Sherry Boschert

OAKLAND, CALIF. — The gap in HIV care received by black patients compared with white patients has narrowed, but disparities remain a problem, William D. King, M.D., said at a conference sponsored by the American Foundation for AIDS Research.

A 2005 study found that 84% of HIV-infected patients overall receive highly active antiretroviral therapy (HAART), but blacks were less likely than whites to get HAART, said Dr. King, an internal medicine/HIV specialist in Los Angeles. Dr. King is a speaker for Pfizer Inc., which makes antiretroviral medication.

Blacks are more likely than whites to be uninsured or on Medicaid and thus are less likely to have access to HAART, compared with patients who have private insurance. Among Medicaid recipients, blacks and Hispanic patients are less likely to receive HAART than are whites, according to a recent study by Dr. King and his associates that has been submitted for publication.

Other data have shown that within the Veterans Affairs system, HIV-infected blacks and Hispanics have higher mortality than do HIV-infected white patients.

Physician attitudes play a role in the disparities, he added. Physicians are more reluctant to treat a patient who they think will not adhere to therapy. A 2000 study found that physicians who were given patient vignettes were more likely to rate them as unlikely to adhere to therapy if the patient was described as African American rather than white, even if the rest of the vignette was identical.

The interval between seeing a physician for HIV care and receiving a protease inhibitor to treat it averaged 409 days for black patients, significantly longer than the 311 days for white patients and 306 days for Hispanics, a 2003 study found. Patient attitudes and distrust also play a role in these disparities by making some less willing to seek care, Dr. King said at the conference, which was cosponsored by the Pacific AIDS Education and Training Center.

In a 2005 study of 500 African Americans, 75% said they believe institutions are trying to stop HIV, but 15% felt that AIDS is a form of genocide. Overall, 59% said they believe information about AIDS is being withheld from the poor, and 53% stated that a cure for AIDS exists but is being withheld from the poor. Men who had the highest level of conspiracy beliefs had more negative attitudes about condoms and were less likely to use them.

Dr. King suggested that more HIV services come to minority neighborhoods, and that more educational materials get translated into languages other than English. Physicians should pay attention to the quality and quantity of their communications with minority patients, and develop culturally relevant materials. More community education is needed to reduce the stigma associated with HIV and to reach out to stakeholders in black communities, such as religious organizations, he said.

A separate study of 8,319 records on 1,717 patients seen for HIV at two medical centers between 2000 and 2003 found that blacks were more likely than whites to be hospitalized, Linda Wotring, Ph.D., and Jonathan A. Cohn, M.D., reported in a poster at the meeting. The odds of being hospitalized were 70% higher for black men and 80% higher for black women, compared with white men, reported Dr. Wotring of the Michigan Department of Community Health, Detroit, and Dr. Cohn of Wayne State University, Detroit.

The chances of hospitalization remained significantly higher for blacks than for whites after adjustment for other factors that increased the risk of admission, including injection drug use or noninjection drug use, a history of an AIDS-defining illness, no history of a clinic visit, and having Medicare or Medicaid rather than private insurance.

The investigators will study whether the risk for hospitalization is associated with less access to medications and other health services for blacks.

Distrust and misconceptions about HIV remain widespread, Jerry T. Nessel, M.D., and Beny J. Primm, M.D., reported in a separate poster presentation. In surveys of 1,440 attendees at nine medical and health conferences, only 9% of respondents knew that HIV was not created in the laboratory, and that the virus came from chimpanzees or monkeys, said Dr. Nessel and Dr. Primm of the Addiction Research and Treatment Corp., New York.

OAKLAND, CALIF. — The gap in HIV care received by black patients compared with white patients has narrowed, but disparities remain a problem, William D. King, M.D., said at a conference sponsored by the American Foundation for AIDS Research.

A 2005 study found that 84% of HIV-infected patients overall receive highly active antiretroviral therapy (HAART), but blacks were less likely than whites to get HAART, said Dr. King, an internal medicine/HIV specialist in Los Angeles. Dr. King is a speaker for Pfizer Inc., which makes antiretroviral medication.

Blacks are more likely than whites to be uninsured or on Medicaid and thus are less likely to have access to HAART, compared with patients who have private insurance. Among Medicaid recipients, blacks and Hispanic patients are less likely to receive HAART than are whites, according to a recent study by Dr. King and his associates that has been submitted for publication.

Other data have shown that within the Veterans Affairs system, HIV-infected blacks and Hispanics have higher mortality than do HIV-infected white patients.

Physician attitudes play a role in the disparities, he added. Physicians are more reluctant to treat a patient who they think will not adhere to therapy. A 2000 study found that physicians who were given patient vignettes were more likely to rate them as unlikely to adhere to therapy if the patient was described as African American rather than white, even if the rest of the vignette was identical.

The interval between seeing a physician for HIV care and receiving a protease inhibitor to treat it averaged 409 days for black patients, significantly longer than the 311 days for white patients and 306 days for Hispanics, a 2003 study found. Patient attitudes and distrust also play a role in these disparities by making some less willing to seek care, Dr. King said at the conference, which was cosponsored by the Pacific AIDS Education and Training Center.

In a 2005 study of 500 African Americans, 75% said they believe institutions are trying to stop HIV, but 15% felt that AIDS is a form of genocide. Overall, 59% said they believe information about AIDS is being withheld from the poor, and 53% stated that a cure for AIDS exists but is being withheld from the poor. Men who had the highest level of conspiracy beliefs had more negative attitudes about condoms and were less likely to use them.

Dr. King suggested that more HIV services come to minority neighborhoods, and that more educational materials get translated into languages other than English. Physicians should pay attention to the quality and quantity of their communications with minority patients, and develop culturally relevant materials. More community education is needed to reduce the stigma associated with HIV and to reach out to stakeholders in black communities, such as religious organizations, he said.

A separate study of 8,319 records on 1,717 patients seen for HIV at two medical centers between 2000 and 2003 found that blacks were more likely than whites to be hospitalized, Linda Wotring, Ph.D., and Jonathan A. Cohn, M.D., reported in a poster at the meeting. The odds of being hospitalized were 70% higher for black men and 80% higher for black women, compared with white men, reported Dr. Wotring of the Michigan Department of Community Health, Detroit, and Dr. Cohn of Wayne State University, Detroit.

The chances of hospitalization remained significantly higher for blacks than for whites after adjustment for other factors that increased the risk of admission, including injection drug use or noninjection drug use, a history of an AIDS-defining illness, no history of a clinic visit, and having Medicare or Medicaid rather than private insurance.

The investigators will study whether the risk for hospitalization is associated with less access to medications and other health services for blacks.

Distrust and misconceptions about HIV remain widespread, Jerry T. Nessel, M.D., and Beny J. Primm, M.D., reported in a separate poster presentation. In surveys of 1,440 attendees at nine medical and health conferences, only 9% of respondents knew that HIV was not created in the laboratory, and that the virus came from chimpanzees or monkeys, said Dr. Nessel and Dr. Primm of the Addiction Research and Treatment Corp., New York.

OAKLAND, CALIF. — The gap in HIV care received by black patients compared with white patients has narrowed, but disparities remain a problem, William D. King, M.D., said at a conference sponsored by the American Foundation for AIDS Research.

A 2005 study found that 84% of HIV-infected patients overall receive highly active antiretroviral therapy (HAART), but blacks were less likely than whites to get HAART, said Dr. King, an internal medicine/HIV specialist in Los Angeles. Dr. King is a speaker for Pfizer Inc., which makes antiretroviral medication.

Blacks are more likely than whites to be uninsured or on Medicaid and thus are less likely to have access to HAART, compared with patients who have private insurance. Among Medicaid recipients, blacks and Hispanic patients are less likely to receive HAART than are whites, according to a recent study by Dr. King and his associates that has been submitted for publication.

Other data have shown that within the Veterans Affairs system, HIV-infected blacks and Hispanics have higher mortality than do HIV-infected white patients.

Physician attitudes play a role in the disparities, he added. Physicians are more reluctant to treat a patient who they think will not adhere to therapy. A 2000 study found that physicians who were given patient vignettes were more likely to rate them as unlikely to adhere to therapy if the patient was described as African American rather than white, even if the rest of the vignette was identical.

The interval between seeing a physician for HIV care and receiving a protease inhibitor to treat it averaged 409 days for black patients, significantly longer than the 311 days for white patients and 306 days for Hispanics, a 2003 study found. Patient attitudes and distrust also play a role in these disparities by making some less willing to seek care, Dr. King said at the conference, which was cosponsored by the Pacific AIDS Education and Training Center.

In a 2005 study of 500 African Americans, 75% said they believe institutions are trying to stop HIV, but 15% felt that AIDS is a form of genocide. Overall, 59% said they believe information about AIDS is being withheld from the poor, and 53% stated that a cure for AIDS exists but is being withheld from the poor. Men who had the highest level of conspiracy beliefs had more negative attitudes about condoms and were less likely to use them.

Dr. King suggested that more HIV services come to minority neighborhoods, and that more educational materials get translated into languages other than English. Physicians should pay attention to the quality and quantity of their communications with minority patients, and develop culturally relevant materials. More community education is needed to reduce the stigma associated with HIV and to reach out to stakeholders in black communities, such as religious organizations, he said.

A separate study of 8,319 records on 1,717 patients seen for HIV at two medical centers between 2000 and 2003 found that blacks were more likely than whites to be hospitalized, Linda Wotring, Ph.D., and Jonathan A. Cohn, M.D., reported in a poster at the meeting. The odds of being hospitalized were 70% higher for black men and 80% higher for black women, compared with white men, reported Dr. Wotring of the Michigan Department of Community Health, Detroit, and Dr. Cohn of Wayne State University, Detroit.

The chances of hospitalization remained significantly higher for blacks than for whites after adjustment for other factors that increased the risk of admission, including injection drug use or noninjection drug use, a history of an AIDS-defining illness, no history of a clinic visit, and having Medicare or Medicaid rather than private insurance.

The investigators will study whether the risk for hospitalization is associated with less access to medications and other health services for blacks.

Distrust and misconceptions about HIV remain widespread, Jerry T. Nessel, M.D., and Beny J. Primm, M.D., reported in a separate poster presentation. In surveys of 1,440 attendees at nine medical and health conferences, only 9% of respondents knew that HIV was not created in the laboratory, and that the virus came from chimpanzees or monkeys, said Dr. Nessel and Dr. Primm of the Addiction Research and Treatment Corp., New York.

