World Osteoporosis Day (WOD) is observed every year on 20th October worldwide and is dedicated to creating global awareness for osteoporosis prevention, diagnosis and treatment. This year 2022, the World Osteoporosis Day theme is “Step Up for Bone Health”, intending to encourage people around the world to check for bone density and bone health status regularly (especially people above 50) and inculcate healthy lifestyle to strengthen the bone health.

Osteoporosis is a bone disease when our body loses too much bone, makes too little bone, or both. Consequently, bones become weak and may break from falls or, in severe cases, from sneezing or minor bumps. Osteoporosis literally means “porous bone.” While healthy bone looks like a honeycomb when viewed under a microscope, the holes and spaces in the honeycomb in osteoporotic bone are much larger than in healthy bone. As one can’t feel bones weakening, osteoporosis is often called a silent disease. But there is an increased fracture risk because of decreased bone density or deteriorating bone quality. Breaking a bone (fracture) is often the first sign of osteoporosis; some may notice losing height and getting shorter, or their upper back is curving forward.

Osteoporotic bone fractures are most likely to occur in the hip, spine or wrist. Apart from pain, osteoporosis can cause some patients to lose height and often leads to a stooped or hunched posture. Osteoporosis limits mobility, often leading to feelings of isolation or depression. 20% of elderly who break a hip die within one year from complications related to the broken bone.

Globally, one out of three women and one out of five men aged 50 years and older will suffer an osteoporotic fracture. Because of osteoporosis, bones become weak and fragile, breaking easily. Even a minor fall, a sneeze, a bump, or a sudden movement can break an osteoporotic bone. Fractures due to osteoporosis can be life-threatening and a major cause of pain and long-term disability.

Throughout our life, mature bone tissue is resorbed (removed) from the skeleton by the Osteoclasts (cells that degrade bone), followed by the formation of new bone by Osteoblasts (bone-forming cells). This process, called ‘Bone remodelling,’ is a lifelong process that controls the reshaping or replacement of bone following fractures and micro-damage, which occurs during regular activity. In this process, almost 100% of the skeleton is replaced in the first year of life. In adults, remodelling proceeds at about 10% per year. In the regulation of bone remodelling, two sub-processes are involved, bone resorption and bone formation: an imbalance in the two results in many metabolic bone diseases, such as osteoporosis. If the bone formed is more than the bone resorbed, it leads to increased bone mass, as usually happens in young adults between the ages of 15 and 25. But if osteoclasts resorb more bone than that formed by osteoblasts, as generally occurs after age 35, bone mass starts declining. If this loss of bone mass occurs at a pathologically accelerated pace, more than what normally happens in older adults, it leads to osteoporosis.

WHAT ARE THE CAUSES OF OSTEOPOROSIS?

There are mainly two types of osteoporosis: primary and secondary. Primary osteoporosis is when bone loss occurs due to normal human ageing without apparent cause. Primary osteoporosis is the most common form of the disease and includes postmenopausal osteoporosis (type I) and senile osteoporosis (type II). Postmenopausal osteoporosis occurs exclusively in women after menopause. During the peri-menopausal transition period, there is a drop in estrogen (female hormone) levels which leads to more bone resorption than formation, resulting in osteoporosis. Senile osteoporosis, on the other hand, affects both men and women. Unlike postmenopausal osteoporosis, which occurs due to menopause in women, senile osteoporosis is due to ageing alone. It has become a worldwide bone disease with the ageing of the world population. It increases the risk of bone fracture and seriously affects human health in the elderly.

Secondary osteoporosis is when bone loss results from a specific, well-defined clinical disorder or medication. While Steroid medications can be lifesaving treatments for some conditions, they can also cause bone loss & osteoporosis. These drugs are often referred to as steroids, glucocorticoids or corticosteroids. Steroid-induced osteoporosis is the most common form of secondary osteoporosis and the first cause in young people. Bone loss and increased rate of fractures occur early after the initiation of corticosteroid therapy and are then related to dosage and treatment duration. Apart from steroids, drugs that can cause osteoporosis include heparin, warfarin, cyclosporine, aluminium-containing antacids, anti-seizure medications, cancer chemotherapeutic drugs, medroxyprogesterone, excess doses of thyroid hormone, etc. Many diseases can cause osteoporosis, including endocrine disorders like hyperthyroidism, hypogonadism, hypopituitarism, primary hyperparathyroidism, diabetes mellitus, eating disorders, growth hormone deficiency and acromegaly.

A fragility or low-trauma fracture is defined as a pathological fracture resulting from minimal trauma. Human bone is extraordinarily strong; ounce for ounce, bone is stronger than steel. So, a high force is required to fracture a normal bone. But an osteoporotic bone may fracture due to non-significant, low-impact trauma, such as a fall from a standing height or less.

WHAT IS THE RELATIONSHIP OF PREGNANCY WITH OSTEOPOROSIS?

