Osteoporosis remains under-recognised and under-treated, particularly in men. So what can pharmacists do to help male customers spot the condition early enough to minimise the impact? 

In the past few years the problem of osteoporosis in men has been recognised as an important public health issue, particularly as life expectancy continues to rise. Sometimes called the ‘silent disease’ as there are usually no tell-tale symptoms until the first break – or ‘fragility fracture’ – occurs, it adds considerably to the fracture burden and costs, medical, social care and quality of life.

What is osteoporosis?

Osteoporosis occurs when the struts which make up the mesh-like structure within bones become thin, causing bones to become fragile and break easily following a minor bump or fall. Although fractures can occur in different parts of the body, the wrists, hips and spine are most commonly affected.

According to the Royal Osteoporosis Society (ROS), people who have had one fracture are at greater risk of another - around 23% of secondary fractures occur within a year of the first fracture. These broken bones can lead to the pain associated with osteoporosis, and spinal fractures can also cause loss of height and curvature of the spine.

Prevalence in men

The majority of people view osteoporosis solely as a ‘woman’s disease’, and it is true that It develops less often in men because they have larger skeletons, their bone loss starts later and progresses more slowly, and they have no period of rapid hormonal change and bone loss.

“Men in their fifties do not experience the rapid loss of bone mass that women do in the years following the menopause”, explains Dr Emma Derbyshire nutritionist from the Health and Food Supplements Information Service (www.hsis.org). “By age 65 or 70, however, men and women lose bone mass at the same rate, and the absorption of calcium, an essential nutrient for bone health throughout life, decreases in both sexes.”

Indeed, ROS says one in five men over the age of 50 will break a bone mainly due to osteoporosis, and it is often not until then that a diagnosis is made. This makes it especially important for men to be aware of risk factors that could lead to osteoporosis.

Risk factors

According to ROS, our risk of osteoporosis is largely hereditary, with genetic factors dictating up to 80 per cent of our likelihood of developing the disease.

Ageing is another factor. Bone tissue starts to naturally decrease from age thirty, plus becoming less steady on your feet also becomes more likely with age, which increases the risk of slipping or tripping, and breaking a bone in a fall.

Being of Caucasian or Asian origin is also a risk. People of Afro-Caribbean origin have a lower risk of osteoporosis and broken bones than those of Caucasian or Asian origin, because their bones are bigger and stronger.

In addition, medical conditions such as rheumatoid arthritis, secondary hyperparathyroidism (excessive levels of parathyroid hormone), hyperthyroidism and medical conditions which affect the absorption of nutrients from food, such as coeliac disease or Crohn’s disease, can also result in osteoporosis.

Lifestyle links

There are other factors that can also contribute to the development of osteoporosis which can help community pharmacists spot and diagnose it in their male customers much earlier.

As with so many conditions, poor diet, lack of exercise, smoking, excessive alcohol consumption and eating disorders may increase the risk. What's more, among men with these lifestyle habits, few recognise the disease as a significant threat to their mobility and independence.

Then there are medications that are known to affect bone strength and therefore could increase the risk of osteoporosis:

• glucocorticoid (steroids) tablets, if taken for more than three months
• anti-epileptic medications
• prostate cancer treatments that affect either the production of the male hormone testosterone, or the way it works in the body
• medications used for people who have undergone gender confirmation, especially if it's discontinued
   

There is a secondary list of those which may affect bone strength, although ROS says more research is needed. These are:

• proton pump inhibitors (PPIs)
• diabetic medications in the glitazone group, including pioglitazone
• tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs)
   

Opening up

When it comes to bringing up the subject with your male customers, ROS nurse consultant Sarah Leyland says: “Men can be more reticent about getting help, and because many of them consider it a woman’s condition they may even be resistant to seeing it as their problem.”