SAN FRANCISCO — None of the newer biomarkers being evaluated as possible predictors of cardiovascular risk has been studied enough to be considered ready for clinical use, Michael H. Alderman, M.D., said at the annual meeting of the American Society of Hypertension.

Conventional risk factors such as blood pressure, insulin resistance, diabetes, obesity, lipids, and family history account for 50% of cardiovascular risk, so any biomarkers that could further gauge risk would be useful. A biomarker is a substance that can be measured precisely in serum or urine and is related to subsequent occurrence of cardiovascular disease—such as cholesterol, said Dr. Alderman of Albert Einstein College of Medicine, New York.

A handful of newer, more precise biomarkers appears to be more intimately associated with the development of cardiovascular disease, and they look like they will be useful. These include C-reactive protein, neurocytokines, and uric acid. So far, however, there is “suggestive, but for the most part not yet convincing, evidence that these new biomarkers add to the predictive value already contained in the markers that we have,” Dr. Alderman said at a press briefing during the meeting, where he gave a summary of reports on the newer biomarkers.

To be useful, a new risk marker would have to make a contribution beyond what's obtained from conventional risk markers. “I don't think that's been formally tested” with the newer biomarkers, he said.

Tests for the new risk marker would have to be reproducible at different times and in different populations, and would have to define an important amount, or proportion, of risk, he said. Lastly, an assay for the biomarker would need to be feasible and cost effective when applied to a population.

“Those kinds of questions have been asked of blood pressure screening and cholesterol screening, but haven't been asked of cytokines,” for example, he said.

Dr. Alderman said he believes that uric acid is an independent risk factor for cardiovascular events, particularly in hypertensive patients, but the data supporting this are inconsistent. Other data showing that uric acid is predictive of elevated blood pressure may be more interesting and useful, he said.

“For most of these [new biomarkers], we're not at the point where they're useful, but I think that we're awfully close,” Dr. Alderman said.

SAN FRANCISCO — None of the newer biomarkers being evaluated as possible predictors of cardiovascular risk has been studied enough to be considered ready for clinical use, Michael H. Alderman, M.D., said at the annual meeting of the American Society of Hypertension.

Conventional risk factors such as blood pressure, insulin resistance, diabetes, obesity, lipids, and family history account for 50% of cardiovascular risk, so any biomarkers that could further gauge risk would be useful. A biomarker is a substance that can be measured precisely in serum or urine and is related to subsequent occurrence of cardiovascular disease—such as cholesterol, said Dr. Alderman of Albert Einstein College of Medicine, New York.

A handful of newer, more precise biomarkers appears to be more intimately associated with the development of cardiovascular disease, and they look like they will be useful. These include C-reactive protein, neurocytokines, and uric acid. So far, however, there is “suggestive, but for the most part not yet convincing, evidence that these new biomarkers add to the predictive value already contained in the markers that we have,” Dr. Alderman said at a press briefing during the meeting, where he gave a summary of reports on the newer biomarkers.

To be useful, a new risk marker would have to make a contribution beyond what's obtained from conventional risk markers. “I don't think that's been formally tested” with the newer biomarkers, he said.

Tests for the new risk marker would have to be reproducible at different times and in different populations, and would have to define an important amount, or proportion, of risk, he said. Lastly, an assay for the biomarker would need to be feasible and cost effective when applied to a population.

“Those kinds of questions have been asked of blood pressure screening and cholesterol screening, but haven't been asked of cytokines,” for example, he said.

Dr. Alderman said he believes that uric acid is an independent risk factor for cardiovascular events, particularly in hypertensive patients, but the data supporting this are inconsistent. Other data showing that uric acid is predictive of elevated blood pressure may be more interesting and useful, he said.

“For most of these [new biomarkers], we're not at the point where they're useful, but I think that we're awfully close,” Dr. Alderman said.

SAN FRANCISCO — None of the newer biomarkers being evaluated as possible predictors of cardiovascular risk has been studied enough to be considered ready for clinical use, Michael H. Alderman, M.D., said at the annual meeting of the American Society of Hypertension.

Conventional risk factors such as blood pressure, insulin resistance, diabetes, obesity, lipids, and family history account for 50% of cardiovascular risk, so any biomarkers that could further gauge risk would be useful. A biomarker is a substance that can be measured precisely in serum or urine and is related to subsequent occurrence of cardiovascular disease—such as cholesterol, said Dr. Alderman of Albert Einstein College of Medicine, New York.

A handful of newer, more precise biomarkers appears to be more intimately associated with the development of cardiovascular disease, and they look like they will be useful. These include C-reactive protein, neurocytokines, and uric acid. So far, however, there is “suggestive, but for the most part not yet convincing, evidence that these new biomarkers add to the predictive value already contained in the markers that we have,” Dr. Alderman said at a press briefing during the meeting, where he gave a summary of reports on the newer biomarkers.

To be useful, a new risk marker would have to make a contribution beyond what's obtained from conventional risk markers. “I don't think that's been formally tested” with the newer biomarkers, he said.

Tests for the new risk marker would have to be reproducible at different times and in different populations, and would have to define an important amount, or proportion, of risk, he said. Lastly, an assay for the biomarker would need to be feasible and cost effective when applied to a population.

“Those kinds of questions have been asked of blood pressure screening and cholesterol screening, but haven't been asked of cytokines,” for example, he said.

Dr. Alderman said he believes that uric acid is an independent risk factor for cardiovascular events, particularly in hypertensive patients, but the data supporting this are inconsistent. Other data showing that uric acid is predictive of elevated blood pressure may be more interesting and useful, he said.

“For most of these [new biomarkers], we're not at the point where they're useful, but I think that we're awfully close,” Dr. Alderman said.

Among U.S. adults aged 60 years or older, 6% fewer lost all their teeth in 1999–2002, compared with 1988–1994, the Centers for Disease Control and Prevention reported.

The proportion of older adults with no natural teeth decreased from 31% in 1988–1994 to 25% in the most recent time period, a 20% improvement, according to an analysis of data from the National Health and Nutrition Examination Survey (MMWR 2005;54(SS-3):1–44).

Smokers were more likely than nonsmokers to have no natural teeth: 14% of current smokers had lost all their teeth, compared with 5% of people who had never smoked.

The dental health of U.S. adults as a whole had improved by the 1999–2002 survey, but there were still disparities based on race and income, the report shows. Among higher-income adults, 16% had untreated tooth decay in the most recent time period, compared with 41% of poor adults. Non-Hispanic blacks retained fewer teeth than Mexican Americans or non-Hispanic whites.

The study included data on 16,128 adults aged 20 years or older in 1988–1994 and 8,805 in 1999–2002. The mean number of permanent teeth among adults averaged 23 in the earlier time period and 24 in the more recent time period. A normal, full set includes 28 teeth.

The prevalence of root caries decreased from 23% in 1988–1994 to 18% in 1999–2002.

The report is the first by the CDC to look at the rate of enamel fluorosis, a disfiguring hypomineralization of enamel related to exposure to fluoride during tooth formation. Enamel fluorosis occurred in 23% of adults in the 1999–2002 survey, though most cases were mild, with white spots on the teeth. Moderate to severe fluorosis, which involves discoloration or pitting of teeth, was reported in about 2% of adults.

Physicians can contribute to adult patients' dental health by considering, for example, how medications might affect saliva flow and make teeth more susceptible to decay, said William R. Maas, D.D.S., director of the CDC's division of oral health. Smokers in the study had fewer teeth and more untreated decay. Tooth loss also is related to diet, nutritional status, and obesity.

“By attending to these issues, physicians can work in partnership with the dental profession” to help their patients maintain dental health, he said.

While the overall improvement in dental health is encouraging, the fact that lower-income adults have twice the rate of untreated tooth decay, compared with more affluent adults, is unacceptable, said Richard Haught, D.D.S., president of the American Dental Association.

As the federal and state governments consider reforming Medicaid, it's important to ensure that Medicaid will continue to cover dental benefits and will emphasize prevention of dental disease, he added.

Among U.S. adults aged 60 years or older, 6% fewer lost all their teeth in 1999–2002, compared with 1988–1994, the Centers for Disease Control and Prevention reported.

The proportion of older adults with no natural teeth decreased from 31% in 1988–1994 to 25% in the most recent time period, a 20% improvement, according to an analysis of data from the National Health and Nutrition Examination Survey (MMWR 2005;54(SS-3):1–44).

Smokers were more likely than nonsmokers to have no natural teeth: 14% of current smokers had lost all their teeth, compared with 5% of people who had never smoked.

The dental health of U.S. adults as a whole had improved by the 1999–2002 survey, but there were still disparities based on race and income, the report shows. Among higher-income adults, 16% had untreated tooth decay in the most recent time period, compared with 41% of poor adults. Non-Hispanic blacks retained fewer teeth than Mexican Americans or non-Hispanic whites.

The study included data on 16,128 adults aged 20 years or older in 1988–1994 and 8,805 in 1999–2002. The mean number of permanent teeth among adults averaged 23 in the earlier time period and 24 in the more recent time period. A normal, full set includes 28 teeth.

The prevalence of root caries decreased from 23% in 1988–1994 to 18% in 1999–2002.

The report is the first by the CDC to look at the rate of enamel fluorosis, a disfiguring hypomineralization of enamel related to exposure to fluoride during tooth formation. Enamel fluorosis occurred in 23% of adults in the 1999–2002 survey, though most cases were mild, with white spots on the teeth. Moderate to severe fluorosis, which involves discoloration or pitting of teeth, was reported in about 2% of adults.

Physicians can contribute to adult patients' dental health by considering, for example, how medications might affect saliva flow and make teeth more susceptible to decay, said William R. Maas, D.D.S., director of the CDC's division of oral health. Smokers in the study had fewer teeth and more untreated decay. Tooth loss also is related to diet, nutritional status, and obesity.

“By attending to these issues, physicians can work in partnership with the dental profession” to help their patients maintain dental health, he said.

While the overall improvement in dental health is encouraging, the fact that lower-income adults have twice the rate of untreated tooth decay, compared with more affluent adults, is unacceptable, said Richard Haught, D.D.S., president of the American Dental Association.

As the federal and state governments consider reforming Medicaid, it's important to ensure that Medicaid will continue to cover dental benefits and will emphasize prevention of dental disease, he added.

Among U.S. adults aged 60 years or older, 6% fewer lost all their teeth in 1999–2002, compared with 1988–1994, the Centers for Disease Control and Prevention reported.

