Osteoporosis: Bones of contention

In New Delhi, 36-year-old Dinesh Raheja, a chronic bronchial asthma patient undergoing steroid-based treatment, complained of severe backache. Investigations showed he was suffering from secondary hypoparathyroidism (a physiologic state in which the parathyroid hormones are low) with severe osteoporosis.

Osteoporosis—the thinning and weakening of the bones that leads to their breakage even with little force—is no longer just a woman’s problem that occurs around menopause. Neither is it any more an affliction of the elderly.

After the age of 30, everyone, as a natural course, begins to lose bone mass at the rate of 1% per year—women in their 40s at a higher rate because of the hormonal changes taking place in the body around menopause. But now “the silent thief", as osteoporosis is referred to, is finding younger victims—of both sexes—leaving them vulnerable to serious fractures and injuries.

And doctors stress that Indians, who have lower bone density than North Americans and Europeans, are at greater risk. Says Kaushal Malhan, knee and hip surgeon at the Wockhardt Hospital in New Delhi: “Osteoporosis fractures occur 10-20 years earlier in Indians as compared to Caucasians." Quoting data from the World Health Organization, orthopaedic surgeon S.K.S. Marya of Max Healthcare, New Delhi, says that one in every eight men and one in three women in India have osteoporosis.

The forecasts are ominous. Says Dr Malhan: “It is predicted that one in two women and one in eight men will suffer an osteoporosis-related fracture in their lifetime. Of these, 15-30%, will die of fracture complications. About 50% of these who survive will not walk independently and one third will be totally dependent functionally." What’s worse, osteoporosis can lead to severe dental problems as well.

Most doctors say that while old age or menopause-related osteoporosis is natural and inevitable (although with care, it can still be prevented), the trend of “non risk" groups developing brittle bones can be blamed on that old culprit—changed lifestyle and changing dietary habits. Not getting enough calcium, vitamin D and phosphorous contributes to bone thinning.

In addition, a tendency for lower bone mass may pass from parent to child. Apart from genetic factors, there are environmental factors and ethnic differences, too, that put one at risk.

Add to that, causes such as steroid-induced osteoporosis—asthma and cancer patients who have been subjected to steroid-based treatment are known to face bone loss.

Doctors also point out how due to various health fads that stress on avoiding dairy products, calcium intake is dipping. Also, cocooned in air-conditioned offices, vitamin D, created from sunlight, is absorbed in short measure. With fog and pollution acting as sunscreens, there’s even less access to sunlight. Not surprisingly, in India, a large number of middle-class people have relatively low vitamin D, so crucial for calcium absorption.

Although treatable with biphosphonates, physical therapy, dietary and lifestyle modifications, osteoporosis is a very painful condition and expensive to rehabilitate. As Dr Marya points out, it all depends on who is winning at the moment—the osteoclasts (which remove the calcium from the bone) or the osteoblasts (which deposit the calcium in the bone).

Pumping in calcium is one way of treating the problem, but to make the calcium stick to the bones and not get excreted, you need vitamin D. Often, oral supplementation is not sufficient and this is where biphosphonates come in. These are chemical compounds that prevent osteoclast activity. However, these are very costly medications and, as Dr Marya says, treatment of osteoporosis is temporary and you cannot hope to reverse it totally. At the most, severe cases can become moderate and moderate can become mild, he says.

So how can one prevent it?

Achieving a high peak bone mass is crucial—the higher the peak bone mass, the greater the bone loss needed to reach the osteoporosis risk threshold. So how can one achieve this? Says Bangalore-based orthopaedic consultant, Deepak Sharan: “There is strong evidence that physical activity early in life contributes to stronger bones and less likelihood of falls, even though exercises help the elderly, too." Dr Sharan recommends weight bearing or impact exercises such as jogging, brisk walking and stair climbing.

Doctors stress that it is important to get enough sunlight exposure and consume adequate vitamins, proteins and milk during childhood. Dr Marya also stresses how important it is for pregnant women to take enough calcium supplementation as it is the time when acute loss happens.

Getting a bone density test done is a good way of knowing the risk. Dr Sharan points out how countries such as the US, UK and Australia have national programmes providing for subsidized Bone Mass Measurement by DEXA Scan and treatment for high-risk groups.

In India, awareness levels about osteoporosis among the public and medical professionals are low. Although camps are held, testing techniques are often limited to X-rays and ultrasounds that don’t necessarily give the true picture. Compounding the problem is that osteoporosis often has no symptoms and one finds out only after breaking a bone.

Judicious calcium supplementation also helps. Says Dr Sharan: “The problem lies with half-baked information such as human gut is not designed to absorb milk and calcium supplements should not be taken because it is not absorbed and causes kidney stones." For women experiencing menopause, hormone replacement therapy (HRT) can prevent potential damage to the bones. Millions of women across the world use HRT for relief of menopausal symptoms, including vasomotor flushes and sweats. It’s also well established that oestrogen therapy protects the bone. But recent research linking HRT with increased risks of cancer is forcing a rethink on the subject. Says Dr Malhan: “There are difficulties in extrapolating the results from trials using a specific HRT product to advise women on the wide range of other hormone products, doses, combinations and routes of administration. However, in the absence of evidence that other products are safer, the data suggest that for many women, the risks associated with long-term use of HRT outweigh the benefits."

So all said and done, it’s good to bone up on calcium when you are still under 30 and exercise a lot as a good preventive measure.

BONE UP ON CALCIUM RESERVES

Calcium is the most abundant mineral in the human body. The average adult body contains in total approximately 1kg of calcium, 99% of which is in the skeleton and teeth in the form of calcium phosphate salts. But it is very difficult to make calcium sit on the bones. Here are some strategies to jog along calcium aborption in the body:

1) Get your fibre from fruit and vegetables

2) Minimize salt intake

3) Spend regular time in the sun, or supplement with vitamin D

4) Impact loading exercises such as jogging or a regular brisk walk

5) Ensure that your magnesium intake is adequate

6) Reduce your sugar intake

7) Avoid soft drinks

8) Cut down tea and coffee

9) Do not smoke

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