It is certainly a matter of grave concern when 1 out of 2 adult Indians have osteopenia (low bone density, a precursor of osteoporosis) and 1 out of 5 have osteoporosis.
On the occasion of World Osteoporosis Day, let us target the most modifiable risk factor, i.e. ignorance about the silent bone disease, to create awareness.
So, what is osteoporosis?
A healthy bone has small holes and spaces. However, as in the case of osteoporosis, the holes and spaces in the bone structure become wider. They lose their density, because of which they become susceptible to breakage. The outside of the bone structure also becomes weaker, thinner, fragile and brittle.
So, put simply, osteoporosis is a bone disease. The literal meaning of osteoporosis is ‘porous bone.’ It is a condition wherein the bones weaken and lose their strength, become thinner and vulnerable to breakage, which is why people with osteoporosis are at an exponentially higher risk of having fractures.
Why should bone health be a matter of significance all throughout the lifespan?
Bone is a dynamic living tissue wherein old bone tissues are broken down and replaced by new bone tissues. This is known as bone remodeling.
Upto 30 years of age, our body naturally builds more bone tissue than we lose and that is how our bone mass increases. By 30 years of age, most of us would have attained our peak bone mass, which is the amount of bone tissue present at the end of skeletal maturation.
Although ethnicity and genes also determine the peak bone mass we can attain, this highlights the importance of building up good reserves by eating a balanced diet and engaging in regular physical activity right from childhood days.
From the 30s onwards, gradually bone mass production slows down, while bone destruction increases its pace. This results in gradual bone mass loss, which is slower in men than women.
The pace of bone density loss picks up even more in women when they are close to reaching menopause. However, by 65 years of age, men and women lose bone mass at the same rate.
Though osteoporosis is more common in women, especially postmenopausal and elderly, osteopenia is common in males and younger adults in India.
Which are the most common sites of osteoporotic fracture?
While osteoporosis can break any bone, the site of the most common osteoporotic fractures include;
- Wrist
- Hip
- Spine (vertebrae)
- Distal arm
- Ribs
What can osteoporosis lead to?
It is needless to say that osteoporosis leads to a negative quality of life. It is a lifelong condition.
A fracture or bone breakage, particularly of the hip or spine, is the most gruesome consequence of osteoporosis. It leads to immobility and even confinement to bed, which gives birth to a host of other problems.
There is an increased risk of death within the first year after the injury.
Age, general health, location of fracture and how severe it is will determine how quickly one will heal from a fracture from osteoporosis. Then, people with osteoporosis take longer than usual to heal from bone fractures.
Psychologically speaking, it may also lead to a feeling of isolation and even depression in some cases.
What are the risk factors of osteoporosis?
When we talk of risk factors that predispose us to osteoporosis, we segregate them into two major categories; the non-modifiable risk factors, over which we have no control and the modifiable risk factors, which can be taken care of, because they are usually lifestyle oriented, to reduce our susceptibility to osteoporosis.
What are the non-modifiable risk factors?
- The older one gets, it increases the likelihood of osteoporosis
- Older adults aged 65 or more
- Female gender
- Family history of osteoporosis
- A bone fracture after 50 years of age
- Early or premature menopause
- Post-menopausal women (a fall in estrogen levels accelerates bone mass decline)
- Non-Hispanic White women and Asian women
- Non-Hispanic White men
- Certain medical conditions and their concurrent medications and medical procedures that reduce the absorption of calcium in the intestine (do not stop any treatment, or change or stop any medication yourself to prevent osteoporosis)
What are the modifiable risk factors?
- Poor chronic dietary intake of calcium
- Poor chronic dietary intake of protein
- Poor vitamin D status
- High sodium intake (through salt and other sodium rich foods)
- Undernourished with body mass index <18.5. (Body weight of 60 kg and a height of 155 cm may significantly increase the risk of osteoporosis in women).
- Sedentary lifestyle with little to no physical activity
- Smoking cigarettes and using other tobacco products
- History of alcohol abuse
- Consumption of soft drinks containing phosphoric acid
- Unawareness about osteoporosis and bone health
If you have any of the above risk factors, both, non-modifiable and modifiable, talk to your doctor for screening for bone density and ask what you can do to keep your bones healthy.
What signs and symptoms should I watch out for?
Osteoporosis is known as the silent bone disease because there are usually no symptoms of bone weakening. There are no apparent signs of it until one breaks a bone or goes for a bone density test. However, there are some indications that should ring a warning bell;
- Your grip strength is weak
- Your height measurement during physical examination may turn out to be lesser than your reported height. A loss of about an inch or more (due to a compression in the spine) should make you take an appointment with an orthopedic doctor at the earliest.
