Osteoporosis

Your bones are the strong, resilient framework that supports your entire body. While they might seem static, bones are dynamic, living tissues constantly undergoing a process of renewal, where old bone is broken down and new bone is formed. In a healthy body, this process is balanced. 

However, with osteoporosis, this balance is disrupted, leading to a condition where bone loss outpaces bone formation. The result is bones that become progressively weaker, thinner, and more porous, resembling a honeycomb with larger holes. This guide aims to shed light on osteoporosis, from its underlying mechanisms to its widespread impact and more.

Osteoporosis is a systemic skeletal disorder characterised by low bone mass and micro-architectural deterioration of bone tissue, leading to increased bone fragility and a consequent increase in fracture risk. In simpler terms, it means your bones become weak and brittle, making them much more susceptible to breaking.

To understand osteoporosis, it's helpful to know that bone is a living tissue, constantly being remodelled. Throughout your life, specialised cells called osteoclasts break down old bone tissue (resorption), while other cells called osteoblasts build new bone tissue (formation). This continuous cycle ensures your bones remain strong and healthy.

During childhood and adolescence, bone formation outpaces resorption, leading to an increase in bone density, culminating in what's known as peak bone mass, typically reached in your late 20s or early 30s. After this peak, a gradual decline in bone mass begins. With osteoporosis, the rate of bone resorption significantly exceeds bone formation, leading to a net loss of bone tissue. This creates larger spaces within the bone's internal structure, reducing its density and strength.

The impact of this weakened structure is profound: bones that were once robust enough to withstand normal stresses become fragile, leading to fractures from minor falls, bumps, or even spontaneous events like coughing or sneezing. The most common fracture sites for osteoporosis are the hip, spine (vertebrae), and wrist, but any bone can be affected.

Osteoporosis is a major global health concern, affecting many people all around the globe. In India, the prevalence of osteoporosis is substantial and widely recognised as an emerging public health challenge. It is a pervasive condition across a considerable portion of the adult population in India, with women being particularly vulnerable.

Osteoporosis is primarily categorised into two main types, with additional classifications for specific causes:

Primary Osteoporosis (Most Common): This is the most prevalent form and accounts for the vast majority of cases. It's not caused by another underlying medical condition but is related to the natural ageing process and hormonal changes.

• Postmenopausal Osteoporosis (Type I): This type primarily affects women after menopause. The sharp decline in oestrogen levels during menopause significantly accelerates bone loss, as oestrogen plays a crucial role in maintaining bone density. This typically leads to rapid bone loss in the first 5-10 years post-menopause, increasing the risk of fractures, especially in the spine (vertebrae) and wrist.
• Senile Osteoporosis (Type II): This type affects both men and women, usually after the age of 70. It's associated with the gradual, age-related decline in bone formation and reduced calcium absorption. Fractures due to senile osteoporosis commonly occur in the hip and spine.
• Idiopathic Osteoporosis: This is a rare form where the cause of bone loss is unknown. It can affect younger adults and, occasionally, children.

Secondary Osteoporosis: This type occurs when bone loss is a direct result of another medical condition, certain medications, or specific lifestyle factors. Treating the underlying cause is crucial for managing secondary osteoporosis. Examples include:

• Endocrine disorders: Overactive thyroid (hyperthyroidism), overactive parathyroid glands (hyperparathyroidism), Cushing's syndrome, diabetes.
• Gastrointestinal diseases: Conditions that impair nutrient absorption, such as coeliac disease, inflammatory bowel disease (Crohn's disease, ulcerative colitis), and bariatric surgery.
• Rheumatological conditions: Rheumatoid arthritis, ankylosing spondylitis.
• Kidney or liver disease: Chronic kidney disease can impair vitamin D metabolism.
• Blood disorders: Multiple myeloma, thalassemia.
• Medication-induced: Long-term use of corticosteroids (e.g., prednisone, prednisolone), some anti-seizure medications, certain cancer treatments (e.g., for breast or prostate cancer that affect hormone levels), proton pump inhibitors (PPIs) for acid reflux.
• Lifestyle factors: Chronic excessive alcohol consumption, long-term smoking, and prolonged immobility or bed rest.

Osteoporosis develops when the delicate balance between bone formation and bone resorption is disrupted, leading to more bone being broken down than built. While ageing is a primary factor, several specific causes contribute to this imbalance:

Declining Oestrogen Levels (in women): This is the leading cause of primary osteoporosis in women. Oestrogen plays a critical role in maintaining bone density. After menopause, the sharp drop in oestrogen levels significantly accelerates bone loss, particularly in the first 5-10 years.

Declining Testosterone Levels (in men): While less dramatic than in women, men also experience a gradual decline in testosterone with age. Low testosterone levels can contribute to bone loss.

