Mend the Creak

Dr Ambrish Mithal is chairman and head, Endocrinology and Diabetes Division at Medanta, The Medicity, Gurgaon
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Preventive measures can fend off an impending osteoporosis epidemic

LAST WEEK, I received a frantic call from a lady telling me that her frail 70-year-old mother (who I was treating for diabetes) tripped on a rug next to the bed and was unable to get up. She was taken to the nearest hospital. The next morning, I got a call confirming my worst fear: she had fractured her hip bone. The daughter was told her mother had osteoporosis and required surgery. The fall, she said, was not really on a hard floor, and not from a height; so why did her bone break?

This is what happens in osteoporosis, which means ‘porous bones’—sieve-like bones that break with minimal injury. Typically, it does not pain till a bone breaks. Our skeleton provides a frame for our body and protection for the organs within, much like the metal beams and girders that support buildings. Like metal, bones also suffer wear and tear. Unlike metal, however, bones are living tissues and have a remarkable capacity to regenerate and heal. Sites of minor damage are constantly replaced by new, healthy bones. When the capacity of the body to form new bones is unable to keep up with bone loss, there is progressive weakening, resulting in osteoporosis.

During childhood and adolescence, our skeleton grows rapidly. Enabled by vitamin D, the skeleton builds its calcium stores, particularly during puberty. In girls, the bone tissue accumulated during the ages of 11 to 13 approximately equals the amount lost during 30 years following menopause. Boys have bigger bones than girls and accumulate more mineral over a longer period of time. From the age of 30, we begin to lose bone gradually, a process that is accelerated at menopause in women. If left unchecked, this loss gradually weakens the bones, making them brittle and resulting in fractures, typically in those aged over 65. Attainment of a higher bone mass during adolescence with calcium, protein, vitamin D and exercise is critical to prevention of fractures later on. Osteoporosis is sometimes called a ‘paediatric disease with geriatric consequences’. Typically, fractures due to osteoporosis occur at the hip, spine or wrist and can have a life-changing impact.

Globally, one in three women and one in five men are at risk of suffering an osteoporotic fracture. Genetics plays an important role. Maternal history of hip fracture is a powerful predictor of osteoporosis, which has assumed epidemic proportions in economically developed countries with large elderly populations. Coupled with longevity, lifestyle changes promote the development of this condition, critical among which is a decline in physical activity. Greater time spent indoors means a low vitamin D level, which is essential for calcium absorption. Smoking, excess intake of alcohol and caffeinated products, indiscriminate use of ‘steroid’ medications and lower consumption of antioxidant-containing fruits and vegetables are other factors.

India is a country of more than 1.2 billion people undergoing a rapid economic transition. While the proportion of elderly in India (about 10 per cent) is lower than in well off countries like Japan, where the average life span is 84 years (versus 67 for India), the sheer numbers in India make the country vulnerable to the epidemic, according to the International Osteoporosis Foundation, Asia-Pacific Audit, 2013. Poor protein and calcium intake could also have a role in increasing osteoporosis risk.

Coming back to our patient. What does diabetes have to do with osteoporosis? Uncontrolled diabetes has a long-term impact on our organs—eyes, kidneys, nerves, heart and others. Recent studies indicate that bones are not spared by this ‘sweetness’ either. People with type 2 diabetes have a 70 per cent greater risk of fractures, even with preserved bone density. The exact mechanism is under rigorous study, but we know 40 per cent of Indians living in metros have diabetes at the age of 60.

There is a lot we can do to protect ourselves. Appropriate lifestyle changes can reduce fracture risk vastly. If over 50, ensure intake of 1,000 mg calcium and 1,000-2,000 IU of vitamin D daily—under medical advice. Exercise done in vertical posture and resistance training can help preserve bone and reduce risk of falls. Fall prevention strategies should be adopted. A proper diagnosis, using a bone density test in those over 60, followed by medication as advised by your doctor, can reduce your fracture rate by as much as half. There is no reason to despair. Instead, take proactive steps to preserve your bones.