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Raloxifene belongs to the group of selective estrogen receptor modulators (SERMs). It interacts with both estrogen receptor alpha and beta, but the postreceptor responses differ from those of estrogens. Raloxifene exerts tissue specific responses that differ from estrogens. The drug increases bone mass by 2-3% and inhibits the risk of subsequent vertebral fractures by 30-50%. Raloxifene reduces the risk of breast cancer by 76% after treatment for four years and builds an atrophic endometrium without any bleedings. Furthermore, the risk of endometrial cancer is not increased. The drug exerts positive effects on plasma lipids, but the effects of these changes on subsequent risk of myocardial infarction and cardiovascular death are still unknown. The main side effects are leg cramps, increases in hot flushes and peripheral oedema. Like estrogen, the drug increases the relative risk for venous thrombosis by a factor three.

Vitamin D is an important regulator of calcium homeostasis in the body and it plays an essential role in bone metabolism. 1,25(OH)2D (calcitriol), the active metabolite of vitamin D stimulates intestinal calcium and phosphate absorption, thereby maintaining sufficient concentrations of these ions in the extracellular fluids, necessary for normal mineralization of bone matrix. Furthermore, calcitriol exerts a number of important functions in regulating bone metabolism. Similar to other classical steroid hormones, calcitriol regulates the transcription of a large number of target genes. A large number of recent studies of the mechanisms of genomic actions of calcitriol have been published. The aim of this review is to give a summary of these recent findings. The interaction between calcitriol and the vitamin D receptor as well as receptor structure and function in relation to transcriptional regulation are discussed.

On the basis of five cases the typical clinical picture of patients with severe vitamin D deficiency is presented. The diagnosis can easily be mistaken and it is not uncommon that rheumatic or malignant diseases are suspected instead. By using a simple screening blood test consisting of 25-OH-vitamin D, PTH and alkaline phosphatase most cases will be diagnosed correctly. Important risk factors are reviewed, the most important being: elderly > 70 years, persons with low exposure to direct sunlight, gastrointestinal diseases and persons in anti-convulsive treatment. A treatment regimen consisting of oral supplementation of 1000-1500 mg calcium + 1000 IU vitamin D to patients with an isolated low 25-OH-vitamin D (< 20 nmol/l) is recommended. If the patient also has raised values of PTH or alkaline phosphatase an intramuscular dose of 100,000 IU ergocalciferol pr week for one month is given.

Three hundred and seventy-four general practitioners (GPs) in Denmark filled in a questionnaire on practices regarding prevention of coronary heart disease (CHD), cancer, osteoporosis, and overweight/underweight. Half of the GPs were questioned about the issue of prevention based upon female case stories and the other half on male case stories with identical wording. The GPs more often in relation to: Prevention of CHD gave dietary counselling and recommended weight loss to slightly overweight male than female patients. Prevention of cancers gave dietary counselling and recommended weight loss and increase of exercise to female than to male patients. Prevention of osteoporosis recommended a supplement of calcium and vitamin D to female than to male patients. Treatment of underweight recommended weight gain and discussion of psycho-social issues to underweight female than male patients. In conclusion, GPs distinguish between men and women in relation to prevention strategies in general practice. There is a need for well-described prevention and action strategies with relevant gender differentiation for use in general practice.

Three hundred and seventy-four general practitioners (GPs) in Denmark filled in a questionnaire on attitudes to include information on gender and diet in the strategy for prevention of coronary heart disease, cancer, osteoporosis, and overweight/underweight. Risk factors for disease in general were ranked as follows: smoking, alcohol, stress, diet, physical exercise, heredity and hygiene. The patients' lack of motivation, insufficient time for each patient, and inadequate knowledge about nutrition were stated as barriers to dietary counselling. The GPs stated that the gender of the patient was important only to the counselling on osteoporosis. Lack of time and insufficient knowledge were perceived as barriers for including gender specific issues in prevention. It is concluded that GPs consider dietary counselling important but lack time and knowledge. The results point at a need for better pre- and postgraduate training in nutrition, and for a better reimbursement system for time spent on prevention.

This article reviews the pathogenesis of glucocorticoid-induced osteopenia (GIO). GIO is a result of direct and indirect mechanisms leading to: 1) decreased intestinal calcium absorption, 2) decreased renal calcium reabsorption, 3) increased osteoclast activity with increased bone resorption, 4) decreased osteoclast activity with decreased bone formation. The mainly osteoclast activity is raised on the basis of secondary hyperparathyroidism. The different possible treatments in order to prevent GIO are reviewed on the basis of the results of the most important studies about the subject. We conclude that before a secure recommendation about prophylactic treatment can be made more prospective studies with fracture incidence as a measure should be made. However, on the basis of the studies that have already been made, it seems rational to give patients in longterm glucocorticoid treatment a calcium supplement of 0.5-1 g/day either in tablet form or by changing the diet, combined with a vitamin-D supply: either ergocalciferol 600-800 IU/day (e.g. in the form of 2 multivitamin tabs/day) or calcitriol 0.5 microgram/day.

A so-called osteoporosis-profile has become increasingly popular among Danish doctors. Future bone loss in peri- and postmenopausal women is estimated by means of an algorithm comprising serum osteocalcin and alkaline phosphatases as markers of bone formation and urinary calcium and hydroxyproline excretions, corrected for creatinine, as markers of bone resorption. The osteoporosis-profile, performed by Medi-Lab, was tested in six females aged 46-56 years. Three different diets were used on three successive week-ends, each ending with a collagen-free supper and an overnight fast. Individual changes in estimated bone loss of up to 200-300% were found, demonstrating that the test was useless in a single person.