.

DESIGN

Cross-sectional analysis.

SETTING

Women's Health and Aging Studies II (WHAS-II), Baltimore, Maryland.

PARTICIPANTS AND MEASUREMENTS

The analytic sample for this study included 250 women aged 76-86 years old who underwent DXA evaluation at round 4. Frailty was determined using validated screening criteria. Severe osteopenia was defined as BMD between -2.0 SD and -2.49 SD and osteoporosis as BMD less than -2.5 SD (lumbar spine and/or proximal femur). Sarcopenia was determined by the appendicular lean mass by height(2) (aLM/ht(2) method) and considered present when the value was less then -2 SD compared to young women.

RESULTS

Mean age of study subjects was 79.6 (±2.7) years. Overall prevalence of frailty was 6.8% (n=17). Severe osteopenia/osteoporosis occurred in 42.1% (n=7) in the frail group, 28% (n=33) in the pre frail group and 25.2% in the robust group. Sarcopenia was present in 52.9% (n=9) in the frail group, 42% (n=50) in the pre frail and 41.2% (n=47) in the robust group. Almost sixteen percent (n=39) had severe osteopenia/osteoporosis concomitant to sarcopenia. In an adjusted logistic regression model, severe osteopenia/osteoporosis (OR: 2.1; 95% CI: 0.68-6.6, p=0.196) and sarcopenia (OR: 3.1; 95% CI: 0.88-11.1; p=0.077) were individually associated with frailty, though not statistically significant. On the other hand, the likelihood of being frail was substantially higher in the presence of these two syndromes (OR: 6.4; 95% CI: 1.1-36.8, p=0.037).

CONCLUSION

These findings suggest a concomitant impact of severe osteopenia/osteoporosis plus sarcopenia in regard to frailty status in a sample of oldest old women living in the community.

Relative contributions of multiple determinants to bone mineral density in men

SUMMARY

Focus on individual risk factors for osteoporosis could allocate disproportionate attention to trivial relationships. We tested many recognized risk factors of osteoporosis for their association with bone mineral density (BMD) in multivariate models among men. Lean mass accounted for the most variance, with substantially less accounted for by demographic, strength, and health factors.

INTRODUCTION

Osteoporosis in men has gained recognition as a public health problem, generating an interest in the search for risk factors. Isolation of individual risk factors could allocate disproportionate attention to relationships that may be of limited consequence.

METHODS

The Boston Area Community Health/Bone (BACH/Bone) Survey is a population-based study of randomly selected community-dwelling men (age, 30-79 years). BMD and lean mass were measured by dual X-ray absorptiometry. Socioeconomic status, health history, and lifestyle factors were obtained via interview. Hormone levels and markers of bone turnover were obtained from non-fasting blood samples. Multivariate analyses measured relative contributions of covariates to femoral neck (hip), one-third distal radius (wrist), and lumbar spine BMD.

RESULTS

Factors positively associated with BMD in multivariate models at the three sites were black race and appendicular lean mass. Asthma was consistently negatively associated. Various other risk factors also contributed significantly to each of the individual sites. R (2) values for the hip, wrist, and spine were 41%, 30%, and 24%, respectively. Lean mass accounted for the most explained variance at all three sites.

CONCLUSIONS

These data emphasize the limitation of focusing on individual risk factors and highlight the importance of potentially modifiable lean mass in predicting BMD.