Pregnancy and lactation can lead to osteoporosis in susceptible women called PLO (Pregnancy and Lactation Associated Osteoporosis). PLO is often discovered after a pregnant or breastfeeding woman develops severe back pain and an X-ray reveals multiple vertebral fractures.

The outward signs of osteoporosis (Back pain due to a fractured or collapsed vertebra, loss of height over time, easily broken bones, stooped posture/Dowager’s hump) combined with a patient’s gender and age are strong indicators of osteoporosis. However, while X-rays will show a broken bone, they won’t show osteoporosis unless there is a significant bone loss of 50% or more. Therefore, dual X-ray absorptiometry (DXA), a state-of-the-art technique for measuring bone mineral density (BMD) to calculate bone calcium, is used to diagnose osteoporosis.

WHAT IS A BMD TEST?

A BMD test measures your BMD and compares it to an established norm or standard to give you a score. Although no bone density test is 100% accurate, the BMD test is a significant predictor of whether a person will develop a fracture in the future. The DXA machine compares your BMD test results to the BMD of a healthy young adult and gives you an index called T-score. A T-score score of 0 means your BMD equals the norm for a healthy young adult, a score of more than 0 means your BMD is better than the norm, and a score below zero means your BMD is below the norm. A T-score between +1 and −1 is deemed normal or healthy. A T-score between −1 and −2.5 denotes that you have low bone mass, although not low enough to be diagnosed with osteoporosis. A T-score of −2.5 or lower means that you are having osteoporosis. The more negative number, the more severe the osteoporosis is.

SHOULD YOU GET YOUR BONE DENSITY CHECKED?

Most young, healthy people do not require a bone density test. But your risk for osteoporosis increases when you age because bone density tends to decrease as people grow older. That is especially true in women. So, a bone density test is recommended if you’re a woman 65 or older (70y for men), have lost height (a height loss of 1.5 inches or more signifies compression fractures in the spine), or have a history of fragility fracture.

CAN OSTEOPOROSIS AND FRACTURES BE PREVENTED?

Yes, osteoporosis and fractures can be prevented if action is taken early. Fractures due to osteoporosis devastate millions of people worldwide and result in enormous socio-economic costs to society and healthcare systems. Yet, despite practical medical advances to lessen fracture risk, only a minority of men and women take treatment. Hardly 20% of patients with osteoporotic fractures are diagnosed or treated for osteoporosis, the underlying disease. In 2010, some 12.3 million people at high risk for osteoporotic fractures were left untreated in Europe alone.

WHAT SHOULD I DO TO HAVE HEALTHY BONES AND A FRACTURE-FREE FUTURE?

There is much that individuals can do to promote their bone health, beginning in childhood and continuing into old age. These activities contribute to bone health and overall health and vitality. Five steps to healthy bones and a fracture-free future include: improving lifestyle, good nutrition, regular exercise, checking osteoporosis risk factors, and, if needed, bone density testing and treatment

1) EXERCISE. Regular exercise is the first step to keeping your bones and muscles moving. Weight-bearing, muscle-strengthening, and balance-training exercises are best. Weight-bearing exercises are also essential in stimulating new bone formation. Recommended guidelines for physical activity include at least 30 minutes daily for adults and 60 minutes for children. One should exercise 4-5 times a week and not break for more than two days at a stretch.

2) NUTRITION. Ensure that your diet is rich in bone-healthy nutrients, like calcium, vitamin D and protein, which are essential for bone health. You should have safe exposure to sunshine to help you get enough vitamin D. Vitamin D is crucial for strong bones and muscles. If there is no Vitamin D, our bodies cannot effectively absorb calcium, which is essential to good bone health. In addition, eat plenty of green leafy vegetables such as broccoli and spinach, which are good sources of vitamin K. Many studies have demonstrated that vitamin K can increase bone mineral density in osteoporotic people and reduce fracture rates.

3) LIFESTYLE. Maintain healthy body weight. Avoid negative lifestyle habits, avoiding smoking, alcohol and substance abuse.

4) RISK FACTORS. Find out whether you have risk factors. Seek your doctor’s attention to help you in this regard, especially if you have a family history of osteoporosis, have had a previous fracture or are taking specific medications that affect bone health.

5.) TESTING & TREATMENT. Get tested and treated if needed. 

If you have already developed osteoporosis or a history of a stress fracture, lifestyle measures like dietary measures and exercise alone are not enough to cure it. If you’re at high risk, you will likely need medication and lifestyle changes to help protect yourself against fractures.

CARRY HOME MESSAGE ON WOD 2022

Step Up for Your Bone Health:

1) Get enough calcium & vitamin D and eat a well-balanced diet.

3) Eat foods that are good for bone health, such as fruits & vegetables.

4) Avoid smoking and substance abuse.

Dr Shariq Masoodi, Professor, Department of Endocrinology SKIMS Srinagar

Disclaimer: The views and opinions expressed in this article are the personal opinions of the author.

The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.