- Your loved ones will notice a change in your natural posture that results in a curved or arched back wherein you stoop forward.
- You suffer from shortness of breath (which can occur due to compression fracture that may lead to reduced lung capacity)
- Lower back pain and neck pain (the weak spine bones can develop tiny cracks even under the normal pressure. This leads to vertical collapse of spine bones, making the vertebrae shorter, which can lead to back pain or neck pain)
- If a minor injury or a routine activity has led to a bone fracture although it shouldn’t have in the first place (in severe osteoporosis, even a mild bump, or routine activities like walking, lifting light load, coughing or sneezing can lead to a bone fracture).
How is osteoporosis diagnosed?
A routine diagnosis of osteoporosis requires one to undergo a bone density scan/test known as densitometry or dual energy X-ray absorptiometry (DEXA). Prior to that, your medical history will be taken, along with a physical examination and a routine blood work will be conducted, especially with the inclusion of vitamin D status assessment.
Medical history
Among several important factors, your doctor will certainly ask you regarding;
- Age
- General health
- Previous fractures
- Family history of osteoporosis
- Lifestyle habits (diet, smoking, tobacco usage, alcohol, physical activity)
- Menstrual history (in case of women)
- Current and past medications
- Medical procedures you may have undergone
Physical examination
- Height measurement
- Balance and gait assessment
- Posture
- Muscle strength
Routine blood work
This is done to check your overall biochemical health status which will also include vitamin D, which aids in the absorption of calcium. Since calcium balance is very intricately maintained in the human body, routine blood value of calcium will not depict the correct bone density status.
Bone density test
Dual energy X ray absorptiometry (DEXA) is an imaging test that uses x-rays (under minimal radiation) that help to accurately diagnose the bone density status. It measures the density of calcium and other minerals in the bones at any point in the body. Still, it is usually used to measure bone density in the lower back (lumbar spine), hip (near the hip joint) and femoral neck (at the top of the thighbone or femur) and wrist.
It is like a routine x-ray procedure. It takes only 10-15 minutes to conduct.
The test will generate two scores, known as a T-score.
- One will compare your bone density to that of a healthy young adult
- The second score will compare your bone density to that of those of the same age, gender and ethnic background
The higher the score, the denser the bones.
As per the World Health Organization;
- T score is -1 or greater – Your bone density is normal
- T score is between -1 and -2.5 – You have low bone density, which is known as osteopenia
- T score is -2.5 or less: You have osteoporosis regardless of whether you have sustained a fracture or not.
A DEXA scan can also predict the future risk of fracture and also assess how well you are responding to the treatment of osteoporosis.
How can I prevent osteoporosis?
It is advisable to take prophylactic measures to prevent bone loss. Lifestyle changes form the core of good bone health.
- Throughout the life span, it is necessary to consume a balanced diet with all the macro and micronutrients in recommended amounts. Staying away from fad diets and eating disorders is a must.
- Maintaining a good calcium status helps to keep the bones strong and slow down the bone loss. Please note that calcium intake even in desired amounts cannot completely prevent bone loss. As we age, our ability to absorb calcium reduces. Should our diet be inadequate in calcium, the calcium will leach from the bones and thus reduce the bone mass.
- Adolescents, adult men and women need 1000 mg of calcium per day, while lactating women need 1200mg/day. Infants need 300mg/day, 1-3 years old need 500mg/day, 4-6 years old need 550mg day/ 7-9 years old need 650 mg per day, and 19-12 years old need 850mg/day of calcium.
- Foods rich in calcium include dairy products, green leafy vegetables (barring spinach), pulses and legumes, beans, nuts, seeds, broccoli, tofu, salmon, fortified plant milk, fortified breakfast cereals among others. The bioavailability (how much gets absorbed out of what we eat) of calcium is higher from dairy sources than the non-dairy ones.
- Vitamin D is both a nutrient we eat and a hormone our bodies make. It is a fat-soluble vitamin that has long been known to help the body absorb and retain calcium and phosphorus, thus significant for bone health.
- Taking vitamin D in appropriate amounts aids in the absorption of calcium from the intestine. Adult men and women in India need 600 IU per day, and so do the children and children aged less than 1 (infants), need 400 IU of vitamin D per day.