The benefits and risks of testosterone replacement therapy: a review

Increased longevity and population aging will increase the number of men with late onset hypogonadism. It is a common condition, but often underdiagnosed and undertreated. The indication of testosterone-replacement therapy (TRT) treatment requires the presence of low testosterone level, and symptoms and signs of hypogonadism. Although controversy remains regarding indications for testosterone supplementation in aging men due to lack of large-scale, long-term studies assessing the benefits and risks of testosterone-replacement therapy in men, reports indicate that TRT may produce a wide range of benefits for men with hypogonadism that include improvement in libido and sexual function, bone density, muscle mass, body composition, mood, erythropoiesis, cognition, quality of life and cardiovascular disease. Perhaps the most controversial area is the issue of risk, especially possible stimulation of prostate cancer by testosterone, even though no evidence to support this risk exists. Other possible risks include worsening symptoms of benign prostatic hypertrophy, liver toxicity, hyperviscosity, erythrocytosis, worsening untreated sleep apnea or severe heart failure. Despite this controversy, testosterone supplementation in the United States has increased substantially over the past several years. The physician should discuss with the patient the potential benefits and risks of TRT. The purpose of this review is to discuss what is known and not known regarding the benefits and risks of TRT.

Androgens and bone

Testosterone is the major gonadal sex steroid produced by the testes in men. Testosterone is also produced in smaller amounts by the ovaries in women. The adrenal glands produce the weaker androgens dehydroepiandrosterone, dehydroepiandrosterone sulfate, and androstenedione. These androgens collectively affect skeletal homeostasis throughout life in both men and women, particularly at puberty and during adult life. Because testosterone can be metabolized to estradiol by the aromatase enzyme, there has been controversy as to which gonadal sex steroid has the greater skeletal effect. The current evidence suggests that estradiol plays a greater role in maintenance of skeletal health than testosterone, but that androgens also have direct beneficial effects on bone. Supraphysiological levels of testosterone likely have similar effects on bone as lower levels via direct interaction with androgen receptors, as well as effects mediated by estrogen receptors after aromatization to estradiol. Whether high doses of synthetic, non-aromatizable androgens may, in fact, be detrimental to bone due to suppression of endogenous testosterone (and estrogen) levels is a potential concern that warrants further study.

Relationship of sex steroid hormones with bone mineral density (BMD) in a nationally representative sample of men

OBJECTIVE

Sex steroid hormones influence bone mineral density (BMD) in women, but are less well-studied in men. We evaluated the association of serum total and free sex steroid hormones and SHBG with osteopaenia in a nationally representative sample of men aged 20-90 years.

DESIGN

BMD and sex steroid hormones were measured among participants in NHANES III, a cross-sectional study of the US population.

POPULATION

A total of 1185 adult men in morning examination session of Phase I of NHANES III (1988-91).

MEASUREMENTS

Relation of oestradiol (E(2)), testosterone, and SHBG concentrations with BMD. Osteopaenia was defined as 1-2.5 SD below the mean for white men aged 20-29 years.

RESULTS

Men in the lowest quartile of free E(2) had 70% increased odds (OR = 1.69, 95% CI 0.95-2.98) of osteopaenia compared with men in the highest quartile. Men in the lowest quartile of free testosterone had nearly four times the odds of osteopaenia than those in the highest quartile (OR = 3.82, 95% CI 1.87-7.78). Lower concentrations of SHBG appeared protective against osteopaenia (P-trend = 0.01). Neither total testosterone nor total E(2) was associated with BMD, although men with clinically low E(2) (< 20 ng/l) had lower BMD (0.930 g/cm(2), 95% CI 0.88-0.98) than men with normal-range E(2) (1.024 g/cm(2), 95% CI 1.01-1.04; P = 0.004). Findings for free E(2) were most pronounced among elderly men, while the findings for free testosterone were most pronounced among younger men.

CONCLUSIONS

In this nationally representative study, men with lower free E(2), lower free testosterone, and higher SHBG concentrations in circulation were more likely to have low BMD.

