WHO has named 20th October as World Osteoporosis Day to reiterate the value of often poorly understood bone health.
Osteoporosis is the thinning and demineralisation of bone leadings to disruption of bone microstructure. This is a huge age related problem seen in one in every three females and one in every five males above the age of 50 yrs. Menopause accelerates the process in females.
Such is the magnitude of this problem that their number is larger than patients with stroke, heart attacks and breast cancer all put together in females alone. This is a silent disease process until it is evident in a bony fracture. Every fracture brings another fracture sooner. Such fractures reduces quality as well as length of life considerably.
Bone though apparently silent is a very active tissue metabolically .It is continuously being resorbed and freshly laid down known as remodelling. The peak bone mass (PBM) is generally seen in puberty .Slowly the rate of loss of bone mass overtakes rebuilding activity and therefore osteoporosis naturally sets in ageing population . However ,it can be modified considerably if we follow the recommendations such as avoiding sedentary habits ,regular exercise, healthy nutrition with enough calcium and protein from efficient sources, endocrine status monitoring and keeping vigil on drugs. Substances such as high daily steroids( > 7.5 mg prednisone) for over three months, use of diabetes drug thiozolidendione, anti acid drugs PPI or androgen deprivation drugs may speed up osteoporosis.
Extra salt intake ,smoking, alcohol abuse also speed up osteoporosis.
However ,excess vitamin A and excessively thin individual or careless dieting may accelerate osteoporosis.
Many diseases of Gastro intestinal tracts with poor absorption, kidney and liver diseases, series of systemic inflammatory - immunologically mediated diseases including that of musculoskeletal system add fuel to the fire as they weaken the body overall.
Diagnosis is not very difficult if we screen the individual with their background profile. Typically an ageing thin female over 50 years of age with past history of fracture is a most likely candidate for osteoporosis. However ,it’s not unusual to come across even middle aged men with osteoporosis in appropriate setting.
Vertebral fractures might occur even without trauma or fall and if so they are more sinister indicator of increasing osteoporosis and impending fracture of spine or other long bones. Extra bending forward (kyphosis) and loss of height in old people specially females are often seen in neglected cases due vertebral compression fractures. Occasionally restrictive lung disease may also present as its bony sequele .
A low body mass index ( BMI < 21 kg/ m2 ) in aged person suggests likelihood of future hip bone fracture and also doubles the risk for spinal fracture.
Prevention is the key, therefore high index of suspicion specially within the vulnerable group is must .
Every effort should be made to prevent the fall without making the person inactive. Ageing people with inadequate muscle strength and poor coordination abilities are likely to fall easily specially in poorly lit surroundings. Therefore extra care for old and debilitated is important.
Future risk assessment tools are available but few authentic normograms are there in our setting to be used for correct interpretation of such data in given geographical locality. BMD (Bone Mineral Density) testing ,Vertebral imaging with MRI and BTM (Biochemical Turnover Markers) for bony resorption and formation markers are available to specify the cause and extent.
How to treat?
prevention of osteoporosis is the most valuable intervention and is achieved easily by adopting a healthy life style which includes regular weight bearing exercise and walking daily for 30-40 minutes along with back and posture exercises on most days of the week and adequate protein intake. Children and young adult should achieve their peak bone age by leading active life in young age for future bone reserves .
Adequate amount of calcium and vitamin D is the cornerstone of maintaining positive bone health and prevention of osteoporosis.1200 mg of elemental calcium daily should be the dose for females above 50 years and for males above 65 yrs. Calcium carbonate is cheap and efficient source but they are a little gastric irritant to some, for those who don’t tolerate carbonate salt calcium citrate, although little expensive, may be better.
Vitamin D is very necessary for calcium absorption and also adds to muscle strength. 600-800 iu /day is the daily requirement which is available in fortified milk, salt water fish and liver meat in large amount. Two to three days in a week of sunlight exposure helps to produce enough vitamin D naturally .Those who are ill and taking some other drugs may need more. Alcohol and excessive caffeine increase the requirement.
Most of the treatment of severe osteoporosis and consequent fractures are treated with anti bone absorptive drugs such as oestrogen,biphosphonates (i.e. Zolendronic acid) selective oestrogen receptor modulators and recently new found human monoclonal antibody. Currently available anabolic agents including parathyroid hormone (PTH) increase laying down of bones thus helping the healing specially in difficult cases.
( Author is Former professor and Head RIMS,Jharkhand)