Ageing: As people age, the rate of bone formation naturally slows down, while bone resorption often continues at a similar or even increased pace. This leads to a gradual net loss of bone density over time in both men and women, contributing to senile osteoporosis.

Insufficient Calcium Intake: Calcium is the primary mineral component of bone. A lifelong diet lacking adequate calcium can lead to suboptimal peak bone mass and increased bone loss later in life.

Vitamin D Deficiency: Vitamin D is crucial for the absorption of calcium from the gut and for bone mineralisation. Insufficient vitamin D levels impair the body's ability to use calcium effectively, leading to weaker bones.

Certain Medical Conditions (Secondary Osteoporosis):

• Hyperthyroidism (overactive thyroid): Excess thyroid hormone can speed up bone metabolism, leading to faster bone loss.
• Hyperparathyroidism (overactive parathyroid glands): These glands regulate calcium levels, and excessive parathyroid hormone can pull calcium from bones.
• Cushing's Syndrome: A condition involving high levels of cortisol, which can inhibit bone formation.
• Chronic Kidney Disease: Impairs vitamin D activation and calcium-phosphate balance.
• Gastrointestinal disorders: Conditions like coeliac disease, Crohn's disease, or ulcerative colitis can reduce the absorption of calcium and vitamin D.
• Rheumatoid Arthritis: Both the inflammation and some medications used for RA can contribute to bone loss.
• Anorexia Nervosa: Malnutrition and hormonal imbalances associated with this eating disorder severely impact bone health.

Certain Medications:

• Corticosteroids: Long-term use of oral or injected corticosteroids (e.g., prednisone) is a major cause of secondary osteoporosis, as they directly suppress bone formation.
• Anti-seizure medications: Some anticonvulsants can interfere with vitamin D metabolism.
• Proton Pump Inhibitors (PPIs): Long-term use of these acid-reducing drugs (e.g., omeprazole) may reduce calcium absorption.
• Certain cancer treatments: Some hormonal therapies for breast and prostate cancer.

Lifestyle Factors:

• Sedentary Lifestyle/Lack of Weight-Bearing Exercise: Physical activity, especially weight-bearing and resistance exercises, stimulates bone formation. Inactivity leads to bone loss.
• Smoking: Tobacco use directly harms bone cells, reduces blood supply to bones, and interferes with calcium absorption.
• Excessive Alcohol Consumption: Heavy alcohol intake can interfere with calcium and vitamin D absorption, reduce bone formation, and increase the risk of falls.
• Low Body Mass Index (BMI): Being underweight is a risk factor, as lower body weight means less stress on bones, which can lead to lower bone density.

Osteoporosis is often referred to as a "silent disease" because, in its early stages, it typically produces no noticeable symptoms. Many people are unaware they have the condition until a bone fracture occurs from a minor fall or even spontaneously.

When symptoms do appear, they are usually related to a fracture. Common symptoms associated with osteoporotic fractures include:

• Back Pain: This is a very common symptom, particularly if it's sudden and severe, indicating a vertebral compression fracture in the spine. The pain may worsen with standing or walking and ease with lying down.
• Loss of Height Over Time: Multiple vertebral compression fractures can cause the spine to shorten, leading to a noticeable decrease in overall height.
• Stooped Posture (Kyphosis or "Dowager's Hump"): As vertebrae collapse, the upper back can become increasingly curved and rounded, leading to a hunched posture.
• Bone Fractures that Occur More Easily than Expected: This is the hallmark symptom. Fractures may result from:
  • Minor falls: A fall from standing height or less.
  • Minimal trauma: Such as a bump, cough, or sneeze.
  • Spontaneous fractures: Where there's no apparent trauma. Common fracture sites include the wrist, hip, and spine.
• Pain in bones and muscles: Some individuals may experience general bone and muscle aches, though this is less specific than fracture-related pain.

If you notice any of these symptoms, especially a sudden back pain or a loss of height, it's crucial to consult your doctor.

Diagnosing osteoporosis involves assessing your risk factors, evaluating your symptoms (if any), and most importantly, measuring your bone density.

Medical History and Physical Examination:

• Your doctor will ask about your personal and family medical history, including any previous fractures, menopause status (for women), lifestyle habits (diet, exercise, smoking, alcohol), and medications you are taking (especially corticosteroids).
• They will also perform a physical examination, checking your height (for any loss) and posture.