Sex hormones, their receptors and bone health

Sex steroids regulate skeletal maturation and preservation in both men and women, as already recognized in the 1940s by Albright and Reifenstein. The impact of gonadal insufficiency on skeletal integrity has been widely recognized in adult men and women ever since. In the context of their skeletal actions, androgens and estrogens are no longer considered as just male and female hormones, respectively. Androgens can be converted into estrogens within the gonads and peripheral tissues and both are present in men and women, albeit in different concentrations. In the late 1980s, sex steroid receptors were discovered in bone cells. However, the understanding of sex steroid receptor activation and translation into biological skeletal actions is still incomplete. Due to the complex metabolism, sex steroids may have not only endocrine but also paracrine and/or autocrine actions. Also, circulating sex steroid concentrations do not necessarily reflect their biological activity due to strong binding to sex hormone binding globulin (SHBG). Finally, sex steroid signaling may include genomic and non-genomic effects in bone and non-bone cells. This review will focus on our current understanding of gonadal steroid metabolism, receptor activation, and their most relevant cellular and biological actions on bone.

Recent trends in the treatment of testosterone deficiency syndrome

Testosterone deficiency syndrome (TDS) is defined as a clinical and biochemical syndrome associated with advancing age and is characterized by typical symptoms and deficiency in serum testosterone levels. TDS is a result of the interaction of hypothalamo-pituitary and testicular factors. Now, treatment of TDS with testosterone is still controversial due to a lack of large, controlled clinical trials on efficacy. The risks of treatment with testosterone appear to be minimal, although long-term studies on the safety of testosterone therapy are lacking. The aim of the therapy is to establish a physiological concentration of serum testosterone in order to correct the androgen deficiency, relieve its symptoms and prevent long-term sequelae. All of the available products, despite their varying pharmacodynamic and pharmacokinetic profiles, are able to reach this goal. Newer testosterone patches seem not to cause severe skin irritation. Testosterone gels minimize the skin irritation while providing flexibility in dosing and a low discontinuation rate. Oral testosterone undecanoate (TU) is free of liver toxicity. Recent formulation of oral TU markedly increased shelf-live, a major drawback in the older preparation. Producing swings in testosterone levels rising rapidly to the supraphysiological range is not the case with the new injectable long-acting preparation of TU. To be able to rapidly react and stop treatment in cases where side-effects and contraindications are detected, the short-acting transdermal and oral delivery modes have certain advantages. However, there is no evidence that the use of an injectable long-acting TU in men with TDS has limitations in clinical application for this reason. The use of dehydroepiandrosterone is still controversial because of a lack of well designed long-term trials, although some recent studies suggest positive effects on various body systems. Only a few studies have been carried out to investigate the effect of hCG (human chorionic gonadotropin) in TDS with some positive results on various body systems.

Testosterone therapy in the aging male

The decline, with aging, in serum concentrations of biologically active forms of testosterone in men is an indisputable fact and some men will eventually develop symptoms of late-onset hypogonadism (LOH) with its clinical consequences. LOH reduces quality of life and may pose important risk factors for frailty, changes in body composition, cardiovascular disease, sexual dysfunction and osteoporosis. Testosterone supplementation in cases of LOH will restore serum testosterone levels into the physiologic range; will restore metabolic parameters to the eugonadal state, increase muscle mass, strength, and function; maintaine or improve BMD reducing fracture risk; will improve neuropsychological function (cognition and mood); libido and sexual functioning; and enhance quality of life. The ultimate goals, however, are to maintain or regain a high quality of life, to reduce disability, to compress major illnesses into a narrow age range and to add life to years. To achieve these goals men must also adjust their lifestyle to optimize dietary habits, as well as to exercise and to abstain from smoking life-long. Monitoring these patients is a shared responsibility that cannot be taken lightly. The physician must emphasize to the patient the need for periodic evaluations and the patient must agree to comply with these requirements. The physician's evaluation should include an assessment of the clinical response and monitoring must be tailored to the indications and individual needs of the patient.