The proportion of older adults with no natural teeth decreased from 31% in 1988–1994 to 25% in the most recent time period, a 20% improvement, according to an analysis of data from the National Health and Nutrition Examination Survey (MMWR 2005;54(SS-3):1–44).

Smokers were more likely than nonsmokers to have no natural teeth: 14% of current smokers had lost all their teeth, compared with 5% of people who had never smoked.

The dental health of U.S. adults as a whole had improved by the 1999–2002 survey, but there were still disparities based on race and income, the report shows. Among higher-income adults, 16% had untreated tooth decay in the most recent time period, compared with 41% of poor adults. Non-Hispanic blacks retained fewer teeth than Mexican Americans or non-Hispanic whites.

The study included data on 16,128 adults aged 20 years or older in 1988–1994 and 8,805 in 1999–2002. The mean number of permanent teeth among adults averaged 23 in the earlier time period and 24 in the more recent time period. A normal, full set includes 28 teeth.

The prevalence of root caries decreased from 23% in 1988–1994 to 18% in 1999–2002.

The report is the first by the CDC to look at the rate of enamel fluorosis, a disfiguring hypomineralization of enamel related to exposure to fluoride during tooth formation. Enamel fluorosis occurred in 23% of adults in the 1999–2002 survey, though most cases were mild, with white spots on the teeth. Moderate to severe fluorosis, which involves discoloration or pitting of teeth, was reported in about 2% of adults.

Physicians can contribute to adult patients' dental health by considering, for example, how medications might affect saliva flow and make teeth more susceptible to decay, said William R. Maas, D.D.S., director of the CDC's division of oral health. Smokers in the study had fewer teeth and more untreated decay. Tooth loss also is related to diet, nutritional status, and obesity.

“By attending to these issues, physicians can work in partnership with the dental profession” to help their patients maintain dental health, he said.

While the overall improvement in dental health is encouraging, the fact that lower-income adults have twice the rate of untreated tooth decay, compared with more affluent adults, is unacceptable, said Richard Haught, D.D.S., president of the American Dental Association.

As the federal and state governments consider reforming Medicaid, it's important to ensure that Medicaid will continue to cover dental benefits and will emphasize prevention of dental disease, he added.

SAN FRANCISCO — Physicians who see patients with osteoporosis should have a visual acuity chart on the office wall to check eyesight, Steven R. Cummings, M.D., advised at a meeting on osteoporosis that was sponsored by the University of California, San Francisco.

Reduced visual acuity greatly increases the risk for falling and for hip fractures. Usually poor vision is due to treatable risk factors such as the need for an updated glasses prescription, or cataracts, said Dr. Cummings, who is professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Impaired vision can double or quadruple the risk for hip fracture. At least one study shows that repairing cataracts can reduce the risk of falling by 34% (Br. J. Ophthalmol. 2005;89:53–9).

Dr. Cummings noted that the following additional risk factors are worth addressing to prevent fractures:

▸ Vertebral fracture. Having a vertebral fracture—even a painless, asymptomatic one that's detected only by x-ray—increases the risk for future vertebral fracture two- to fourfold. Older women with a previous vertebral fracture have a 1%–3% annual rate of hip fracture, and randomized trials suggest that pharmacologic treatment can lower that risk.

▸ Nonspine fractures. Having any kind of nonspine fracture nearly doubles or triples the risk for having a future nonspine fracture. Even with normal bone density, having a nonspine fracture makes a future nonspine fracture more likely.

▸ Familial history. People who had a parent develop a hip fracture have double the risk for hip fracture themselves, compared with people whose parents did not have hip fractures. This is true regardless of bone mineral density. A wrist fracture in a parent increases an offspring's risk of wrist fracture. “There's some suggestion that this increased familial risk may be specific to the type of fracture,” he said.

Studies have found no association, however, between patients' reports of parents who had osteoporosis or spine fractures and the patients' own risk for those problems, probably because “osteoporosis” and “spine fracture” are rather nonspecific terms used with different meanings.

▸ Weight. Women have a higher risk for serious fractures if they are losing weight involuntarily compared with maintaining or gaining weight. The involuntary weight loss is a marker for frailty. Fractures of the hip, humerus, spine, or pelvis commonly are referred to as “frailty fractures,” he noted.

Voluntary weight loss through diet or exercise diminishes a woman's bone mineral density, but it's not clear whether this increases fracture risk, he said.

▸ Corticosteroid use. Taking more than 10 mg/day of prednisone or comparable doses of other corticosteroids reduces spinal bone density by 5%–10% in the first year, with most of the loss during the first 6 months. Higher doses of steroids reduce spinal bone density even more. Fracture risk increases even more quickly—within 1–2 months of starting corticosteroids. “There's a suggestion here that corticosteroids increase your risk for fractures in ways besides causing bone loss,” perhaps by killing osteocytes in bone and limiting the ability of bone to respond to stimulators, he said.

Consider starting preventive therapy to prevent fractures if patients who will be taking steroids for at least several months have low bone densities or a history of fracture, Dr. Cummings suggested.

▸ Smoking. Cigarette smoking approximately doubles the risk for hip fracture regardless of a person's bone density, probably because smoking is associated with poorer health, weaker muscles, and impaired balance.

▸ Diabetes. Patients with diabetes have triple the risk for foot fractures and double the risk for humerus or hip fractures, compared with nondiabetic patients. If you see a patient with one of these fractures, look for diabetes, and watch for these fractures in patients already diagnosed with diabetes, he advised.

▸ Stroke. Patients who have had a stroke or who are in nursing homes are at very high risk for hip fractures, warranting pharmacotherapy to preserve and strengthen bone. Each year 4%–6% of nursing home patients develop hip fractures. In patients over age 70 who have had a stroke, 3%–5% of women develop hip fractures per year.

SAN FRANCISCO — Physicians who see patients with osteoporosis should have a visual acuity chart on the office wall to check eyesight, Steven R. Cummings, M.D., advised at a meeting on osteoporosis that was sponsored by the University of California, San Francisco.

Reduced visual acuity greatly increases the risk for falling and for hip fractures. Usually poor vision is due to treatable risk factors such as the need for an updated glasses prescription, or cataracts, said Dr. Cummings, who is professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Impaired vision can double or quadruple the risk for hip fracture. At least one study shows that repairing cataracts can reduce the risk of falling by 34% (Br. J. Ophthalmol. 2005;89:53–9).

Dr. Cummings noted that the following additional risk factors are worth addressing to prevent fractures:

▸ Vertebral fracture. Having a vertebral fracture—even a painless, asymptomatic one that's detected only by x-ray—increases the risk for future vertebral fracture two- to fourfold. Older women with a previous vertebral fracture have a 1%–3% annual rate of hip fracture, and randomized trials suggest that pharmacologic treatment can lower that risk.

▸ Nonspine fractures. Having any kind of nonspine fracture nearly doubles or triples the risk for having a future nonspine fracture. Even with normal bone density, having a nonspine fracture makes a future nonspine fracture more likely.

▸ Familial history. People who had a parent develop a hip fracture have double the risk for hip fracture themselves, compared with people whose parents did not have hip fractures. This is true regardless of bone mineral density. A wrist fracture in a parent increases an offspring's risk of wrist fracture. “There's some suggestion that this increased familial risk may be specific to the type of fracture,” he said.

Studies have found no association, however, between patients' reports of parents who had osteoporosis or spine fractures and the patients' own risk for those problems, probably because “osteoporosis” and “spine fracture” are rather nonspecific terms used with different meanings.

▸ Weight. Women have a higher risk for serious fractures if they are losing weight involuntarily compared with maintaining or gaining weight. The involuntary weight loss is a marker for frailty. Fractures of the hip, humerus, spine, or pelvis commonly are referred to as “frailty fractures,” he noted.

Voluntary weight loss through diet or exercise diminishes a woman's bone mineral density, but it's not clear whether this increases fracture risk, he said.

▸ Corticosteroid use. Taking more than 10 mg/day of prednisone or comparable doses of other corticosteroids reduces spinal bone density by 5%–10% in the first year, with most of the loss during the first 6 months. Higher doses of steroids reduce spinal bone density even more. Fracture risk increases even more quickly—within 1–2 months of starting corticosteroids. “There's a suggestion here that corticosteroids increase your risk for fractures in ways besides causing bone loss,” perhaps by killing osteocytes in bone and limiting the ability of bone to respond to stimulators, he said.

Consider starting preventive therapy to prevent fractures if patients who will be taking steroids for at least several months have low bone densities or a history of fracture, Dr. Cummings suggested.

▸ Smoking. Cigarette smoking approximately doubles the risk for hip fracture regardless of a person's bone density, probably because smoking is associated with poorer health, weaker muscles, and impaired balance.

▸ Diabetes. Patients with diabetes have triple the risk for foot fractures and double the risk for humerus or hip fractures, compared with nondiabetic patients. If you see a patient with one of these fractures, look for diabetes, and watch for these fractures in patients already diagnosed with diabetes, he advised.

▸ Stroke. Patients who have had a stroke or who are in nursing homes are at very high risk for hip fractures, warranting pharmacotherapy to preserve and strengthen bone. Each year 4%–6% of nursing home patients develop hip fractures. In patients over age 70 who have had a stroke, 3%–5% of women develop hip fractures per year.

SAN FRANCISCO — Physicians who see patients with osteoporosis should have a visual acuity chart on the office wall to check eyesight, Steven R. Cummings, M.D., advised at a meeting on osteoporosis that was sponsored by the University of California, San Francisco.

Reduced visual acuity greatly increases the risk for falling and for hip fractures. Usually poor vision is due to treatable risk factors such as the need for an updated glasses prescription, or cataracts, said Dr. Cummings, who is professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

Impaired vision can double or quadruple the risk for hip fracture. At least one study shows that repairing cataracts can reduce the risk of falling by 34% (Br. J. Ophthalmol. 2005;89:53–9).

Dr. Cummings noted that the following additional risk factors are worth addressing to prevent fractures:

▸ Vertebral fracture. Having a vertebral fracture—even a painless, asymptomatic one that's detected only by x-ray—increases the risk for future vertebral fracture two- to fourfold. Older women with a previous vertebral fracture have a 1%–3% annual rate of hip fracture, and randomized trials suggest that pharmacologic treatment can lower that risk.

▸ Nonspine fractures. Having any kind of nonspine fracture nearly doubles or triples the risk for having a future nonspine fracture. Even with normal bone density, having a nonspine fracture makes a future nonspine fracture more likely.