Bone Mineral Density (BMD) Test / DEXA Scan:

• This is the gold standard for diagnosing osteoporosis. A Dual-energy X-ray Absorptiometry (DEXA or DXA) scan is a quick, non-invasive, and painless X-ray procedure that uses very low doses of radiation to measure the density of bones, typically in the hip and spine (the most common sites for osteoporotic fractures).
• The results are reported as a T-score, which compares your bone density to that 

Blood and Urine Tests:
These tests are used to:

• Rule out secondary causes: Check for underlying medical conditions that could be contributing to bone loss (e.g., thyroid problems, parathyroid disorders, kidney or liver disease, coeliac disease).
• Measure calcium and vitamin D levels: Ensure adequate levels are present.
• Assess bone turnover markers: Blood or urine tests can sometimes measure markers that indicate the rate at which bone is being broken down or formed. These can help assess treatment effectiveness.

FRAX® Tool:

• The Fracture Risk Assessment Tool (FRAX®) is a computer-based algorithm that estimates a person's 10-year probability of experiencing a major osteoporotic fracture (hip, spine, wrist, or shoulder) based on their bone density (DEXA T-score, if available) and other clinical risk factors (age, sex, BMI, family history of hip fracture, smoking, alcohol intake, steroid use, and certain medical conditions). This tool helps doctors decide who would benefit most from treatment.

The primary goal of osteoporosis treatment is to prevent fractures. Treatment plans are individualised, taking into account the patient's age, risk factors, severity of osteoporosis, and other health conditions. Treatment typically involves a combination of lifestyle modifications and medication.

1. Lifestyle Modifications

These are foundational for all individuals, regardless of whether they are on medication.

• Calcium and Vitamin D Intake: Ensuring adequate intake is crucial.
  • Calcium: Adults generally need 1000-1200 mg of calcium daily (from dairy, leafy greens, fortified foods, or supplements).
  • Vitamin D: Essential for calcium absorption. Recommended daily intake is 800-1000 IU (International Units), often requiring supplements, especially in regions with limited sun exposure.
• Regular Weight-Bearing and Muscle-Strengthening Exercise:
  • Weight-bearing exercises (e.g., walking, jogging, dancing, climbing stairs, hiking) help build and maintain bone density.
  • Muscle-strengthening exercises (e.g., lifting weights, using resistance bands) improve muscle mass, strength, and balance, reducing fall risk.
  • Balance exercises (e.g., Tai Chi, yoga) are particularly important for fall prevention.
• Avoid Smoking and Excessive Alcohol: Both significantly increase bone loss and fracture risk.
• Fall Prevention: Modify the home environment (remove tripping hazards, good lighting, grab bars) and manage vision/hearing issues.

2. Medications

These are typically prescribed for individuals with osteoporosis (T-score -2.5 or lower), or osteopenia with a high FRAX score, or those who have already experienced a fragility fracture.

• Bisphosphonates: These are the most commonly prescribed medications. They work by slowing down the rate of bone breakdown (resorption). They can be taken orally (e.g., alendronate, risedronate, ibandronate) as weekly or monthly pills, or intravenously (e.g., zoledronic acid) as an annual infusion.
  
  • Examples: Alendronate, Risedronate, Ibandronate, Zoledronic Acid.
• Denosumab (Prolia): An injectable medication given as a subcutaneous injection every six months. It's a monoclonal antibody that inhibits a protein crucial for osteoclast formation and function, thereby decreasing bone resorption.
• Selective Oestrogen Receptor Modulators (SERMs):
  
  • Raloxifene: Mimics the beneficial effects of oestrogen on bone density without affecting breast or uterine tissue in the same way. Used in postmenopausal women, it can also reduce the risk of breast cancer.
• Hormone Replacement Therapy (HRT): Oestrogen therapy can prevent bone loss in postmenopausal women. While effective for bone, HRT also carries risks for some women and is typically considered for symptoms of menopause, with bone protection as an added benefit, rather than as a primary osteoporosis treatment.
• Anabolic (Bone-Building) Agents: These medications work by stimulating new bone formation, rather than just slowing bone breakdown. They are typically reserved for individuals with severe osteoporosis or those who have not responded to other treatments.
  
  • Teriparatide: A synthetic form of parathyroid hormone, given daily by injection for a limited time (usually 18-24 months).
  • Abaloparatide: Similar to teriparatide, also an injectable.
  • Romosozumab: A newer anabolic agent that both increases bone formation and decreases bone resorption, given monthly by injection for 12 months.
• Calcitonin: A hormone involved in calcium regulation, available as a nasal spray or injection. It's sometimes used for acute pain from vertebral fractures but is less potent than bisphosphonates for long-term bone density improvement.

Treatment with medications like Deca Durabolin and others requires consistent adherence and regular monitoring by a healthcare professional.