Picking a bone with contemporary osteoporosis management: Nutrient strategies to enhance skeletal integrity

Epidemic rates of osteoporosis in the western world have yielded intense efforts to develop management approaches to combat this potentially devastating disorder; recent research has unveiled innovative strategies which hold considerable promise for prevention of skeletal compromise and amelioration of suboptimal bone health. According to many algorithms and practice directives, the contemporary assessment and management of osteoporosis focuses heavily on determination of fracture risk and pharmaceutical intervention for those patients deemed to be at high risk. While routine recommendations for calcium and vitamin D have been incorporated into most regimens, disproportionately little attention has been given to recent research elucidating improved bone health and diminution in fracture rates experienced by patients receiving specific nutrients. In mainstream medical practice, clinical analysis and management of nutritional or dietary issues is sometimes perceived as unconventional, primitive or unsophisticated health care. Recent evidence-based research, however, supports intervention with adequate amounts of specific nutrients including vitamin D, strontium, vitamin K, and essential fatty acids in the prevention and primary management of osteoporosis.

Positive associations of bone mineral density with body mass index, physical activity, and blood triglyceride level in men over 70 years old: a TCVGHAGE study

It is known that osteoporosis decreases physical function in older males. However, the role of metabolic parameters and physical activity influencing older men's bone status remains unclear. Thus, this study was designed to evaluate calcaneus bone mass by ultrasonic screening and the associated physical and metabolic functions in older men. This was a cross-sectional study. Three hundred sixty-eight older men (average age, 78.8 years) living in a veterans' home were enrolled. We measured body height and weight, waist and hip circumference, body fat, lean body mass, blood pressure, 6-min walking distance, complete blood count, and blood biochemical profile. Broadband ultrasound attenuation (BUA) and T-score were recorded using Soundscan quantitative ultrasound over the right calcaneus. The range of calcaneus BUA was 27.3-134.0; T-score was from -4.78 to 3.43. Of the total participants, 36.4% were osteopenic (-2.5 < T-score < -1.0) and 16.3% were osteoporotic (T-score <or= -2.5). BUA correlated with weight, body mass index (BMI), waist circumference, hip circumference, body fat, lean body mass, serum triglycerides, high-density lipoprotein-cholesterol, albumin, prealbumin, fasting and PC-2h blood insulin, red blood cell count, hemoglobin concentration, and 6-min walking distance. Multiple regression stepwise analysis revealed that only BMI, distance of 6-min walking, and blood triglyceride level were independently and positively associated with the values of BUA. Calcaneus bone mass is significantly and positively associated with BMI, blood triglycerides, and 6-min walking distance in older men.

Age related variation of salivary testosterone values in healthy Japanese males

OBJECTIVE

We examined age associated variation in salivary testosterone values among Japanese males as well as anthropometric measurements.

METHODS

Salivary samples were collected in pretreated sodium azide treated tubes. The first series: 15-79-year-old males (n = 99); two morning and two evening samples were collected at home for two days. The second series: 90-year-old males (n = 29); one morning sample was collected. Testosterone values were determined using an iodine125-based radioimmunoassay kit modified for saliva.

RESULTS

Results show 1) a significant decrease in salivary testosterone values from 20s to 40s and older, 2) no significant decline after 40 through 90 years old, 3) no significant age-related differences in the degree of intraindividual diurnal fluctuation across age groups of 40-70s, and 4) higher BMI is associated with the lower salivary testosterone among 40-70s.

CONCLUSIONS

These results suggest that neither a constant decrease of salivary testosterone values or markedly reduced intraindividual fluctations are universal aspects of aging. Older males may maintain relatively high testosterone levels compared to younger men and a relatively 'robust' neuroendocrinological system.

