Evidence Synthesis Pilot Program 

Screening Men for Osteoporosis: 

Who & How

Department of Veterans Affairs

Health Services Research & Development Service

May 2007

Investigators:

Paul Shekelle, MD, PhD 

Director

 

Brett Munjas, BA

Project Manager/Literature Database Manager

Hau Liu, MD

Elaine Wong, MD

Content Experts/Physician Reviewers

Neil Paige, MD

Caroline Goldzweig, MD

Physician Reviewers/Health Services Researchers

Annie Zhou, MS

Marika Suttorp, MS

Statisticians

Prepared for: 

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420 

Prepared by:

Greater Los Angeles Veterans Affairs Healthcare 

System/Southern California/RAND Evidence-based 

Practice Center 

Los Angeles, CA
ii 

Suggested Citation 

Shekelle P, Munjas B, Liu H, Paige N, and Zhou A. “Screening Men for Osteoporosis: 

Who & How.” Department of Veterans Affairs. May 2007. 

Technical Experts & Consultants* 

Eric Orwoll, MD, Oregon Health Sciences University, Portland, OR. 

William Duncan, MD, VA Central Office, Washington, DC. 

* Service as a technical expert for this report does not imply endorsement of 

the report’s findings. 

This information is distributed solely for the purposes of pre-dissemination peer review. It has 

not been formally disseminated by the Department of Veterans Affairs and does not represent 

an official or non-official VA determination or policy.

This report is based on research conducted by the Greater Los Angeles Veterans Affairs 

Healthcare System and Southern California Evidence-based Practice Center (EPC) under 

contract to the Department of Veterans Affairs. The findings and conclusions in this document 

are those of the author(s) who are responsible for its contents and do not necessarily represent 

the views of the Department of Veterans Affairs. Therefore, no statement in this article should 

be construed as an official position of the Department of Veterans Affairs. 

This report is intended as a reference and not as a substitute for clinical judgment. 

This report may be used, in whole or in part, as the basis for the development of clinical 

practice guidelines and other quality enhancement tools, or as a basis for reimbursement and 

coverage policies. The Department of Veterans Affairs endorsement of such derivative 

products may not be stated or implied. 

FINANCIAL DISCLOSURE: No investigators have any affiliations or financial involvement (e.g., 

employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or 

patents received or pending, or royalties) that conflict with material presented in the report. 
iii 

PREFACE 

VA’s Health Services Research and Development Service (HSR&D) works to improve the cost, 

quality, and outcomes of health care for our nation’s veterans. Collaborating with VA leaders, 

managers, and policy makers, HSR&D focuses on important health care topics that are likely to 

have significant impact on quality improvement efforts. One significant collaborative effort is 

HSR&D’s Evidence-based Synthesis Pilot Project (ESP). Through this project, HSR&D 

provides timely and accurate evidence syntheses on targeted health care topics. These products 

will be disseminated broadly throughout VA and will: inform VA clinical policy, develop 

clinical practice guidelines, set directions for future research to address gaps in knowledge, 

identify the evidence to support VA performance measures, and rationalize drug formulary 

decisions. 

HSR&D provided funding for the two Evidence Based Practice Centers (EPCs) supported by the 

Agency for Healthcare Research and Quality (AHRQ) that also had an active and publicly 

acknowledged VA affiliation—Southern California EPC and Portland, OR EPC—so they could 

develop evidence syntheses on requested topics for dissemination to VA policymakers. A 

planning committee with representation from HSR&D, Patient Care Services, Office of Quality 

and Performance, and the VISN Clinical Management Officers, has been established to identify 

priority topics and to insure the quality of final reports. 

Comments on this evidence report are welcome and can be sent to Susan Schiffner, ESP Program 

Manager, at Susan.Schiffner@va.gov . 
HSR&D Evidence Synthesis Pilot Program – 

Screening Men for Osteoporosis: Who & How 1

EXECUTIVE SUMMARY

BACKGROUND

Although 25% of men over the age of 60 will sustain osteoporotic fractures during their lifetime, data 

suggest that male osteoporosis is underdiganosed and undertreated. In order to help inform decisions 

about whether the Veterans Health Administration should develop screening guidelines for male 

osteoporosis, summaries of what is known about 1) the epidemiology of male osteoporosis, and 2) the 

validity of tools to screen and diagnose male osteoporosis are needed. 

The Key Questions were: 

Key Question 1. What are the prevalence of and risk factors for osteopenia, osteoporosis and 

osteoporotic fractures among men in general and among male Veterans specifically? 

Key Question 2. Are there any validated tools (outside of central bone density) to screen for 

osteoporosis in men? 

Key Question 3. What values of BMD determined by Dual energy X-ray Absorptiometry (DXA) (and 

by different DXA techniques) have been used to diagnose osteopenia and osteoporosis; and what is the 

evidence regarding the relationship between differing definitions and the development of osteoporotic 

fractures? 

METHODS

We searched PubMed from 1990-2006 using standard search terms. Titles, abstracts, and articles were 

reviewed in duplicate by physicians trained in the critical analysis of literature. Data were extracted by 

quantitative analysts. Pooled analyses were performed for the comparison of either calcaneal ultrasound 

or the Osteoporosis Screening Tool compared to central DXA; all other data were narratively 

summarized. 