▸ Familial history. People who had a parent develop a hip fracture have double the risk for hip fracture themselves, compared with people whose parents did not have hip fractures. This is true regardless of bone mineral density. A wrist fracture in a parent increases an offspring's risk of wrist fracture. “There's some suggestion that this increased familial risk may be specific to the type of fracture,” he said.

Studies have found no association, however, between patients' reports of parents who had osteoporosis or spine fractures and the patients' own risk for those problems, probably because “osteoporosis” and “spine fracture” are rather nonspecific terms used with different meanings.

▸ Weight. Women have a higher risk for serious fractures if they are losing weight involuntarily compared with maintaining or gaining weight. The involuntary weight loss is a marker for frailty. Fractures of the hip, humerus, spine, or pelvis commonly are referred to as “frailty fractures,” he noted.

Voluntary weight loss through diet or exercise diminishes a woman's bone mineral density, but it's not clear whether this increases fracture risk, he said.

▸ Corticosteroid use. Taking more than 10 mg/day of prednisone or comparable doses of other corticosteroids reduces spinal bone density by 5%–10% in the first year, with most of the loss during the first 6 months. Higher doses of steroids reduce spinal bone density even more. Fracture risk increases even more quickly—within 1–2 months of starting corticosteroids. “There's a suggestion here that corticosteroids increase your risk for fractures in ways besides causing bone loss,” perhaps by killing osteocytes in bone and limiting the ability of bone to respond to stimulators, he said.

Consider starting preventive therapy to prevent fractures if patients who will be taking steroids for at least several months have low bone densities or a history of fracture, Dr. Cummings suggested.

▸ Smoking. Cigarette smoking approximately doubles the risk for hip fracture regardless of a person's bone density, probably because smoking is associated with poorer health, weaker muscles, and impaired balance.

▸ Diabetes. Patients with diabetes have triple the risk for foot fractures and double the risk for humerus or hip fractures, compared with nondiabetic patients. If you see a patient with one of these fractures, look for diabetes, and watch for these fractures in patients already diagnosed with diabetes, he advised.

▸ Stroke. Patients who have had a stroke or who are in nursing homes are at very high risk for hip fractures, warranting pharmacotherapy to preserve and strengthen bone. Each year 4%–6% of nursing home patients develop hip fractures. In patients over age 70 who have had a stroke, 3%–5% of women develop hip fractures per year.

SAN FRANCISCO — Measuring bone mineral density in older patients is as justifiable as measuring lipids, Dennis M. Black, Ph.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Lipid testing and treatment for high cholesterol is accepted as an integral part of primary care, but bone densitometry and treatment for low bone density aren't as readily accepted, said Dr. Black, professor of epidemiology and biostatistics at the university. That's partly because measurements and treatments for osteoporosis came along well after tests and treatments for heart disease and its risk factors, he explained.

By the numbers, the value of bone density testing stacks up nicely against the value of lipid testing. Studies have shown that people with cholesterol measurements in the highest quartile have four times the risk for heart disease compared with people whose cholesterol measurements are in the lowest quartile, Dr. Black said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is the lowest quartile compared with those in the highest quartile.

Heart disease risk increases from about 0.5% in the lowest low-density lipoprotein (LDL) quartile to about 4% in the highest lipid quartile. Hip fracture risk increases from about 0.5% in the highest quartile of hip bone density to about 10% in the quartile with the least hip bone density.

Cost-effectiveness compares well, too, he added. Screening lipid levels in a 52-year-old woman and treating her for an LDL level greater than 160 mg/dL costs about $400,000 per quality-adjusted life-year. Screening bone density in a 65-year-old woman and treating her with bisphosphonates for a T-score of −2.5 (suggesting osteoporosis) costs about $30,000 per quality-adjusted life-year, “which is considered cost-effective,” Dr. Black said.

The National Osteoporosis Foundation recommends bone mineral density testing for all women aged 65 years and older, and for postmenopausal women with a risk factor for osteoporosis.

The definition of risk factors for osteoporosis is a bit murky. Dr. Black includes postmenopausal women who have a history of fracture after menopause, whose mothers have a history of fracture (especially hip fracture), who take steroids, or who have very low body weight. Very low body weight commonly is considered being below 125 pounds, but that depends somewhat on height, he added.

The U.S. Preventive Services Task Force recommends bone mineral density measurements for all women above age 60. Medicare covers bone density tests for women over age 65.

Dr. Black recently analyzed 16 years of follow-up data on women in the Study of Osteoporotic Fractures and found that a single measurement of hip bone density is a good predictor of fracture risk. In these white women with a mean age of 71 years, 5% of those in the highest quartile of hip bone density developed a hip fracture over the 16-year period, compared with 32% of women in the lowest quartile of hip bone density.

The difference was “fairly dramatic” he said. Women with the lowest quartile of hip bone density on a single measurement at the start of the study had an immediate increase in risk for hip fracture that continued as far out as 16 years.

“If it's not possible to repeat bone density measurements in 2, 3, or 4 years, you know that the (one) value that you have is still going to be predictive long term,” he said.

There is a growing recognition that T scores shouldn't be used for peripheral measurements. If a patient brings you a printout from a wrist bone density measurement that she got in a pharmacy, use that as an opportunity to talk about bone health and maybe get a more central bone density measurement, he suggested.

SAN FRANCISCO — Measuring bone mineral density in older patients is as justifiable as measuring lipids, Dennis M. Black, Ph.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Lipid testing and treatment for high cholesterol is accepted as an integral part of primary care, but bone densitometry and treatment for low bone density aren't as readily accepted, said Dr. Black, professor of epidemiology and biostatistics at the university. That's partly because measurements and treatments for osteoporosis came along well after tests and treatments for heart disease and its risk factors, he explained.

By the numbers, the value of bone density testing stacks up nicely against the value of lipid testing. Studies have shown that people with cholesterol measurements in the highest quartile have four times the risk for heart disease compared with people whose cholesterol measurements are in the lowest quartile, Dr. Black said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is the lowest quartile compared with those in the highest quartile.

Heart disease risk increases from about 0.5% in the lowest low-density lipoprotein (LDL) quartile to about 4% in the highest lipid quartile. Hip fracture risk increases from about 0.5% in the highest quartile of hip bone density to about 10% in the quartile with the least hip bone density.

Cost-effectiveness compares well, too, he added. Screening lipid levels in a 52-year-old woman and treating her for an LDL level greater than 160 mg/dL costs about $400,000 per quality-adjusted life-year. Screening bone density in a 65-year-old woman and treating her with bisphosphonates for a T-score of −2.5 (suggesting osteoporosis) costs about $30,000 per quality-adjusted life-year, “which is considered cost-effective,” Dr. Black said.

The National Osteoporosis Foundation recommends bone mineral density testing for all women aged 65 years and older, and for postmenopausal women with a risk factor for osteoporosis.

The definition of risk factors for osteoporosis is a bit murky. Dr. Black includes postmenopausal women who have a history of fracture after menopause, whose mothers have a history of fracture (especially hip fracture), who take steroids, or who have very low body weight. Very low body weight commonly is considered being below 125 pounds, but that depends somewhat on height, he added.

The U.S. Preventive Services Task Force recommends bone mineral density measurements for all women above age 60. Medicare covers bone density tests for women over age 65.

Dr. Black recently analyzed 16 years of follow-up data on women in the Study of Osteoporotic Fractures and found that a single measurement of hip bone density is a good predictor of fracture risk. In these white women with a mean age of 71 years, 5% of those in the highest quartile of hip bone density developed a hip fracture over the 16-year period, compared with 32% of women in the lowest quartile of hip bone density.

The difference was “fairly dramatic” he said. Women with the lowest quartile of hip bone density on a single measurement at the start of the study had an immediate increase in risk for hip fracture that continued as far out as 16 years.

“If it's not possible to repeat bone density measurements in 2, 3, or 4 years, you know that the (one) value that you have is still going to be predictive long term,” he said.

There is a growing recognition that T scores shouldn't be used for peripheral measurements. If a patient brings you a printout from a wrist bone density measurement that she got in a pharmacy, use that as an opportunity to talk about bone health and maybe get a more central bone density measurement, he suggested.

SAN FRANCISCO — Measuring bone mineral density in older patients is as justifiable as measuring lipids, Dennis M. Black, Ph.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Lipid testing and treatment for high cholesterol is accepted as an integral part of primary care, but bone densitometry and treatment for low bone density aren't as readily accepted, said Dr. Black, professor of epidemiology and biostatistics at the university. That's partly because measurements and treatments for osteoporosis came along well after tests and treatments for heart disease and its risk factors, he explained.

By the numbers, the value of bone density testing stacks up nicely against the value of lipid testing. Studies have shown that people with cholesterol measurements in the highest quartile have four times the risk for heart disease compared with people whose cholesterol measurements are in the lowest quartile, Dr. Black said. Stratifying hip bone density by quartile, the risk for hip fracture increases 10-fold in people whose bone density is the lowest quartile compared with those in the highest quartile.

Heart disease risk increases from about 0.5% in the lowest low-density lipoprotein (LDL) quartile to about 4% in the highest lipid quartile. Hip fracture risk increases from about 0.5% in the highest quartile of hip bone density to about 10% in the quartile with the least hip bone density.

Cost-effectiveness compares well, too, he added. Screening lipid levels in a 52-year-old woman and treating her for an LDL level greater than 160 mg/dL costs about $400,000 per quality-adjusted life-year. Screening bone density in a 65-year-old woman and treating her with bisphosphonates for a T-score of −2.5 (suggesting osteoporosis) costs about $30,000 per quality-adjusted life-year, “which is considered cost-effective,” Dr. Black said.

The National Osteoporosis Foundation recommends bone mineral density testing for all women aged 65 years and older, and for postmenopausal women with a risk factor for osteoporosis.

The definition of risk factors for osteoporosis is a bit murky. Dr. Black includes postmenopausal women who have a history of fracture after menopause, whose mothers have a history of fracture (especially hip fracture), who take steroids, or who have very low body weight. Very low body weight commonly is considered being below 125 pounds, but that depends somewhat on height, he added.

The U.S. Preventive Services Task Force recommends bone mineral density measurements for all women above age 60. Medicare covers bone density tests for women over age 65.

Dr. Black recently analyzed 16 years of follow-up data on women in the Study of Osteoporotic Fractures and found that a single measurement of hip bone density is a good predictor of fracture risk. In these white women with a mean age of 71 years, 5% of those in the highest quartile of hip bone density developed a hip fracture over the 16-year period, compared with 32% of women in the lowest quartile of hip bone density.