- Take the sunshine vitamin for atleast 15 minutes every day between 10am to 3 pm should you be light-skinned. In those who have more melanin, you might need to spend more time to get your share of vitamin D from the sun.
- If you remain confined to home or at work and cannot step out to take your vitamin D naturally, then please reach out to your doctor to ask whether you might need a supplement.
- Best sources of vitamin D in the diet include; fatty fish, cod liver oil, fish liver oils, salmon, tuna fish, sardines. Small amounts are found in egg yolks, cheese, mushrooms exposed to UVB. Foods fortified with vitamin D include breakfast cereals, orange juice, dairy or non-dairy milk and their products. Read the nutrition label to check the ingredients and values.
- Please be cautious of the fact that you are not supposed to consume either calcium or vitamin D supplements or any bone health supplement until and unless they have been prescribed by a doctor or a nutritionist, upon diagnosis of deficiency, or should your health condition warrant their usage.
- Maintaining adequate protein intake is necessary as protein is what gives the bone its structure. The emphasis has to be on consuming lean protein, eggs, pulses and legumes, nuts and seeds, plant milk and their products or dairy products in recommended amounts.
- Magnesium helps to signal and direct the calcium towards the bone. Foods rich in magnesium include whole grains, nuts, seeds, green leafy vegetables, and beans.
- Foods rich in zinc help to promote the formation of osteoblasts, the new bone tissue producing cells and prevent breakdown of bone. Legumes, nuts, seeds, meat, eggs, and whole grains are good sources of zinc in the diet.
- Vitamin K helps to increase bone mineral density and reduce the risk of fractures. Foods rich in vitamin K include the dark green leafy vegetables.
- Taking vitamin C, the antioxidant, in appropriate amounts through food helps to protect the bone cells from damage by fighting off the free radicals. Rich sources of vitamin C in the diet include; oranges, guava, Indian gooseberry, papaya, kinu, mausambi, malta, bell peppers, cabbage, and cauliflower among others.
- Engage in weight-bearing exercises such as walking and stair climbing among others on most days of the week. These activities strengthen the bones and improve balance and coordination without putting too much stress on the bones. Infact, they push and pull the muscles against the bones which signal the cells (osteoblasts) to produce new bone tissue. It is advisable to talk to your doctor first before beginning any new exercise regime.
- Watch your consumption of soft drinks containing phosphoric acid and caffeine.
- Drink caffeine-containing beverages in moderation.
- Restrict your salt intake to no more than a teaspoon a day if you have normal blood pressure and ½ teaspoon if you have hypertension.
- The easiest way to avoid excess salt and sodium consumption in the diet is to stay off ready-to-eat and processed food, bread, pickles, pickled vegetables, papad, sun dried food, food preserved in brine, soya sauce, ketchup, cured meat, cold cuts, salted chips, salted nuts, bakery goods, cheese and foods containing cheese.
- Quit tobacco in any form
- Abstain from alcohol
How is osteoporosis treated?
Diagnosis of osteopenia, the precursor of osteoporosis, a state of low bone mass density opens the window of opportunity to prevent osteoporosis. The bones are certainly not normal but not as badly damaged and weak as in case of osteoporosis. Leaving osteopenia untreated can lead to osteoporosis. Osteoporosis can worsen without treatment, with the bones becoming thinner or weaker.
The prognosis of osteoporosis is good if it is detected and treated early.
Osteoporosis is a lifelong or a chronic condition once diagnosed. There is no cure for it. But appropriate treatment helps in improving the bone mass that decreases the risk of future fractures. Infact, treatment works better if the root cause is identified and corrected. That said, the bone mass can never return to normal even with treatment.
You will need regular appointments with your orthopedic doctor and also bone mass density scans.
The treatment of osteoporosis is aimed at slowing down, stopping and preventing further bone mass loss with concurrent bone mass improvement.
In addition to all of the above rules that apply for the prevention of osteoporosis, you will be put on appropriate medications, asked to prevent falls and avoid any activity that would predispose you to a fracture.
Your doctor will most likely put you on a calcium supplement with vitamin D, after taking into account your T score, calcium intake and vitamin D status. Please bear in mind that you are not supposed to overdo the supplements and only consume them in prescribed amounts. Your diet and supplements together should never cross the 2000mg calcium per day threshold otherwise it may predispose you to the risk of developing kidney stones.
Disclaimer: The information shared in the blog is aimed at increasing your awareness and is not a substitute for professional medical advice.
To consult Dr. Roy for a personalized nutrition plan, register here or write to her at info@nafldnutrition.in
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