JAMA. July 6, 2005; Vol 294, No.1: 113 BOOKS, Osteoporosis The Myth of Osteoporosis: What Every Woman Should Know About Creating Bone Health, by Gillian Sanson, 225 PP, $19.95, ISBN 09721233 4 2, Ann Arbor, Mich, MCD Publications, 2003. UNTIL HER HIP FRACTURE, MY MOTHER was a ferocious shopper. Even in her early 70s, my mother would race down Fifth Avenue in New York City, shopping bags in hand, leaving me out of breath and begging for a rest. Then, at age 72 years, my mother fractured her hip. Suddenly, our lives changed, and these days we mostly shop from catalogs. Clearly, osteoporosis has had a profound impact on my mother and. our family. For this reason, l initially approached Gillian Sanson's The Myth of Osteoporosis with significant reservations. However, Sanson approaches the topic of osteoporosis with insight and wisdom, and by the end of her book, my reservations had turned to enthusiasm. Sanson raises several important issues concerning the diagnosis and treatment of osteoporosis. First, bone density is only one component of bone strength. Bone strength is also determined by bone microarchitecture, vitality, and the ability of bone to repair itself. Second, there ate no international normal reference standards for dual x ray absorptiometry machines. Manufacturers set their own standards, and, therefore, women's bone density results will likely vary among machines, regions, and countries. Third, while a severe deficiency in dietary calcium can lead to deficient bone formation, high dietary calcium intake will not always prevent osteoporosis. Serum calcium levels ate tightly regulated, and calcium absorption varies greatly between individuals. Therefore, not all dietary calcium will be absorbed, and calcium supplements do not guarantee adequate bone density. One highly controversial issue that the author raises is whether medications; currently prescribed to treat osteoporosis are safe and significantly reduce the incidence of hip fracture. l strongly agree that it is important to be cautious about the long term safety of all drugs. The Women's Health Initiative studies have raised substantial concerns about the association of combined estrogen and progesterone postmenopausal hormone therapy with cardiovascular disease and gynecologic cancers, and, therefore, these medications need to be prescribed with caution. As for drugs for osteoporosis, Sanson states that we do not understand the implications of longterm bisphosphonate use and that it is unknown whether prolonged inhibition of osteoclast mediated. Bone remodeling promotes long term bone health. l SLrongly agree but take issue with her presentation of women as being "easily swayed because the medicalization of menopause has paved the way for the medicalization of bone mineral loss." While it is possible for women to view the normal aging process as a disease, the stereotype is simplistic and does not pay adequate respecL Lo the thoughtful consideration many women give their health. Although l do not agree with everything in this book, l respect the author for raising important issues that merit further discussion. l found of greatest value her holistic approach to preventing hip fracture. Sanson wisely stresses; that overall good health is critical for preventing falls and that staying well means more than. just taking prescription drugs or supplements. Regular exercise, maintaining normal weight, and avoiding smoking and alcohol are key to continued good health. Muscle strength, good balance, and good eyesight are important for preventing falls. As l read The Myth of Osteoporosis, l frequently reflected on my mother's experience. Did she fracture her hip because of low bone density or because she lived in an old house with a narrow twisting staircase that lacked good lighting? l think back to my mother's description of how she ventured down into the basement one night, forgot to turn on the light, missed the step in the dark, and ended up with a fractured hip. l can only speculate as to whether my mother, had she read Sanson's chapter on preventing falls, would have stopped, turned on the light, and, instead of falling down that flight of stairs, would still be leaving me in her wake, breathless and sweaty amid the shoppers in New York City. Victoria Seewaldt, MD
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