Book Review

The Osteoporosis Primer

N Engl J Med 2001; 344:615February 22, 2001

Article

The Osteoporosis Primer
Edited by Janet E. Henderson and David Goltzman. 372 pp., illustrated. New York, Cambridge University Press, 2000. $64.95. ISBN: 0-521-64446-1

As its title suggests, The Osteoporosis Primer aims to be an introductory textbook that relates the clinical presentation of osteoporosis to its biochemical basis. According to the preface, “It is aimed primarily at individuals who require an introduction to the domain of metabolic bone disease. This will include students considering a career related to metabolic bone disease, physicians in general practice, geriatricians, rheumatologists, and others.” To this end, the book is ambitious in targeting a very wide audience. It is organized into four sections, which cover the molecular basis of bone metabolism, the determinants of peak bone mass, the pathophysiology of the aging skeleton, and clinical aspects of osteoporosis. The chapters in each section are written by acknowledged experts, and in general the content and treatment are excellent. Each chapter therefore represents a useful component in a collection of reviews. In my view, the strength of this publication lies in the chapters themselves. Its weakness lies in the lack of cohesiveness of the entire book.

In an osteoporosis primer, one might expect to be gently taught the principles of the disease. In many of the chapters, particularly in the section on the molecular and cellular environment of bone, there is almost no reference to osteoporosis. I was left wondering about the role of endochondral bone formation, bone cells, and cytokines in osteoporosis and was reminded of my undergraduate training, when the relevance of anatomy, physiology, and biochemistry to clinical medicine was unclear. This problem is due in part to the order of the chapters. Some would argue that a knowledge of bone remodeling is essential for understanding the cellular and biochemical aspects of osteoporosis, but it is not until page 200, past the halfway mark in the book, that this becomes clear.

The authorship is drawn exclusively from North America, and a North American perspective is to be expected. This is most evident in the review of treatments for osteoporosis. Treatments that are commonly available outside North America are not mentioned. Important omissions include the calcitonins, steroid-like molecules (including tibolone), flavonoids, and vitamin K. The chapter on nongenetic determinants of peak bone mass persuades us that teenagers should be taking 1300 to 1500 mg of calcium daily, a view that is evangelical to all but North Americans. This leads me to observe that the level of evidence given in support of conclusions varies among the chapters. Uncertainties about the effects of hormone-replacement therapy on cardiovascular disease are critically reviewed, whereas exercise, smoking, and calcium intake are not reviewed with the same rigor. Finally, primary care physicians may notice important omissions. There is, for example, no discussion of the consequences of osteoporosis or its management, other than pharmaceutical intervention.

These criticisms arise largely because of the title of the book. This is not a primer on osteoporosis, but it does contain an excellent collection of reviews. It is not for the uninitiated but rather for those with incomplete knowledge of the field who wish to extend their breadth of interest. To this end, it is a very useful contribution to the literature.

John A. Kanis, M.D.
World Health Organisation Centre for Metabolic Bone Disease, Sheffield S10 2RX, United Kingdom