Male hypogonadism : an update on diagnosis and treatment

Male hypogonadism is one of the most common endocrinologic syndromes. The diagnosis is based on clinical signs and symptoms plus laboratory confirmation via the measurement of low morning testosterone levels on two different occasions. Serum luteinizing hormone and follicle-stimulating hormone levels distinguish between primary (hypergonadotropic) and secondary (hypogonadotropic) hypogonadism. Hypogonadism associated with aging (andropause) may present a mixed picture, with low testosterone levels and low to low-normal gonadotropin levels. Androgen replacement therapy in hypogonadal men has many potential benefits: improved sexual function, an enhanced sense of well-being, increased lean body mass, decreased body fat, and increased bone density. However, it also carries potential risks, including the possibility of stimulating the growth of an occult prostate cancer. The benefits of androgen therapy outweigh the risks in men with classic hypogonadism. However, for men with mild hypogonadism or andropause, the balance between benefits and risks is not always clear. Unfortunately, studies to date have included too small a number of patients and have been too short in duration to provide meaningful data on the long-term risks versus the benefits of androgen replacement therapy in these populations. Several products are currently marketed for the treatment of male hypogonadism. Weekly-to-biweekly injections of testosterone cypionate (cipionate) or testosterone enanthate (enantate) are widely used, as they are economical and generally well tolerated. However, once-daily transdermal therapies have become increasingly popular and now include both patch and gel systems. Intramuscular injection of testosterone undecanoate is an attractive new therapy that can be administered quarterly. To confirm an adequate replacement dosage, assessment of clinical responses and measurement of serum testosterone levels generally suffice. For selected men, serial measurement of bone mineral density during androgen therapy might be helpful to confirm end-organ effects. For men aged >50 years, we advocate measurement of hematocrit for detection of polycythemia and a digital rectal examination with a serum prostate-specific antigen level measurement for prostate cancer screening during the first few months of androgen therapy. Subsequently, a hematocrit should be obtained yearly or after changes in therapy, and annual prostate cancer screening can be offered to the patient after a discussion of its risks and benefits.

Alendronate for osteoporosis in men with androgen-repleted hypogonadism

Male hypogonadism is associated with low bone mineral density (BMD) and an increased risk of fractures. Testosterone replacement therapy improves BMD in young hypogonadal men. This effect is milder in older patients, who are at greater risk for fractures. We studied the effects of alendronate or placebo on BMD in 22 osteoporotic men, 29-69 years of age (mean, 50.2+/-11.2 years) with long-standing hypogonadism, receiving standard testosterone replacement treatment. Alendronate 10 mg daily (n=11) increased lumbar-spine BMD by 6.0 and 8.4% at 6 and 12 months, respectively, compared with -0.5% at 6 months and +3.3% at 12 months in the placebo group (n=11; P<0.005). Alendronate also increased mean femoral-neck BMD by 1.9% after 1 year, compared to a 1.4% decrease with placebo (P<0.005), and increased the total body bone mineral content by 4.4%, compared to a 0.6% decrease with placebo (P=0.07). After 6 months alendronate suppressed urinary deoxypyridinoline by 50% (P<0.005), compared to a 24% decrease in the placebo group. Both the alendronate and placebo groups continued with alendronate 70 mg once weekly for the following 2 years. Lumbar-spine BMD during this open-label study phase did not change significantly in the group originally treated with alendronate, but continued to increase in the placebo-alendronate group by 5.4, 6.5, and 6.2% after 18 (6 months of alendronate), 24 and 36 months, respectively (P<0.05). Femoral-neck BMD continued to increase in both groups receiving active therapy; in the alendronate-alendronate group by 3.7, 2.7, and 5.2% after 18, 24, and 36 months, respectively (P=0.01), and in the placebo-alendronate group by 0.7 and 1.9% at 24 (first 12 months of alendronate) and 36 months, respectively (P<0.05). Our results support the long-term administration of alendronate along with testosterone replacement to men with hypogonadism-induced osteoporosis.