RESULTS

We screened 564 titles and performed a more detailed review on 378 articles. From this, we identified 

173 articles that addressed risk factors for osteoporosis, 27 articles that addressed diagnostic tools, and 

31 articles about differing DXA levels and fracture risk. We identified an older high quality metaanalysis of risk factors for osteoporosis. Of the risk factors assessed in this review that the authors 

classified as something other than high risk, VA policymakers selected alcohol use, diabetes mellitus 

type II, and spinal cord injury as the factors for assessment in this review. 
HSR&D Evidence Synthesis Pilot Program – 

Screening Men for Osteoporosis: Who & How 2

KEY QUESTION #1: What are the prevalence of and risk factors for osteopenia, osteoporosis and 

osteoporotic fractures among men in general and among male Veterans specifically? 

PREVALENCE

 There are no VA specific data on prevalence of osteopenia and osteoporosis in men. 

 Applying NHANES III estimates of prevalence to veteran-specific enrollee data we estimate the 

prevalence of osteoporosis in male veterans of 200,000 – 400,000; and of osteopenia in male 

veterans of 2-3 million. 

RISK FACTORS

 We found a high quality meta-analysis, and a limited number of articles specific to the risk factors 

alcohol use, diabetes mellitus type II and spinal cord injury. Based on these findings, our review 

suggests the following. 

 Strong predictors of an increased risk of osteoporosis in men include age, low body weight, 

physical inactivity, and weight loss. (GRADE quality of evidence = High; further research is very 

unlikely to change our confidence on the estimate of effect.) 

 Certain health conditions and medications also are strong or moderate predictors of an increased 

risk of osteoporosis in men. The most relevant to VA are prolonged systemic corticosteroid 

therapy and androgen deprivation (in the context of prostate cancer treatment). (GRADE quality of 

evidence = Moderate; further research is likely to have an important impact on our confidence in 

the estimate of effect and may change the estimate.) 

 Alcohol use is probably associated with an increase in osteoporotic fractures, but is not clearly 

associated with an increase in osteoporosis as measured by BMD. (GRADE quality of evidence: 

Fractures = Moderate; further research is likely to have an important impact on our confidence in 

the estimate of effect and may change the estimate; BMD = Very Low; any estimate of effect is 

very uncertain.) 

 There is no evidence that diabetes mellitus type II is a significant risk factor for osteoporosis in 

men. (GRADE quality of evidence: Low; further research is very likely to have an important 

impact on our confidence in the estimate of effect and is likely to change the estimate.) 

 Spinal Cord Injury is likely associated with an increase risk of osteoporosis and possibly 

osteoporotic fractures. (GRADE quality of evidence: BMD=Moderate; further research is likely to 

have an important impact on our confidence in the estimate of effect and may change the estimate; 

Fractures=Low; further research is very likely to have an important impact on our confidence in 

the estimate of effect and is likely to change the estimate.) 

KEY QUESTION #2: Are there any validated tools (outside of central bone density) to screen for 

osteoporosis in men? 

 The evidence for screening tools for men is much more limited than for women. We were only able 

to synthesize evidence on two screening tools: calcaneal ultrasound and the Osteoporosis Screening 

Tool (OST). 

 There is no evidence to suggest that calcaneal ultrasound performs differently in men than in 

women. (GRADE quality of evidence = Moderate; further research is likely to have an important 

impact on our confidence in the estimate of effect and may change the estimate.) 
HSR&D Evidence Synthesis Pilot Program – 

Screening Men for Osteoporosis: Who & How 3

 The OST appears to have comparable (and possibly better) test characteristics than calcaneal 

ultrasound in diagnosing DXA-determined osteoporosis. (GRADE quality of evidence = Low; 

further research is very likely to have an important impact on our confidence in the estimate of 

effect and is likely to change the estimate.) 

 Although calcaneal ultrasound does not appear to be a particularly good test at diagnosing DXAdetermined osteoporosis, it is a strong, independent predictor of fractures in men. (GRADE quality 

of evidence = Moderate; further research is likely to have an important impact on our confidence in 

the estimate of effect and may change the estimate.) 

 Limited data are available on other screening modalities and there is a large gap in our 

understanding of osteoporosis screening tests in men. 

KEY QUESTION #3: What values of BMD determined by DXA (and by different DXA 

techniques) have been used to diagnose osteopenia and osteoporosis; and what is the evidence 

regarding the relationship between differing definitions and the development of osteoporotic 

fractures? 

 The values of BMD determined by DXA that have been used are based on standard deviations (Tscore) away from a reference standard, either young female or young male. 

 Whether to use a young female or a young male reference range in order to identify men as “at 

risk” for osteoporotic fractures is an area of controversy that is not possible to resolve with existing 

data. 

 Until more definitive evidence is available, we believe it is most logically consistent for VA to use 

for the identification of men who might potentially benefit from treatment for osteoporosis the 

same conditions as were used in the randomized controlled trials (RCT), in other words use of the 

young male reference standard. (GRADE quality of evidence = Low; further research is very likely 

to have an important impact on our confidence in the estimate of effect and is likely to change the 

estimate.)