Osteoporosis: an Important Public Health Problem

Osteoporosis refers to a reduction in bone strength. The defining characteristics of a bone include its strength and quality. Osteoporosis can affect the strength, quality or both the characteristics. Osteoporosis is a major cause of pathological fractures in postmenopausal women and the elderly. Although earlier it was believed that it was an inevitable accompaniment of aging, recent data indicate that it is largely preventable.

Who Is at Risk?

Everybody does not develop osteoporosis. Certain populations are especially vulnerable to develop osteoporosis.

• These include females, postmenopausal women, people over 50 years of age and those having a positive family history of osteoporosis.

• Estrogen plays a protective role against the development of osteoporosis in women. This explains why postmenopausal women are at a greater risk for osteoporosis.

• Tall, slender and thin women also run the risk of developing osteoporosis.

• Women represent a vulnerable populace as they have a smaller peak bone mass as compared to men and they tend to lose bone mass more rapidly as they age.

• A diet lacking in vitamin D and calcium also make us prone to osteoporosis.

• Certain medications like Glucocorticoids, blood thinners like Heparin, immunosuppressants like Cyclosporine and anticonvulsants also increase the risk of osteoporosis.

• An inactive lifestyle, excessive smoking, and alcohol usage are additional risk factors.

• Medical conditions like hyperparathyroidism, malignancy, chronic renal and hepatic diseases, amenorrhea and early menopause are also important risk factors.

How Do I Know That I Have Osteoporosis?

Osteoporosis is a silent disease. Most often the individual is not aware of its existence until he suffers a fracture. These fractures occur with the slightest impact and happen during activities like bending, lifting weights, coughing or with other minor stresses. Hence, these fractures are called pathological fractures. This commonly results in the collapse of the spinal vertebrae. The presenting symptoms include severe back pain, a reduction in the height of a person due to the collapsed vertebrae and assumption of a stopped or hunched posture.

Investigations to Confirm Osteoporosis

Approach to the diagnosis should be holistic and comprehensive.

1. Other medical diagnoses which can act as contributory factors need to be ruled out. Physical examination is of vital importance.
2. An enquiry is made into the lifestyle habits and patterns of the individual. Family history is also ascertained.
3. Careful consideration is also given to the drugs that the individual might be taking. Enquiry is also made about the dietary patterns and falls or fractures sustained in the past. Apart from the usual blood and urine tests, an x-ray of the spine is ordered to rule out spinal deformities.
4. The gold standard investigation which confirms the diagnosis is the DEXA scan. It stands for dual energy x-ray absorptiometry which measures the bone mineral density. Minerals impart hardness to a bone and the bone mineral density is ascertained by a score known as the T-score. Specific cut-off values exist which confirm the diagnosis.

Treatment Options of Osteoporosis

• The primary goal in the treatment should be the prevention of fractures and falls.

• A comprehensive nutrition plan is put into place. This includes supplementation with calcium, vitamin D and vitamin K. Optimum calorie consumption is stressed upon.

• Medications aim to achieve one or more of the following goals. Reducing bone loss, increasing bone mineral density and ensuring new bone growth. After weighing the pros and cons, drugs that may be causing bone mineral loss will be stopped.

• Lifestyle changes include getting optimum exercise which ensures reduced age-related bone loss. Data have consistently shown that exercise also increases bone density. Quitting smoking and alcohol is highly beneficial.

• Prevention of falls is also vital. Doormats are used outside the bathroom to prevent falls. Outdoor and indoor canes may be used for additional support. Flooring that is least susceptible to cause slips and falls is encouraged, especially in the bathrooms.

Specific Interventions and Drugs for Osteoporosis

1. Bisphosphonates

These are medications that inhibit osteoclastic activity. Osteoclasts are cells that accelerate bone loss. Commonly used bisphosphonates include Alendronate, Pamidronate, Etidronate, Zoledronic acid, and Risedronate.

2. Parathormone Analogue

This is available in the form of an injection. The generic name of this analogue is Teriparatide. Usage beyond two years is not recommended. This is particularly employed in postmenopausal women and men who are at high risk for fractures.

3. Strontium Ranelate

This is a RANK ligand (RANKL) inhibitor and is beneficial in postmenopausal women.

4. SERMs

These are selective estrogen receptor modulators. These act as estrogen agonists in some tissues and block estrogen's effects in some other tissues. These are not estrogen preparations but they themselves have estrogen-like effects in certain tissues.

5. Calcitonin

This is involved in the metabolism of calcium. It also plays a part in bone metabolism. This is used in women who are at least five years postmenopausal.

6. Hormone Replacement Therapy (HRT)

This is used for both the prevention of osteoporosis in high-risk women and also to treat the hot flushes of menopause.

Emotional After-Effects of Osteoporosis

Osteoporosis comes with its fair share of emotional effects. Since mobility gets impaired, people feel disabled. This paves way for a host of negative mood states like anxiety, depression, panic, and phobia. It is vital to liaise with a mental health professional who will offer appropriate treatment to improve the overall quality of life. Such liaison also helps the patient to better cope with the crisis.

In summary, osteoporosis represents an important public health problem and the aphorism 'prevention is better than cure' sounds very apt in dealing with osteoporosis.

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