ISA, ISSAM and EAU recommendations for the investigation, treatment and monitoring of late-onset hypogonadism in males: scientific background and rationale

Prescription sales for testosterone products have substantially increased over the last several years reflecting the growing awareness of physicians for the potential benefits of testosterone replacement therapy in men with hypogonadism. Indiscriminate administration of testosterone poses a risk and has to be deprecated. Testosterone supplementation to treat late-onset hypogonadism (LOH), a term for androgen deficiency in elderly men, is still controversially discussed mainly due to a lack of large, controlled clinical trials on efficacy and safety. To provide guidance for physicians primarily dealing with aging men, ISSAM is periodically updating and publishing its recommendations as new data become available [Morales A, Lunenfeld B. International Society for the Study of the Aging Male. Investigation, treatment and monitoring of late-onset hypogonadism in males. Official recommendations of ISSAM. International Society for the Study of the Aging Male. Aging Male 2002;5:74-86 and Morales A, Lunenfeld B. Androgen replacement therapy in aging men with secondary hypogonadism. Draft recommendations for endorsement by ISSAM. Aging Male 2001;4:1]. Following a panel discussion at the 4th ISSAM Congress in Prague in February 2004, the International Society of Andrology (ISA), the International Society for the Study of the Aging Male (ISSAM) and the European Association of Urology (EAU) revised existing recommendations on the definition, diagnosis and management of LOH. The recommendations are based on the currently available scientific data on androgen supplementation therapy and should be regarded as provisional until larger-scale, long-term studies are available. While certainly not intending to be exhaustive, this review will highlight some relevant background information and provide the underlying scientific rationale for the ISA, ISSAM and EAU recommendations on LOH published in this issue.

Lack of association between androgen receptor polymorphisms and bone mineral density or physical function in older men

Individuals whose androgen receptors have short polyglutamine tracts (resulting from CAG repeats) may have greater receptor signaling activity of the androgen receptor. We evaluated the association between bone mineral density (BMD) and CAG repeats in 91 older men with normal (control) and low femoral neck (EN) BMD (OP) or a history of femoral fracture (FX). Bioavailable testosterone (BioT) and physical performance, including composite score (EPESE) and physical activity (PASE), were also measured. Comparing FX, OP, and control subjects, we observed BMD Tscores of -2.16 +/- 1.08, -2.26 +/- 0.74, and -0.20 +/- 0.40 (p < 0.001); CAG repeat lengths of 21.9 +/- 2.7, 22.5 +/- 2.4, and 22.3 +/- 2.9 (p = 0.63); BioT levels of 2.29 +/- 1.25, 2.19 +/- 1.11, and 3.99 +/- 1.25 nmol/L (p < 0.001); EPESE scores of 8.0 +/- 3.0, 9.7 +/- 2.0, and 11.3 +/- 0.9 (p < 0.001); and PASE scores of 91 +/- 66, 122 +/- 66, and 200 +/- 55 (p < 0.001), respectively. There were no significant correlations between CAG repeats and BioT or physical performance. Men with osteoporosis or fracture had lower BioT, physical performance, and physical activity than controls. This study found no association between CA G repeats and FN BMD in older men with normal or low BMD or FX.

Androgens and bone

Loss of estrogens or androgens increases the rate of bone remodeling by removing restraining effects on osteoblastogenesis and osteoclastogenesis, and also causes a focal imbalance between resorption and formation by prolonging the lifespan of osteoclasts and shortening the lifespan of osteoblasts. Conversely, androgens, as well as estrogens, maintain cancellous bone mass and integrity, regardless of age or sex. Although androgens, via the androgen receptor (AR), and estrogens, via the estrogen receptors (ERs), can exert these effects, their relative contribution remains uncertain. Recent studies suggest that androgen action on cancellous bone depends on (local) aromatization of androgens into estrogens. However, at least in rodents, androgen action on cancellous bone can be directly mediated via AR activation, even in the absence of ERs. Androgens also increase cortical bone size via stimulation of both longitudinal and radial growth. First, androgens, like estrogens, have a biphasic effect on endochondral bone formation: at the start of puberty, sex steroids stimulate endochondral bone formation, whereas they induce epiphyseal closure at the end of puberty. Androgen action on the growth plate is, however, clearly mediated via aromatization in estrogens and interaction with ERalpha. Androgens increase radial growth, whereas estrogens decrease periosteal bone formation. This effect of androgens may be important because bone strength in males seems to be determined by relatively higher periosteal bone formation and, therefore, greater bone dimensions, relative to muscle mass at older age. Experiments in mice again suggest that both the AR and ERalpha pathways are involved in androgen action on radial bone growth. ERbeta may mediate growth-limiting effects of estrogens in the female but does not seem to be involved in the regulation of bone size in males. In conclusion, androgens may protect men against osteoporosis via maintenance of cancellous bone mass and expansion of cortical bone. Such androgen action on bone is mediated by the AR and ERalpha.