“We talk about ‘first fracture’”, says Ms Leyland, “so if someone has had a wrist fracture for example, that’s a big sign. Similarly spinal fracture, height loss and spinal curvature, or someone who is skinny, or complaining of back pain. Refer them to their GP in the first instance for an initial assessment, or ask them if there is a family history of fracture. Parental history of hip fracture is significant, for example, so if you can make a link with their personal experience you can open up the conversation.”

Treatment options

Men who are found to have a high risk of fracture or who have already broken a bone will normally be referred to specialist centres for assessment and discussion of potential treatments. This is because the diagnosis is more complex in men and some treatments are only licensed to be used for postmenopausal women or men on corticosteroid therapy.

“Three of the bisphosphonates – alendronate 10mg (Fosamax), risedronate 35mg (Actonel once weekly) and zoledronic acid (Aclasta) – have a specific licence for men, as does a form of parathyroid hormone treatment called teriparatide (Forsteo),” says ROS.

“Strontium ranelate (Protelos) is licensed for men in England and Wales although it is not authorised for male use in Scotland. Denosumab (Prolia) is a treatment that is licensed for use in men with bone loss caused by treatments for prostate cancer.

“It may also be prescribed for osteoporosis in men with other causes. Although not licensed for men, the bisphosphonates alendronate 70mg (Fosamax once weekly) and ibandronate (Bonviva) are sometimes prescribed. In practice it is likely that the generic form of alendronate – alendronic acid – will be the first choice treatment for men.”

Advice and signposting

ROS advises that taking an osteoporosis medication is the best method to help strengthen bones, but if men choose not to take them there is plenty of lifestyle advice that pharmacists can offer to mitigate the risk factors they can control.

Maintain a healthy body weight
If you’re underweight or overweight, your risk of osteoporosis and broken bones increases. People with low body weight are more likely to have less bone tissue, and for older people having low body weight also means less fat padding around the hips to cushion the impact of a fall, which makes broken bones more likely.

Lead an active lifestyle
Being physically active strengthens muscles and maintains bone strength. Activity that's good for bones combines weight-bearing exercise with impact, with muscle strengthening exercise.

Maintaining good balance and coordination is also important for reducing the risk of slipping, tripping or falling, and potentially breaking a bone.

Avoid smoking
Smoking slows down the cells that build bone in the body. People who smoke are also found to be at higher risk of breaking their hip as they get older, according to ROS, but for those who quit their risk of breaking a bone begins to return to normal.

Regulate alcohol intake
Alcohol not only affects the cells that build and break down bone, it also increases the likelihood of trips and falls. The government recommends no more than 14 units of alcohol a week, with regular alcohol-free days.

Eat well
Several nutrients, including calcium, magnesium, phosphorous, vitamins D and K, trace minerals such as zinc and copper, and amino acids are important for bone health.

However, according to Dr Derbyshire, the 2019 HSIS Dietary Trends Report showed that whilst men fare better than women in terms of micronutrient intake, a significant proportion of men are at risk from low intakes.

“While it is very difficult for a pharmacist to be reassured that anyone’s diet meets recommendations, you can ensure that all men understand the Public Health England recommendation to take a daily vitamin D supplement”, she says.

“Vitamin D is essential for bone health in its own right as well as improving the absorption of calcium, and you could use a gondola end, shelf or window display to draw attention to osteoporosis and link it with vitamin and mineral products, including calcium, magnesium and vitamin D.”

Make no bones about it – although more common in women, men need to be aware that osteoporosis affects them too, and can have a serious effect on their health and quality of life if not addressed accordingly.

The Royal Osteoporosis Society has a variety of information and services for healthcare professionals as well as the public:

• Leaflets and videos: https://theros.org.uk/information-and-support/printed-information/
• National Training Scheme for Bone Densitometry for healthcare professionals: https://theros.org.uk/healthcare-professionals/courses-and-cpd/national-training-scheme-for-bone-densitometry/
• The Royal Osteoporosis Society Helpline is staffed by nurses with specialist knowledge of osteoporosis and bone health and helpline support officers: 0808 800 0035 or nurses@theros.org.uk

Picture: (iStock) wutwhanfoto