Dr M K Mam
Osteoporosis is one of the major public health problems worldwide and its prevalence is increasing. It is a systemic disorder of bones characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to enhanced bone fragility and consequent increase in fracture risk. The mechanical strength of bone is markedly reduced, making it vulnerable to fractures following a minor trauma. It occurs most commonly in elderly postmenopausal women, but men are also affected. The common belief among the people is that it is simply a component or the consequence of normal aging, which is not the truth and this could be one of the reasons that this problem has some or other remained neglected. It has now been realized that there is more to it than just the aging. It is a silent disease -so called a “silent thief” which slowly nibbles away at the bones and goes unnoticed for years until it is complicated by fractures that occur following a minimal trauma. Common sites of these fractures are the spine, hips and the wrist. These fractures especially the hip fractures are associated with lot of morbidity and mortality which puts an enormous financial burden not only to the affected person but to the family, society and the nation as a whole as the monetary costs associated with osteoporotic fractures are tremendous. These fractures also cause a lot of psychological and social problems thus affecting the quality of the life of the person. Prevention certainly is always better than cure and in order to start a prevention program it is essential that we identify those who are at greatest risk. Diagnosis of osteoporosis is based on bone mineral density (BMD) as assessed by dual energy x-ray absorptiometry (DEXA). DEXA of hip and spine is used to establish or confirm a diagnosis of osteoporosis. It tells us whether someone has a normal, low or osteoporotic bone density level and also indicates if someone is at increased risk of sustaining a fracture.
Who is at risk: We know there are some people who are more at risk than others of getting osteoporosis and sustaining a low trauma fracture. It can be due to many factors that cause or contribute to osteoporosis .It is pertinent to know the risk factors so that we can identify the people who are most likely to sustain a fracture in future. Factors that have been associated with an increased risk of osteoporosis are as under.
Genetics factors: Genetics plays an important role in the development of osteoporosis and it has been reported that about 75% of an individual’s peak bone mass is influenced by genetics. Well known old saying “as mother so daughter” very well applies to osteoporosis. A family history of an osteoporotic fracture in a first degree relative certainly indicates that genetics has a role in development of osteoporosis. Also there are many genetic syndromes which present with osteoporosis. Lot of research is going on and there has been lot of progress in identifying the genes responsible for osteoporosis.
Race: Osteoporosis affects all races and ethnicities, however certain races like Caucasians tend to have the lowest bone mass and are at a higher risk. Again hip fracture is more common in whites than non-whites.
Gender: Osteoporosis is more common in women than in men. Women have a greater risk of fracture than men and its incidence is two to three times more than that in men. Bone mineral density (BMD) is higher in men than in women. Further body size, bone size and width are more in men than in women.
Age: As we age our bones naturally lose some density and become weaker. Normally there is a balance in bone resorption and formation however after age of 35 or so resorption is greater as compared to formation. There occurs approximately 0.5-1% bone loss per year after the age of 30 years in women and with the onset of menopause this certainly increases.
Family history: Osteoporosis is also a familial disease. Studies show that if either of the parents had osteoporosis, then one is more likely to get it. Children of individuals with an osteoporotic fracture are more likely to have low BMD themselves. Again any person who has a family history of osteoporotic fracture in a first degree relative is certainly prone to getting osteoporosis.
Height -body frame: Persons with a small body frame are at a higher risk of having osteoporosis. It has been reported that women with hip fractures are taller than those without.
Life style factors: Inadequate physical activity: Inadequate physical activity is certainly one of the most important risk factors for osteoporosis. Bed rest, immobilization, and sedentary life styles certainly induce rapid bone loss.
Excessive alcohol intake: Risk of osteoporosis and fractures increases with excessive alcohol intake. There is evidence of correlation between chronic alcohol abuse and low bone mass.
Nutritional deficiency: Adequate nutrition is essential for the maintenance of the bone health. Any deficiency of minerals especially calcium, phosphorus and the vitamins especially vitamin D increases the risk. Patients with malabsorption or other intestinal diseases and chronic renal disease are at a high risk for vitamin D deficiency.
Inadequate exposure to sunlight: Vitamin D is naturally made by the skin through exposure to ultraviolet B radiations present in sun light. People somehow spend no or very minimal time outside in the sun and this results in vitamin D deficiency which predisposes to osteoporosis.
Educating the people and making them aware of the fact that osteoporosis is just not a part or consequence of aging but a disorder of bones which can be prevented, diagnosed and treated. Emphasis has to be on educating the people about the gravity of the problem– its effects on the individual and the society, risk factors involved and importance of their role in the prevention programme. We need to work on having a cost effective screening programme as there is evidence that screening is effective in identifying people with low bone mineral density and that treating them can reduce the risk of fractures. Also we need to increase the awareness of health care professionals to recognize those at risk.
To summarize, osteoporosis can be prevented by adapting an early bone healthy life style which includes regular lifelong participation in weight bearing and muscle strengthening exercises ,adequate intake of dietary calcium, vitamin D, proteins and stopping smoking and excess intake of alcohol. Prevention certainly has to start in childhood and has to continue throughout life.
(The author is a Senior Consultant Orthopaedics, Jammu, former Vice Principal, Prof. & Head Orthopaedics, CMC, Ludhiana)
Dr M K Mam