Exercise and aging

There is increasing evidence that the black box we have referred to as"biologic aging" is composed of genetic factors and many types of environmental exposures. Some of the most potentially modifiable elements of this syndrome are those attributable to disuse or insufficient exposure to certain kinds or intensities of physical stressors during the course of the life span. Beneficial adaptations to exercise once thought restricted to genetically endowed master athletes now are seen to occur just as predictably in frail elders with chronic disease, opening the door to vastly improved physical function and associated health benefits. Knowledge of the benefits of physical activity, however well substantiated, may be necessary, but it is not sufficient to change either physician-prescribing habits or the likelihood of adoption and long-term adherence to exercise on the part of patients. Ultimately, the penetration of an exercise prescription to optimize aging into the most inactive cohorts in the community,who have the most to gain from increases in levels of physical activity and fitness, will depend on a combination of clear evidence-based guidelines coupled with health professional training and behavioral programs tailored to age-specific barriers and motivational factors.

Intervertebral disc degeneration can lead to "stress-shielding" of the anterior vertebral body: a cause of osteoporotic vertebral fracture?

STUDY DESIGN

Mechanical testing of cadaveric lumbar motion segments.

OBJECTIVES

To test the hypothesis that degenerative changes in the intervertebral discs can influence loading of the anterior vertebral body in a manner that makes it vulnerable to fracture.

SUMMARY OF BACKGROUND DATA

Measurements of systemic bone loss do not fully explain the patterns of osteoporotic vertebral fractures.

METHODS

Thirty-three cadaveric lumbar motion segments (aged 19-82 years) were subjected to 2 kN of compressive loading while positioned to simulate habitual erect standing postures and forwards bending. Intradiscal stresses were measured in each posture by pulling a miniature pressure transducer along the midsagittal diameter of the disc. "Stress profiles" were then integrated over area to calculate the force acting on the anterior and posterior halves of the vertebral body. These forces were subtracted from the applied 2 kN to determine the compressive force on the neural arch.

RESULTS

In motion segments with nondegenerated discs, <5% of the compressive force was resisted by the neural arch, and forces on the vertebral body were always distributed evenly, irrespective of posture. However, with severely degenerated discs, neural arch load-bearing increased to 40% in the erect posture, and the compressive force on the vertebral body was concentrated anteriorly in forwards bending, and posteriorly in erect posture.

CONCLUSIONS

Severe disc degeneration causes the anterior vertebral body to be stress-shielded during the usual erect posture, and yet severely loaded whenever the spine is flexed. This could help to explain why this region is frequently the site of osteoporotic fracture, and why forward bending movements often precipitate the injury.

Osteoporosis during Continuous Androgen Deprivation: Influence of the Modality and Length of Treatment

OBJECTIVE

To analyze the prevalence of osteoporosis in patients with prostate cancer with and without androgen ablation. To know the influence of the modality and the length of androgen ablation on the prevalence of osteoporosis. To analyze the relative risk of hip fracture.

MATERIAL AND METHODS

In a cross-sectional study, we assessed bone densitometry at the Ward's triangle of the femoral neck in 110 patients with non-metastatic prostate cancer and without biochemical relapse. A cohort of 53 patients under continuous androgen suppression during a median period of 41 months (12-191) formed the study group and 57 age-matched patients that had been submitted to a radical prostatectomy formed a control group.