The difference was “fairly dramatic” he said. Women with the lowest quartile of hip bone density on a single measurement at the start of the study had an immediate increase in risk for hip fracture that continued as far out as 16 years.

“If it's not possible to repeat bone density measurements in 2, 3, or 4 years, you know that the (one) value that you have is still going to be predictive long term,” he said.

There is a growing recognition that T scores shouldn't be used for peripheral measurements. If a patient brings you a printout from a wrist bone density measurement that she got in a pharmacy, use that as an opportunity to talk about bone health and maybe get a more central bone density measurement, he suggested.

STANFORD, CALIF. — The young woman who arrived in labor was accompanied by a large and loud crowd of extended family members who spoke little English. With each contraction, the family yelled louder, Marylouise Martin, recalled.

Instead of simply asking them to be quiet or leave, she pulled aside one of the family members and asked why they were all yelling. “Must yell,” the man told her. “Louder you yell, more beautiful baby will be.”

Cultural differences made the yelling irritating to staff members but a routine part of the birth process to the family, she said at a conference on perinatal and pediatric nutrition.

After a separate, nearby room was found for the family to carry on in, everyone was satisfied, said Ms. Martin, a nurse educator at McLeod Regional Medical Center, Florence, S.C.

She told another tale of a male resident physician at an unnamed hospital who was called to substitute at the last minute for a female physician who could not arrive in time to deliver her patient's baby. The mother cried and tried to refuse his care. The woman's husband fought to remove the resident from the room and was taken away by hospital security officers. The baby was delivered, but the parents left the hospital shortly after the birth without the baby. In their eyes, the woman had been violated, and they could not keep the baby.

The stories illustrate why it's important to pursue cultural competence—the accrual of knowledge and skills that enable providers to adapt health care in accordance with the ethnocultural or religious heritage of the individual patient and the patient's family and community, she said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

In the values of traditional American health care, life is sacred, autonomous decision making is paramount, telling the truth is essential, and suffering should be avoided. In some cultures, however, the family may be the primary decision maker. Some patients may not want to hear about health risks, out of the belief that once potential problems are mentioned, the problems are more likely to develop.

Cultural differences go beyond words, Ms. Martin noted. For example, in Greece and Bulgaria, shaking the head up and down means “No,” not “Yes.”

To increase your cultural awareness and competence, evaluate your own attitudes and biases, and be open to change, she advised. Learn to treat each person with respect and equality, and never assume that a person's ethnic identity tells you anything about his or her cultural values or patterns of behavior.

Work with your patients toward common goals by asking questions and communicating effectively. Speak clearly and slowly in short sentences using simple words, not medical jargon. Avoid phrases like, “The baby crashed,” which can be taken literally.

STANFORD, CALIF. — The young woman who arrived in labor was accompanied by a large and loud crowd of extended family members who spoke little English. With each contraction, the family yelled louder, Marylouise Martin, recalled.

Instead of simply asking them to be quiet or leave, she pulled aside one of the family members and asked why they were all yelling. “Must yell,” the man told her. “Louder you yell, more beautiful baby will be.”

Cultural differences made the yelling irritating to staff members but a routine part of the birth process to the family, she said at a conference on perinatal and pediatric nutrition.

After a separate, nearby room was found for the family to carry on in, everyone was satisfied, said Ms. Martin, a nurse educator at McLeod Regional Medical Center, Florence, S.C.

She told another tale of a male resident physician at an unnamed hospital who was called to substitute at the last minute for a female physician who could not arrive in time to deliver her patient's baby. The mother cried and tried to refuse his care. The woman's husband fought to remove the resident from the room and was taken away by hospital security officers. The baby was delivered, but the parents left the hospital shortly after the birth without the baby. In their eyes, the woman had been violated, and they could not keep the baby.

The stories illustrate why it's important to pursue cultural competence—the accrual of knowledge and skills that enable providers to adapt health care in accordance with the ethnocultural or religious heritage of the individual patient and the patient's family and community, she said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

In the values of traditional American health care, life is sacred, autonomous decision making is paramount, telling the truth is essential, and suffering should be avoided. In some cultures, however, the family may be the primary decision maker. Some patients may not want to hear about health risks, out of the belief that once potential problems are mentioned, the problems are more likely to develop.

Cultural differences go beyond words, Ms. Martin noted. For example, in Greece and Bulgaria, shaking the head up and down means “No,” not “Yes.”

To increase your cultural awareness and competence, evaluate your own attitudes and biases, and be open to change, she advised. Learn to treat each person with respect and equality, and never assume that a person's ethnic identity tells you anything about his or her cultural values or patterns of behavior.

Work with your patients toward common goals by asking questions and communicating effectively. Speak clearly and slowly in short sentences using simple words, not medical jargon. Avoid phrases like, “The baby crashed,” which can be taken literally.

STANFORD, CALIF. — The young woman who arrived in labor was accompanied by a large and loud crowd of extended family members who spoke little English. With each contraction, the family yelled louder, Marylouise Martin, recalled.

Instead of simply asking them to be quiet or leave, she pulled aside one of the family members and asked why they were all yelling. “Must yell,” the man told her. “Louder you yell, more beautiful baby will be.”

Cultural differences made the yelling irritating to staff members but a routine part of the birth process to the family, she said at a conference on perinatal and pediatric nutrition.

After a separate, nearby room was found for the family to carry on in, everyone was satisfied, said Ms. Martin, a nurse educator at McLeod Regional Medical Center, Florence, S.C.

She told another tale of a male resident physician at an unnamed hospital who was called to substitute at the last minute for a female physician who could not arrive in time to deliver her patient's baby. The mother cried and tried to refuse his care. The woman's husband fought to remove the resident from the room and was taken away by hospital security officers. The baby was delivered, but the parents left the hospital shortly after the birth without the baby. In their eyes, the woman had been violated, and they could not keep the baby.

The stories illustrate why it's important to pursue cultural competence—the accrual of knowledge and skills that enable providers to adapt health care in accordance with the ethnocultural or religious heritage of the individual patient and the patient's family and community, she said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

In the values of traditional American health care, life is sacred, autonomous decision making is paramount, telling the truth is essential, and suffering should be avoided. In some cultures, however, the family may be the primary decision maker. Some patients may not want to hear about health risks, out of the belief that once potential problems are mentioned, the problems are more likely to develop.

Cultural differences go beyond words, Ms. Martin noted. For example, in Greece and Bulgaria, shaking the head up and down means “No,” not “Yes.”

To increase your cultural awareness and competence, evaluate your own attitudes and biases, and be open to change, she advised. Learn to treat each person with respect and equality, and never assume that a person's ethnic identity tells you anything about his or her cultural values or patterns of behavior.

Work with your patients toward common goals by asking questions and communicating effectively. Speak clearly and slowly in short sentences using simple words, not medical jargon. Avoid phrases like, “The baby crashed,” which can be taken literally.

SAN FRANCISCO — Recent data challenge the long-standing assumption that sufficient levels of calcium and vitamin D are fundamental in preventing and treating osteoporotic fracture, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Calcium absorption and vitamin D levels decline with age. A number of studies over the years have solidified the idea that calcium and vitamin D supplements are effective and important in preventing osteoporosis and fractures, said Dr. Orwoll, professor of medicine at Oregon Health and Science University, Portland.

Findings from a large, well-designed study stirred up controversy when results indicated there were no differences in the rates of repeat fractures among patients with a previous fracture who took calcium, vitamin D, or calcium and vitamin D.

The investigators randomly assigned 5,292 patients aged 70 and older to one of four groups—800 IU daily oral vitamin D, 1,000 mg calcium, oral vitamin D combined with calcium, or placebo—and followed them for a median of 45 months (Lancet 2005;365:1621–8).

Among the total, 698 (13%) sustained a new low-trauma fracture. Of these, 183 (26%) were hip fractures. Investigators observed no significant differences in the incidence of new, low-trauma fractures between patients who received calcium vs. those who did not (12.6% vs. 13.7%); between those who received vitamin D₃ vs. those who did not (13.3% vs 13.1%) or between patients who received combination treatment and those who received placebo (12.6% vs. 13.4%).

Importantly, by 2 years into the Randomized Evaluation of Calcium or Vitamin D (RECORD) trial, only 55% of patients were still taking the calcium and vitamin D tablets, Dr. Orwoll noted. “This is more a compliance issue than an efficacy trial, but it's in the real world,” he said. Analysis of various subgroups could find no effects on fracture rates from the supplements.

The results contradict earlier findings. A 2003 study of 2,686 people aged 65–85 years who were vitamin D deficient found a 22% lower rate of fractures after 5 years in those who took oral vitamin D (100,000 IU every 4 months) vs. those who took placebo. A 2004 metaanalysis of five randomized, controlled trials of vitamin D for people older than 60 years found a 30% lower risk of falls in those taking vitamin D.

A 2005 metaanalysis of seven randomized trials of vitamin D supplementation with 9,820 participants showed that people taking higher doses (700–800 IU/day) of vitamin D had lower rates of hip fractures or any nonvertebral fractures than participants who took 400 IU/day. Nearly all studies included calcium supplements (JAMA 2005;293:2257–64).

Differences between the RECORD trial and earlier trials may account in part for the conflicting findings, Dr. Orwoll said. In an earlier trial in France, for example, 800 IU/day of vitamin D significantly reduced fracture risk, compared with placebo in frail, elderly patients with a mean age of 85 years; all resided in group housing and had very low baseline levels of calcium and vitamin D (Osteoporosis Int. 2002;13:257–64).

Patients in the RECORD trial were a bit younger (mean age 77 years), had somewhat higher baseline levels of calcium and vitamin D, and were home-dwelling instead of institutionalized. “So calcium and vitamin D might show the most robust effect in the frailest patients,” he suggested.

Whether or not calcium and vitamin D supplements reduce fracture risk, and in which patients, remains to be seen, but they are necessary for maintaining bone mass and muscle function, Dr. Orwoll said. Most adults don't get enough calcium and vitamin D, and current recommendations on adequate vitamin D levels are too low, he added.

The Institute of Medicine in 1997 recommended vitamin D doses of 200 IU/day for adults aged 31–50 years, 400 IU/day for ages 51–70, and 600 IU/ day for older people.

