To the Editor: I read with great interest the article by Mir Sadat Ali, et al “Osteoporosis Among Male Saudi Arabs: Pilot Study” published in November–December 2006 issue of the Annals of Saudi Medicine. I have few concerns about some aspects of this article.
Firstly, issues with the sample, being too small, the subjects were recruited from one geographic area, which is not a true representation of the “male Saudi Arab”. An example of this concern is the fact that the Eastern province is known to have a higher incidence of sickle cell disease, which can give low bone mass and be a potential cause of bias. Moreover, the subjects were “male attending outpatient orthopedic and internal medicine clinic”. That means this is a hospital-based population utilizing “sick” patients to represent a healthy population. This might be accepted in some situations in which the variable is not affected by the health status of the subjects studied, which is not the case in this study. BMD can be significantly affected by other diseases these patients might have, or even by their ambulatory status which might be jeopardized by their diseases.
Secondly, the work-up mentioned did not include 25-hydroxy-vitamin D. Hypovitaminosis D is common in Saudi Arabia and might lead to low bone mass, which is frequently misinterpreted as osteoporosis. Another important cause of secondary osteoporosis is primary idiopathic hypercalcuria. I could not find any effort to detect this entity in the article.
Thirdly, there are a couple of actual DNA scans of the lumbar spine shown in the article, while no scans are shown for the femoral neck. We need to see an example of the femoral neck scan to ensure the appropriate technique.