RESULTS

Both subsets of patients had similar mean age (70.4 vs. 69.2, p=0.07). Mean bone mass was 0.70 g/cm2 in patients under androgen suppression and 0.76 g/cm2 in the control group, p=0.06. The rate of osteoporosis was 41.5% (22/53) and 28.1% (16/57) respectively, p=0.16 and the odds ratio was 1.82 (95% CI 0,82-4.03). The rate of osteoporosis was 41.4% (12/29) in patients under maximal androgen blockade and 41.7% (10/24) in patients under chemical castration, p=0.735. According to the length of the androgen suppression the rate of osteoporosis was 36.4% when it was between 12 and 36 months, 42.1% from 36 to 60 months and 50% when it was longer than 60 months. While the overall relative risk of hip fracture in the control group was 2.0, it was 2.4 when the length of androgen suppression was between 12 and 36 months, 2.9 between 36 and 60 months and 3.9 when it was longer than 60 months.

CONCLUSIONS

Androgen suppression increases the prevalence of osteoporosis in patients with prostate cancer. The modality of continues androgen suppression seems not to affect its prevalence. However the length of androgen suppression would be related to its development. The relative risk of hip fracture is also increasing during the androgen suppression.

Sex hormones and male health: effects on components of the frailty syndrome

Physicians are seeing an increasing number of older male patients with chronic diseases and conditions. However, the potential relevance of low levels of circulating endogenous androgens in connection with these diseases and conditions is generally poorly understood. Research findings have suggested that androgens play a distinct role in bone metabolism, body composition such as muscle and fat mass and fat distribution, cognitive functioning, mood and well being. The aim of this paper is to summarize the currently available data on the association between endogenous androgens and the intermediate or clinically manifest indicators of chronic conditions in men that might contribute to the phenomenon "frailty". The evidence that reductions in endogenous androgens play a role in age-related health problems is circumstantial. Therefore, large-scale randomized trials are needed to establish whether aging males with low serum androgen levels benefit from androgen supplementation.

Andropause:

There is increasing evidence that the common condition of hypogonadism in older men when associated with symptoms responds well to testosterone replacement. Over the last few years there has been a marked increase in the awareness and treatment of the andropause [137]. Long-term side effects of testosterone are uncertain with only eight people over 50 years having been studied for 10 years [138]. Testosterone needs to be considered a quality-of-life drug, similar to sildenafil, and at present it should be used only if it produces symptomatic improvement. There is a need for a men's health study to determine the long-term efficacy and safety of testosterone replacement in older persons.

Benefits of exercise and dietary measures to optimize shifts in body composition with age

Ageing is associated with changes in body composition, including an increase and redistribution of adipose tissue and a decrease in muscle and bone mass, beginning as early as the fourth decade of life. These changes have significant implications for the health and functioning of the individual because of their associations with chronic disease expression and severity, as well as geriatric syndromes such as mobility impairment, falls, frailty and functional decline. Therefore, understanding the preventive and therapeutic options for optimizing body composition in old age is central to the care of patients in mid-life and beyond. Pharmacological interventions are currently available for maintaining or improving bone mass, and much current interest is focused on anabolic agents that will preserve or restore muscle mass, as well as those that can potentially limit adipose tissue deposition. However, in this brief review, non-pharmacological modulation of body composition through appropriate dietary intake and physical activity patterns, will be discussed. There is sufficient evidence currently to suggest that a substantial portion of what have been considered 'age-related' changes in muscle, fat and bone are in fact related either to excess energy consumption, decreased energy expenditure in physical activity, or both factors in combination. In addition, selective underconsumption of certain macro- or micronutrients contributes to losses of muscle and bone mass. Each of the three compartments will be considered in turn, with recommendations for optimizing the size of these body tissue stores in early adulthood, and minimizing undesirable changes typically seen in middle and old age.