A serum level of 30–35 ng/mL of 25-hydroxyvitamin D (25[OH]D) may be ideal for maximizing GI absorption of calcium and avoiding elevated parathyroid levels, Dr. Orwoll noted. A recent poll of six experts suggested that much higher doses of vitamin D supplements are needed to reach those levels. The experts said that 1,000–1,600 IU/day vitamin D would be needed to reach serum levels of 30–32 ng/mL 25(OH)D.

Vitamin D and calcium supplements are inexpensive and safe, so there's little reason not to use them, he said. Recommended daily calcium requirements are scientifically reasonable, even though they're based more on physiologic data than on clinical outcome studies.

Institute of Medicine guidelines in 1997 recommended calcium doses of 1,000 mg/day for adults aged 25–50, 1,200 mg/day for older adults, and 1,000–1,300 mg/day for pregnant or lactating women.

Vitamin D supplementation should be at least 800–1,000 IU/day, Dr. Orwoll said. For pure nutritional inadequacy, it may be appropriate to treat with a loading dose of 50,000 IU per week for 2 months followed by 1,000 IU/day, depending on baseline vitamin D levels. Vitamin D deficiency due to malabsorption or increased catabolism may require doses as high as 100,000 IU/day, he said.

SAN FRANCISCO — Recent data challenge the long-standing assumption that sufficient levels of calcium and vitamin D are fundamental in preventing and treating osteoporotic fracture, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Calcium absorption and vitamin D levels decline with age. A number of studies over the years have solidified the idea that calcium and vitamin D supplements are effective and important in preventing osteoporosis and fractures, said Dr. Orwoll, professor of medicine at Oregon Health and Science University, Portland.

Findings from a large, well-designed study stirred up controversy when results indicated there were no differences in the rates of repeat fractures among patients with a previous fracture who took calcium, vitamin D, or calcium and vitamin D.

The investigators randomly assigned 5,292 patients aged 70 and older to one of four groups—800 IU daily oral vitamin D, 1,000 mg calcium, oral vitamin D combined with calcium, or placebo—and followed them for a median of 45 months (Lancet 2005;365:1621–8).

Among the total, 698 (13%) sustained a new low-trauma fracture. Of these, 183 (26%) were hip fractures. Investigators observed no significant differences in the incidence of new, low-trauma fractures between patients who received calcium vs. those who did not (12.6% vs. 13.7%); between those who received vitamin D₃ vs. those who did not (13.3% vs 13.1%) or between patients who received combination treatment and those who received placebo (12.6% vs. 13.4%).

Importantly, by 2 years into the Randomized Evaluation of Calcium or Vitamin D (RECORD) trial, only 55% of patients were still taking the calcium and vitamin D tablets, Dr. Orwoll noted. “This is more a compliance issue than an efficacy trial, but it's in the real world,” he said. Analysis of various subgroups could find no effects on fracture rates from the supplements.

The results contradict earlier findings. A 2003 study of 2,686 people aged 65–85 years who were vitamin D deficient found a 22% lower rate of fractures after 5 years in those who took oral vitamin D (100,000 IU every 4 months) vs. those who took placebo. A 2004 metaanalysis of five randomized, controlled trials of vitamin D for people older than 60 years found a 30% lower risk of falls in those taking vitamin D.

A 2005 metaanalysis of seven randomized trials of vitamin D supplementation with 9,820 participants showed that people taking higher doses (700–800 IU/day) of vitamin D had lower rates of hip fractures or any nonvertebral fractures than participants who took 400 IU/day. Nearly all studies included calcium supplements (JAMA 2005;293:2257–64).

Differences between the RECORD trial and earlier trials may account in part for the conflicting findings, Dr. Orwoll said. In an earlier trial in France, for example, 800 IU/day of vitamin D significantly reduced fracture risk, compared with placebo in frail, elderly patients with a mean age of 85 years; all resided in group housing and had very low baseline levels of calcium and vitamin D (Osteoporosis Int. 2002;13:257–64).

Patients in the RECORD trial were a bit younger (mean age 77 years), had somewhat higher baseline levels of calcium and vitamin D, and were home-dwelling instead of institutionalized. “So calcium and vitamin D might show the most robust effect in the frailest patients,” he suggested.

Whether or not calcium and vitamin D supplements reduce fracture risk, and in which patients, remains to be seen, but they are necessary for maintaining bone mass and muscle function, Dr. Orwoll said. Most adults don't get enough calcium and vitamin D, and current recommendations on adequate vitamin D levels are too low, he added.

The Institute of Medicine in 1997 recommended vitamin D doses of 200 IU/day for adults aged 31–50 years, 400 IU/day for ages 51–70, and 600 IU/ day for older people.

A serum level of 30–35 ng/mL of 25-hydroxyvitamin D (25[OH]D) may be ideal for maximizing GI absorption of calcium and avoiding elevated parathyroid levels, Dr. Orwoll noted. A recent poll of six experts suggested that much higher doses of vitamin D supplements are needed to reach those levels. The experts said that 1,000–1,600 IU/day vitamin D would be needed to reach serum levels of 30–32 ng/mL 25(OH)D.

Vitamin D and calcium supplements are inexpensive and safe, so there's little reason not to use them, he said. Recommended daily calcium requirements are scientifically reasonable, even though they're based more on physiologic data than on clinical outcome studies.

Institute of Medicine guidelines in 1997 recommended calcium doses of 1,000 mg/day for adults aged 25–50, 1,200 mg/day for older adults, and 1,000–1,300 mg/day for pregnant or lactating women.

Vitamin D supplementation should be at least 800–1,000 IU/day, Dr. Orwoll said. For pure nutritional inadequacy, it may be appropriate to treat with a loading dose of 50,000 IU per week for 2 months followed by 1,000 IU/day, depending on baseline vitamin D levels. Vitamin D deficiency due to malabsorption or increased catabolism may require doses as high as 100,000 IU/day, he said.

SAN FRANCISCO — Recent data challenge the long-standing assumption that sufficient levels of calcium and vitamin D are fundamental in preventing and treating osteoporotic fracture, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Calcium absorption and vitamin D levels decline with age. A number of studies over the years have solidified the idea that calcium and vitamin D supplements are effective and important in preventing osteoporosis and fractures, said Dr. Orwoll, professor of medicine at Oregon Health and Science University, Portland.

Findings from a large, well-designed study stirred up controversy when results indicated there were no differences in the rates of repeat fractures among patients with a previous fracture who took calcium, vitamin D, or calcium and vitamin D.

The investigators randomly assigned 5,292 patients aged 70 and older to one of four groups—800 IU daily oral vitamin D, 1,000 mg calcium, oral vitamin D combined with calcium, or placebo—and followed them for a median of 45 months (Lancet 2005;365:1621–8).

Among the total, 698 (13%) sustained a new low-trauma fracture. Of these, 183 (26%) were hip fractures. Investigators observed no significant differences in the incidence of new, low-trauma fractures between patients who received calcium vs. those who did not (12.6% vs. 13.7%); between those who received vitamin D₃ vs. those who did not (13.3% vs 13.1%) or between patients who received combination treatment and those who received placebo (12.6% vs. 13.4%).

Importantly, by 2 years into the Randomized Evaluation of Calcium or Vitamin D (RECORD) trial, only 55% of patients were still taking the calcium and vitamin D tablets, Dr. Orwoll noted. “This is more a compliance issue than an efficacy trial, but it's in the real world,” he said. Analysis of various subgroups could find no effects on fracture rates from the supplements.

The results contradict earlier findings. A 2003 study of 2,686 people aged 65–85 years who were vitamin D deficient found a 22% lower rate of fractures after 5 years in those who took oral vitamin D (100,000 IU every 4 months) vs. those who took placebo. A 2004 metaanalysis of five randomized, controlled trials of vitamin D for people older than 60 years found a 30% lower risk of falls in those taking vitamin D.

A 2005 metaanalysis of seven randomized trials of vitamin D supplementation with 9,820 participants showed that people taking higher doses (700–800 IU/day) of vitamin D had lower rates of hip fractures or any nonvertebral fractures than participants who took 400 IU/day. Nearly all studies included calcium supplements (JAMA 2005;293:2257–64).

Differences between the RECORD trial and earlier trials may account in part for the conflicting findings, Dr. Orwoll said. In an earlier trial in France, for example, 800 IU/day of vitamin D significantly reduced fracture risk, compared with placebo in frail, elderly patients with a mean age of 85 years; all resided in group housing and had very low baseline levels of calcium and vitamin D (Osteoporosis Int. 2002;13:257–64).

Patients in the RECORD trial were a bit younger (mean age 77 years), had somewhat higher baseline levels of calcium and vitamin D, and were home-dwelling instead of institutionalized. “So calcium and vitamin D might show the most robust effect in the frailest patients,” he suggested.

Whether or not calcium and vitamin D supplements reduce fracture risk, and in which patients, remains to be seen, but they are necessary for maintaining bone mass and muscle function, Dr. Orwoll said. Most adults don't get enough calcium and vitamin D, and current recommendations on adequate vitamin D levels are too low, he added.

The Institute of Medicine in 1997 recommended vitamin D doses of 200 IU/day for adults aged 31–50 years, 400 IU/day for ages 51–70, and 600 IU/ day for older people.

A serum level of 30–35 ng/mL of 25-hydroxyvitamin D (25[OH]D) may be ideal for maximizing GI absorption of calcium and avoiding elevated parathyroid levels, Dr. Orwoll noted. A recent poll of six experts suggested that much higher doses of vitamin D supplements are needed to reach those levels. The experts said that 1,000–1,600 IU/day vitamin D would be needed to reach serum levels of 30–32 ng/mL 25(OH)D.

Vitamin D and calcium supplements are inexpensive and safe, so there's little reason not to use them, he said. Recommended daily calcium requirements are scientifically reasonable, even though they're based more on physiologic data than on clinical outcome studies.

Institute of Medicine guidelines in 1997 recommended calcium doses of 1,000 mg/day for adults aged 25–50, 1,200 mg/day for older adults, and 1,000–1,300 mg/day for pregnant or lactating women.

Vitamin D supplementation should be at least 800–1,000 IU/day, Dr. Orwoll said. For pure nutritional inadequacy, it may be appropriate to treat with a loading dose of 50,000 IU per week for 2 months followed by 1,000 IU/day, depending on baseline vitamin D levels. Vitamin D deficiency due to malabsorption or increased catabolism may require doses as high as 100,000 IU/day, he said.

