Osteoporosis literally means porous bones. Bones are made of a meshwork of osteocytes or bone cells. The more spaced out this mesh is, the more porous and weaker the bone is. It is; as a result, more prone to breaking. In osteoporosis, density and quality of bones decreases. This makes them fragile and more prone to fracture, often as a result of minimal or no external impact.
Incidence and Symptoms:
Globally, 1 in 3 women and 1 in 5 men, over the age of 50 are likely to suffer fracture because of Osteoporosis. 25 million Indians are affected by this condition. However, most may not even be aware. This is because of the asymptomatic nature of the disease. The condition; in most cases goes undiagnosed till a fracture occurs as there are no manifestations. Once a fracture occurs; the condition progresses exponentially, with each subsequent fracture. Each fracture increases the risk of another fracture and further speeds up bone loss. This is called ‘Cascade effect’.
Bones of the hip, wrist and spine are most vulnerable. Spinal fractures can; by far, be the most painful and debilitating.
Besides age, the following factors are known to heighten risk of Osteoporosis:
The Bone is a living breathing tissue:
The bone as a tissue is in constant flux. Older bone cells are removed and newer ones are formed. Hence, diet should contain appropriate amount of Calcium. Also necessary is vitamin D3 without which calcium cannot be absorbed. Calcium is also required in comparatively miniscule amounts by other parts of the body. This may be taken from bones and excess deposited back. For such constant turnover a diet should contain both macronutrients (proteins, carbohydrates and fats and micronutrients (vitamins and minerals).
As the body ages, bone turnover also slows down and bone mass decreases weakening the bones. The critical years of developing bone mass are during childhood and adolescence. During these years, the rate of bone formation outpaces the rate of bone degradation. Hence, bones become larger and stronger. A peak is achieved around the mid-twenties after which bone mass gradually decreases. By the time a person crosses 40 and is approaching 60, the presence of one or more of afore mentioned risk factors synergistically speeds up bone loss and leads to osteoporosis. The more bone mass and density is build up during the formative years, the more the onset of osteoporosis can be delayed.
Age Group – Calcium (mg/day)
0 to 6 months – 300-400
7 to 12 months – 400
1 to 3 years – 500
4 to 6 years – 600
7 to 9 years – 700
10 to 18 years – 1300
Women: 19 to Menopause/ Men: 19-65 – 1000
Women: Post Menopause/ Men 65+ years – 1300
Pregnancy – 1200
Lactation – 1000
Apart from Seafood and fish which are the richest sources of Calcium, milk and other dairy products and Soya are good vegetarian options. Many Indians are vegetarian and consumption of dairy products is heavy. Due to the presence of high amount of fat in dairy products, low fat milk or Soya milk would be a better option, especially for those already having high cholesterol. There are now growing arguments against the merit of supplements. Natural sources; as far as possible should be relied upon.
Vitamin D which works more like a hormone helps assimilation of Calcium. The few dietary sources of Vitamin D include fish liver oil and egg yolk and dairy products. An intake of 1000 IU/ day (International Units) is now believed to be necessary. Cod liver oil is the only dietary source that can be sufficient.
Sunlight exposure of 30 minutes early in the day is recommended. Sunlight passing through glass is not effective. In western countries food is fortified with vitamin D3. Not so in India. In addition, we require a larger does of the vitamin due to our pigmentation. Older people require more exposure. However, younger people are also leading increasingly sedentary lifestyles due to the nature of jobs. In the absence of sufficient Vitamin D, even a calcium rich diet won’t promote bone health.
Avoid caffeine, sodium-rich foods (meaning excessively salty foods), carbonated drinks and alcohol as they leach out calcium from the body. Smoking; especially in women, can be very damaging coupled with an early menopause.
Exercise is important for good bone health. Any physical activity which puts extra strain on the skeleton such as an outdoor sport or some form of exercise stimulates bones and muscles to become stronger. In the absence of such stimulus, bones and skeletons become progressively weak as no signal is sent indicating need to be stronger.
Weight resistance training; thoroughly discussed in previous features and activities like jogging and dancing can go a long way in strengthening bones and improving overall health.
Off course, with age and other constraints, the nature and type physical activities one can undertake may vary. If one is already osteoporotic or arthritic, low to moderate intensity exercise after consulting a physician are strongly advised. But the important thing is to stay active. One may find innovative ways of doing this like not taking the elevator on your way up or walking the short distance to work back home instead of taking a taxi.
All this talk of prevention being better need not discourage the more senior among our readers. Adopting the right diet and exercise at any stage of life is recommended. For people over 30, it slows down bone loss. For people who have already suffered a fracture, it speeds up recovery.
Managing the Condition:
Definitive diagnosis is now routinely done by a bone densitometry test. For osteoporosis to be detected by X-ray, much bone loss would have had to take place; the disease having progressed much further. Hence, densitometry is the preferred tool. Bone density is compared to that of a healthy 25 year old. If it is more than 2.5 times less than that of a healthy 25 year old, osteoporosis is diagnosed. If it is between 1 and 2.5, it is deemed osteopenia; i.e., increased risk but not severe osteoporosis. The extremely high cost of such test ought to give added impetus; if nothing else, to adopt a healthier lifestyle. Besides diagnosis, density scans are also used to monitor risk areas of the skeleton and improvement, if any. Risk assessment beyond the measured the values, judged from the routine of the person and his general health is also very important.
Treatment aims first at stopping loss of bone mass and if possible improving the density. Drugs include anti-resorptive agents that slow break down of bone and anabolic agents that promote formation of new bone. The condition; off course, is chronic. Medications need to be taken continuously since bone loss recurs as soon as they are stopped.
Injectibles that only need to be given once in 6 months or even a year are slowly finding adoption. Hormonal replacement therapy is employed in cases of Menopause. Painkillers which have to be prescribed after every successive fracture would further worsen the dependence on analgesics.
Preventing falls is of high importance. Hip fractures which are the most common are the most debilitating. There is a definite increase in mortality after a debilitating fall of this nature as mobility is lost and host of other complications follow.
Following things can be done to prevent falls:
The Silent Epidemic:
In women over 45, osteoporotic fractures are the leading causes of hospitalization. Women, who have suffered a spinal fracture, are 4 times more likely of sustaining a subsequent fracture in the next year. As the condition progresses, bones may become so weak that even strain and movements that would otherwise be routine may cause fracture. General muscle weakness also adds to loss of mobility and erodes quality of life. The silent nature of the disease means there is a huge undetected population with osteoporosis and hence at increased risk of fractures. The toll on workforce and quality of life worldwide can only be estimated.
The medication available is to be taken in long courses raising concerns of side effects and can at best reduce risk of fractures by 50%. Adopting a better lifestyle in terms of diet and exercise is thus the best option.
These changes should not be treated as a regimen of compulsion but as ways of improving overall quality of life for you and your loved ones.
Health of women in our country is still neglected and women are conditioned to neglect it themselves since their formative years. In addition to ignorance about diet and exercise, women spend most of their lives indoors and engaged in domestic chores that are ergonomically criminal!
So we urge the women who are hip enough to be reading this feature to spread the word and the men to urge their wives and mothers to take that calcium supplement and keep cleaning that dangerously high curtain railing for another day.
Punit G. Pania
‘Fix it before it breaks’
-Indian Society for Bone and Mineral Research (ISBMR)