SAN FRANCISCO — A trend toward using one set of parameters to diagnose osteoporosis in both men and women hasn't caught on in the United States, where sex-specific bone density scores are the norm, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Yet despite the ease of a gender-blind system and some persuasive data, using a sex-specific method is the way to go, at least until more data accumulate on bone loss and fracture risk in men, suggested Dr. Orwoll, professor of medicine at Oregon Health and Science University, Portland.

The evidence supporting the use of one set of parameters is mounting. Studies in recent years have shown, for example, that the 1-year risk for hip fracture overlaps in men and women with the same hip bone mineral densities. As the density gets lower, the risk for fracture increases at essentially the same rate in both sexes.

Such findings have led some bone experts to suggest that it would be easier and logical for clinicians to use just one reference range for diagnosing osteoporosis instead of using separate T scores for men and women. Bone densitometry machines in the United States currently calculate a sex-specific T score.

The International Osteoporosis Foundation in 2000 noted that the same absolute values of bone density in men and women yield the same absolute risk of vertebral or hip fracture, suggesting that using one threshold for calculating risk makes sense. The data on men are scanty, according to the statement.

Those who favor using one set of parameters usually propose using T scores that report the number of standard deviations between current bone density and the mean peak density of a 30-year-old female.

But the problem with using such a strategy, Dr. Orwoll said, is that only about 3% of older men would be identified as osteoporotic, in comparison with a young female reference population, while 19% of older men would be deemed osteoporotic if their T scores came from reference to young male norms.

About 25%–30% of older men will have a fragility fracture, but if the female reference range were used, only a small percentage of them would be identified as osteoporotic.

“So there's a little bit of incongruity in the application of the International Osteoporosis Foundation recommendations, despite the fact that they're scientifically reasonable,” he said.

Dr. Orwoll encouraged clinicians to keep using the current system of sex-specific T scores from densitometry machines until better, long-term, prospective data on fracture risk in men become available.

He added that it's also critical to include other clinical criteria besides T scores in identifying fracture risk in men.

SAN FRANCISCO — A trend toward using one set of parameters to diagnose osteoporosis in both men and women hasn't caught on in the United States, where sex-specific bone density scores are the norm, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Yet despite the ease of a gender-blind system and some persuasive data, using a sex-specific method is the way to go, at least until more data accumulate on bone loss and fracture risk in men, suggested Dr. Orwoll, professor of medicine at Oregon Health and Science University, Portland.

The evidence supporting the use of one set of parameters is mounting. Studies in recent years have shown, for example, that the 1-year risk for hip fracture overlaps in men and women with the same hip bone mineral densities. As the density gets lower, the risk for fracture increases at essentially the same rate in both sexes.

Such findings have led some bone experts to suggest that it would be easier and logical for clinicians to use just one reference range for diagnosing osteoporosis instead of using separate T scores for men and women. Bone densitometry machines in the United States currently calculate a sex-specific T score.

The International Osteoporosis Foundation in 2000 noted that the same absolute values of bone density in men and women yield the same absolute risk of vertebral or hip fracture, suggesting that using one threshold for calculating risk makes sense. The data on men are scanty, according to the statement.

Those who favor using one set of parameters usually propose using T scores that report the number of standard deviations between current bone density and the mean peak density of a 30-year-old female.

But the problem with using such a strategy, Dr. Orwoll said, is that only about 3% of older men would be identified as osteoporotic, in comparison with a young female reference population, while 19% of older men would be deemed osteoporotic if their T scores came from reference to young male norms.

About 25%–30% of older men will have a fragility fracture, but if the female reference range were used, only a small percentage of them would be identified as osteoporotic.

“So there's a little bit of incongruity in the application of the International Osteoporosis Foundation recommendations, despite the fact that they're scientifically reasonable,” he said.

Dr. Orwoll encouraged clinicians to keep using the current system of sex-specific T scores from densitometry machines until better, long-term, prospective data on fracture risk in men become available.

He added that it's also critical to include other clinical criteria besides T scores in identifying fracture risk in men.

SAN FRANCISCO — A trend toward using one set of parameters to diagnose osteoporosis in both men and women hasn't caught on in the United States, where sex-specific bone density scores are the norm, Eric S. Orwoll, M.D., said at a meeting on osteoporosis sponsored by the University of California, San Francisco.

Yet despite the ease of a gender-blind system and some persuasive data, using a sex-specific method is the way to go, at least until more data accumulate on bone loss and fracture risk in men, suggested Dr. Orwoll, professor of medicine at Oregon Health and Science University, Portland.

The evidence supporting the use of one set of parameters is mounting. Studies in recent years have shown, for example, that the 1-year risk for hip fracture overlaps in men and women with the same hip bone mineral densities. As the density gets lower, the risk for fracture increases at essentially the same rate in both sexes.

Such findings have led some bone experts to suggest that it would be easier and logical for clinicians to use just one reference range for diagnosing osteoporosis instead of using separate T scores for men and women. Bone densitometry machines in the United States currently calculate a sex-specific T score.

The International Osteoporosis Foundation in 2000 noted that the same absolute values of bone density in men and women yield the same absolute risk of vertebral or hip fracture, suggesting that using one threshold for calculating risk makes sense. The data on men are scanty, according to the statement.

Those who favor using one set of parameters usually propose using T scores that report the number of standard deviations between current bone density and the mean peak density of a 30-year-old female.

But the problem with using such a strategy, Dr. Orwoll said, is that only about 3% of older men would be identified as osteoporotic, in comparison with a young female reference population, while 19% of older men would be deemed osteoporotic if their T scores came from reference to young male norms.

About 25%–30% of older men will have a fragility fracture, but if the female reference range were used, only a small percentage of them would be identified as osteoporotic.

“So there's a little bit of incongruity in the application of the International Osteoporosis Foundation recommendations, despite the fact that they're scientifically reasonable,” he said.

Dr. Orwoll encouraged clinicians to keep using the current system of sex-specific T scores from densitometry machines until better, long-term, prospective data on fracture risk in men become available.

He added that it's also critical to include other clinical criteria besides T scores in identifying fracture risk in men.

SAN FRANCISCO — Patients receiving bone densitometry should be counseled about their T and their z scores, Steven T. Harris, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The T score compares the patient's bone mineral density with the mean peak bone density of a 30-year-old person of the same sex and is expressed as a number of standard deviations above or below the young person's density, said Dr. Harris of the university.

The z score compares the patient's bone mineral density with mean peak density for someone the same age, and helps give patients some perspective. “In my consultative practice over the years, I've seen many, many, many patients who have been terrified by being told that they have osteoporosis at age 78 by comparing them to that 30-year-old, and yet who feel reassured when you show them where they are relative to their peers,” he said.

Sharing both score types helps give patients a more accurate picture of their bone health. A 55-year-old woman with a z score of −2 has bone density around the lower limits of normal for her age, but her T score would be −3.2 in comparison with a young adult. That patient can be reassured that she's similar to her peers, but should be persuaded that “there is an issue here that needs to be addressed,” he said.

That said, the patient with a T score above −2.5 (the cutoff for osteoporosis) can still have a clinical diagnosis of osteoporosis if other factors are present such as atraumatic vertebral fractures.

Getting a z score can be especially motivating because those patients who are abnormal compared with their peers need the greatest attention to possible secondary causes of low bone density. “If you see an abnormal z score, it makes you worry that much more about something very unusual going on in that particular patient,” he said.

Patients should also be warned that first bone density measurements give a snapshot of the skeleton's current state. But a low T score does not identify the cause of the low bone density, and the patient should not be labeled osteoporotic automatically, he added. Density reports can have a fairly wide margin of error on first-time measurements. In addition, bone density measurements often vary by a few percentage points when done by different machines. Whenever possible, follow-up scans should be performed with the same machine, he advised.

Vitamin D deficiency leading to reduced osteomalacia can produce a low T score that can improve dramatically once the vitamin deficiency is corrected. Celiac disease with malabsorption can lead to a low T score.

Individual T scores for L1-L4 on spinal densitometry are usually aggregated for diagnostic purposes instead of using the individual results for vertebral bodies. The best and worst scores for individual vertebrae should be within one standard deviation of each other. If not, one should suspect an imaging artifact. In these cases, usually the “best” T score is spurious, Dr. Harris said.

It's important to not just read the densitometry report but to look at the scan, he added. A spine with scoliosis, for example, will have changes in facet joints, making the accuracy of densitometry problematic.

Whiteness seen on the L3 and L4 sections of a spinal scan may be due to facet joint sclerosis, skewing density readings. The aggregation of L1-L4 measurements in one such patient produced a T score of −1.7, suggestive of osteopenia. But excluding the L3-L4 measurements, the T score was −2.9, in the range of osteoporosis, he said.

On hip scans, check to make sure the hip was imaged in the correct position, with the femoral shaft straight up and down and with sufficient internal rotation on the leg so that little or none of the lesser trochanter is visible. The scan should include the ischium and the greater trochanter, but the ischium should not be in the scan's femoral neck box.

SAN FRANCISCO — Patients receiving bone densitometry should be counseled about their T and their z scores, Steven T. Harris, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The T score compares the patient's bone mineral density with the mean peak bone density of a 30-year-old person of the same sex and is expressed as a number of standard deviations above or below the young person's density, said Dr. Harris of the university.

The z score compares the patient's bone mineral density with mean peak density for someone the same age, and helps give patients some perspective. “In my consultative practice over the years, I've seen many, many, many patients who have been terrified by being told that they have osteoporosis at age 78 by comparing them to that 30-year-old, and yet who feel reassured when you show them where they are relative to their peers,” he said.

Sharing both score types helps give patients a more accurate picture of their bone health. A 55-year-old woman with a z score of −2 has bone density around the lower limits of normal for her age, but her T score would be −3.2 in comparison with a young adult. That patient can be reassured that she's similar to her peers, but should be persuaded that “there is an issue here that needs to be addressed,” he said.

That said, the patient with a T score above −2.5 (the cutoff for osteoporosis) can still have a clinical diagnosis of osteoporosis if other factors are present such as atraumatic vertebral fractures.

Getting a z score can be especially motivating because those patients who are abnormal compared with their peers need the greatest attention to possible secondary causes of low bone density. “If you see an abnormal z score, it makes you worry that much more about something very unusual going on in that particular patient,” he said.

Patients should also be warned that first bone density measurements give a snapshot of the skeleton's current state. But a low T score does not identify the cause of the low bone density, and the patient should not be labeled osteoporotic automatically, he added. Density reports can have a fairly wide margin of error on first-time measurements. In addition, bone density measurements often vary by a few percentage points when done by different machines. Whenever possible, follow-up scans should be performed with the same machine, he advised.

Vitamin D deficiency leading to reduced osteomalacia can produce a low T score that can improve dramatically once the vitamin deficiency is corrected. Celiac disease with malabsorption can lead to a low T score.

Individual T scores for L1-L4 on spinal densitometry are usually aggregated for diagnostic purposes instead of using the individual results for vertebral bodies. The best and worst scores for individual vertebrae should be within one standard deviation of each other. If not, one should suspect an imaging artifact. In these cases, usually the “best” T score is spurious, Dr. Harris said.

It's important to not just read the densitometry report but to look at the scan, he added. A spine with scoliosis, for example, will have changes in facet joints, making the accuracy of densitometry problematic.

Whiteness seen on the L3 and L4 sections of a spinal scan may be due to facet joint sclerosis, skewing density readings. The aggregation of L1-L4 measurements in one such patient produced a T score of −1.7, suggestive of osteopenia. But excluding the L3-L4 measurements, the T score was −2.9, in the range of osteoporosis, he said.

On hip scans, check to make sure the hip was imaged in the correct position, with the femoral shaft straight up and down and with sufficient internal rotation on the leg so that little or none of the lesser trochanter is visible. The scan should include the ischium and the greater trochanter, but the ischium should not be in the scan's femoral neck box.

SAN FRANCISCO — Patients receiving bone densitometry should be counseled about their T and their z scores, Steven T. Harris, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

The T score compares the patient's bone mineral density with the mean peak bone density of a 30-year-old person of the same sex and is expressed as a number of standard deviations above or below the young person's density, said Dr. Harris of the university.

The z score compares the patient's bone mineral density with mean peak density for someone the same age, and helps give patients some perspective. “In my consultative practice over the years, I've seen many, many, many patients who have been terrified by being told that they have osteoporosis at age 78 by comparing them to that 30-year-old, and yet who feel reassured when you show them where they are relative to their peers,” he said.

Sharing both score types helps give patients a more accurate picture of their bone health. A 55-year-old woman with a z score of −2 has bone density around the lower limits of normal for her age, but her T score would be −3.2 in comparison with a young adult. That patient can be reassured that she's similar to her peers, but should be persuaded that “there is an issue here that needs to be addressed,” he said.

That said, the patient with a T score above −2.5 (the cutoff for osteoporosis) can still have a clinical diagnosis of osteoporosis if other factors are present such as atraumatic vertebral fractures.

Getting a z score can be especially motivating because those patients who are abnormal compared with their peers need the greatest attention to possible secondary causes of low bone density. “If you see an abnormal z score, it makes you worry that much more about something very unusual going on in that particular patient,” he said.

Patients should also be warned that first bone density measurements give a snapshot of the skeleton's current state. But a low T score does not identify the cause of the low bone density, and the patient should not be labeled osteoporotic automatically, he added. Density reports can have a fairly wide margin of error on first-time measurements. In addition, bone density measurements often vary by a few percentage points when done by different machines. Whenever possible, follow-up scans should be performed with the same machine, he advised.

Vitamin D deficiency leading to reduced osteomalacia can produce a low T score that can improve dramatically once the vitamin deficiency is corrected. Celiac disease with malabsorption can lead to a low T score.

Individual T scores for L1-L4 on spinal densitometry are usually aggregated for diagnostic purposes instead of using the individual results for vertebral bodies. The best and worst scores for individual vertebrae should be within one standard deviation of each other. If not, one should suspect an imaging artifact. In these cases, usually the “best” T score is spurious, Dr. Harris said.

It's important to not just read the densitometry report but to look at the scan, he added. A spine with scoliosis, for example, will have changes in facet joints, making the accuracy of densitometry problematic.

Whiteness seen on the L3 and L4 sections of a spinal scan may be due to facet joint sclerosis, skewing density readings. The aggregation of L1-L4 measurements in one such patient produced a T score of −1.7, suggestive of osteopenia. But excluding the L3-L4 measurements, the T score was −2.9, in the range of osteoporosis, he said.

On hip scans, check to make sure the hip was imaged in the correct position, with the femoral shaft straight up and down and with sufficient internal rotation on the leg so that little or none of the lesser trochanter is visible. The scan should include the ischium and the greater trochanter, but the ischium should not be in the scan's femoral neck box.

SAN FRANCISCO — If the first bone density reading after starting bisphosphonate therapy shows bone loss, don't stop or alter therapy, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

In all likelihood the therapy is working, but “noise” in the bone density test results in a lower density measurement. The next time the patient's bone density is taken, it probably will be higher, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He and his associates analyzed data from the 6,459-patient Fracture Intervention Trial and found that among women who lost at least 4% of hip bone density in the first year of treatment with alendronate, 92% gained an average of 5% of hip bone density in the second year of therapy. The study involved postmenopausal women, aged 55–80 years, were randomized to receive alendronate at 5 mg/day for 2 years and 10 mg/day thereafter, or placebo for up to 4.5 years.

“If you were to change treatment or add another drug” after that first follow-up, “they would gain bone and you would look like a hero, but in fact they would have improved even without” any changes, he said.

Among women in the study who gained up to 4% of hip bone density in the first year on alendronate, 67% continued to gain an average of 1% bone density in the second year on therapy.

Of the women who gained a lot of hip bone—8% or more—the first year, 64% lost an average of 1% of hip bone the second year. So patients with the largest gains in bone density during the first year ought to be told: “Watch out—the next year you're likely to lose bone,” he said.

Continuing therapy also is important for reducing the risk of fracture. A comparison of the 18% of women who lost bone after a year of alendronate with the 18% of women who lost the most bone while on placebo indicated a 50% reduction in fracture risk among patients who gained bone density on treatment. A slightly greater reduction in fracture risk was seen in women who lost up to 4% of bone if they were taking alendronate, compared with placebo.

The greatest overall benefits occurred in women who lost more than 4% of bone density in the first year. In this subgroup, taking alendronate reduced the risk of fracture by 80%–90%, compared with placebo. “Stopping treatment in those patients who lose bone is exactly the wrong thing to do,” said Dr. Cummings, who is a consultant and speaker for two companies that make bisphosphonate medications.

If a patient consistently loses bone density over multiple follow-up measurements in a period of years, then it would be reasonable to reassess treatment options, he said.

SAN FRANCISCO — If the first bone density reading after starting bisphosphonate therapy shows bone loss, don't stop or alter therapy, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

In all likelihood the therapy is working, but “noise” in the bone density test results in a lower density measurement. The next time the patient's bone density is taken, it probably will be higher, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He and his associates analyzed data from the 6,459-patient Fracture Intervention Trial and found that among women who lost at least 4% of hip bone density in the first year of treatment with alendronate, 92% gained an average of 5% of hip bone density in the second year of therapy. The study involved postmenopausal women, aged 55–80 years, were randomized to receive alendronate at 5 mg/day for 2 years and 10 mg/day thereafter, or placebo for up to 4.5 years.

“If you were to change treatment or add another drug” after that first follow-up, “they would gain bone and you would look like a hero, but in fact they would have improved even without” any changes, he said.

Among women in the study who gained up to 4% of hip bone density in the first year on alendronate, 67% continued to gain an average of 1% bone density in the second year on therapy.

Of the women who gained a lot of hip bone—8% or more—the first year, 64% lost an average of 1% of hip bone the second year. So patients with the largest gains in bone density during the first year ought to be told: “Watch out—the next year you're likely to lose bone,” he said.

Continuing therapy also is important for reducing the risk of fracture. A comparison of the 18% of women who lost bone after a year of alendronate with the 18% of women who lost the most bone while on placebo indicated a 50% reduction in fracture risk among patients who gained bone density on treatment. A slightly greater reduction in fracture risk was seen in women who lost up to 4% of bone if they were taking alendronate, compared with placebo.

The greatest overall benefits occurred in women who lost more than 4% of bone density in the first year. In this subgroup, taking alendronate reduced the risk of fracture by 80%–90%, compared with placebo. “Stopping treatment in those patients who lose bone is exactly the wrong thing to do,” said Dr. Cummings, who is a consultant and speaker for two companies that make bisphosphonate medications.

If a patient consistently loses bone density over multiple follow-up measurements in a period of years, then it would be reasonable to reassess treatment options, he said.

SAN FRANCISCO — If the first bone density reading after starting bisphosphonate therapy shows bone loss, don't stop or alter therapy, Steven R. Cummings, M.D., advised at a meeting on osteoporosis sponsored by the University of California, San Francisco.

In all likelihood the therapy is working, but “noise” in the bone density test results in a lower density measurement. The next time the patient's bone density is taken, it probably will be higher, said Dr. Cummings, professor emeritus of epidemiology and biostatistics at the university and director of clinical research at the California Pacific Medical Center Research Institute.

He and his associates analyzed data from the 6,459-patient Fracture Intervention Trial and found that among women who lost at least 4% of hip bone density in the first year of treatment with alendronate, 92% gained an average of 5% of hip bone density in the second year of therapy. The study involved postmenopausal women, aged 55–80 years, were randomized to receive alendronate at 5 mg/day for 2 years and 10 mg/day thereafter, or placebo for up to 4.5 years.

“If you were to change treatment or add another drug” after that first follow-up, “they would gain bone and you would look like a hero, but in fact they would have improved even without” any changes, he said.

Among women in the study who gained up to 4% of hip bone density in the first year on alendronate, 67% continued to gain an average of 1% bone density in the second year on therapy.

Of the women who gained a lot of hip bone—8% or more—the first year, 64% lost an average of 1% of hip bone the second year. So patients with the largest gains in bone density during the first year ought to be told: “Watch out—the next year you're likely to lose bone,” he said.

Continuing therapy also is important for reducing the risk of fracture. A comparison of the 18% of women who lost bone after a year of alendronate with the 18% of women who lost the most bone while on placebo indicated a 50% reduction in fracture risk among patients who gained bone density on treatment. A slightly greater reduction in fracture risk was seen in women who lost up to 4% of bone if they were taking alendronate, compared with placebo.

The greatest overall benefits occurred in women who lost more than 4% of bone density in the first year. In this subgroup, taking alendronate reduced the risk of fracture by 80%–90%, compared with placebo. “Stopping treatment in those patients who lose bone is exactly the wrong thing to do,” said Dr. Cummings, who is a consultant and speaker for two companies that make bisphosphonate medications.

If a patient consistently loses bone density over multiple follow-up measurements in a period of years, then it would be reasonable to reassess treatment options, he said.