Several factors can increase your risk of developing osteoporosis:

• Female gender: Women are four times more likely to develop osteoporosis than men.
• Older age: Risk increases significantly with age, particularly after 50.
• Menopause: Rapid oestrogen decline accelerates bone loss.
• Family history: Having a parent or sibling with osteoporosis, especially a hip fracture.
• Low body weight/small frame: Less bone mass to begin with.
• Certain medical conditions: Hyperthyroidism, coeliac disease, chronic kidney disease, etc.
• Long-term use of certain medications: Especially corticosteroids.
• Inadequate calcium and vitamin D intake: Essential for bone health.
• Sedentary lifestyle: Lack of weight-bearing exercise.
• Smoking: Damages bone cells and reduces bone density.
• Excessive alcohol consumption: Harms bones and increases fall risk.
• Ethnicity: White and Asian individuals are at higher risk.
• Early menopause/surgical removal of ovaries: Reduces oestrogen production.
• Eating disorders: Malnutrition and hormonal imbalances (e.g., anorexia nervosa).

The most significant and devastating complication of osteoporosis is a bone fracture, particularly fragility fractures. These fractures can lead to a cascade of serious health problems:

• Fractures (especially hip, spine, wrist): The hallmark complication, often leading to acute pain.
• Chronic pain: From vertebral compression fractures, leading to persistent back pain.
• Loss of height and stooped posture: Multiple vertebral fractures can cause kyphosis, affecting appearance and breathing.
• Reduced mobility and independence: Hip fractures often require surgery and can lead to long-term disability, loss of independence, and need for long-term care.
• Increased mortality: Hip fractures, in particular, are associated with a significantly increased risk of death in the year following the fracture.
• Reduced quality of life: Pain, limited mobility, and fear of falling can severely impact daily activities and mental well-being.
• Pulmonary complications: Severe kyphosis can restrict lung capacity, leading to breathing difficulties.
• Pressure sores: Prolonged immobility post-fracture increases risk of skin breakdown.

Living with osteoporosis involves proactively managing your condition to prevent fractures and maintain your quality of life.

• Strictly adhere to your treatment plan: Take all prescribed medications exactly as directed and attend all follow-up appointments and bone density scans. This is the most crucial step in preventing fractures.
• Focus on fall prevention: Make your home environment safe by removing tripping hazards (loose rugs, clutter), ensuring good lighting, installing grab bars in bathrooms, and using non-slip mats. Wear sturdy, low-heeled shoes.
• Engage in bone-friendly exercise: Continue with regular weight-bearing exercises (like walking) and muscle-strengthening activities (like resistance training). Incorporate balance exercises (Tai Chi, yoga) to reduce fall risk. Consult a physiotherapist or exercise specialist for a safe and effective routine.
• Prioritise calcium and vitamin D: Ensure you get adequate amounts of these vital nutrients through diet and, if necessary, supplements as advised by your doctor.
• Maintain open communication with your healthcare team: Regularly discuss your symptoms, any new pains, medication side effects, or concerns about falls with your GP, endocrinologist, or bone specialist.

"Only women get osteoporosis." 

This is a significant misconception. While women, particularly postmenopausal women, are at a higher risk due to hormonal changes, men can also develop osteoporosis. In fact, about one in five men over 50 will experience an osteoporotic fracture in their lifetime. Men's bone loss often progresses more slowly, but it is equally serious.

"You'll know if you have osteoporosis because your bones will ache." 

Osteoporosis is known as a "silent disease" precisely because it typically has no symptoms until a fracture occurs. Bone pain or aches are generally not direct symptoms of osteoporosis itself, unless a fracture has already happened, especially in the spine. Regular screening through DEXA scans is the only way to detect the condition early.

"Drinking milk and taking calcium supplements is enough to prevent osteoporosis." 

While adequate calcium and vitamin D intake is crucial for bone health, it's not the sole factor. Osteoporosis prevention requires a holistic approach that includes regular weight-bearing exercise, avoiding smoking and excessive alcohol, and managing any underlying medical conditions or medications that contribute to bone loss. For individuals with osteoporosis, medication is often necessary in addition to these lifestyle changes to significantly reduce fracture risk.

Given that osteoporosis is often silent until a fracture occurs, knowing when to seek medical advice is crucial for early detection and intervention.

You should see a doctor if:

• You are a woman over 65 or a man over 70: Routine osteoporosis screening (DEXA scan) is recommended for these age groups.
• You are a postmenopausal woman under 65 with risk factors: Such as a family history of osteoporosis, low body weight, or previous fractures.
• You are a man under 70 with significant risk factors: Including a history of fragility fractures, chronic medical conditions (e.g., hyperthyroidism, coeliac disease), or long-term use of certain medications (e.g., corticosteroids).
• You experience a fracture from a minor fall or minimal trauma: This is often the first sign of osteoporosis and requires immediate medical attention.
• You notice a loss of height or developing a stooped posture: These can indicate vertebral compression fractures.
• You have persistent, unexplained back pain: Especially if it's sudden and severe, as this could be a spinal fracture.
• You are taking medications known to cause bone loss: Such as long-term oral corticosteroids.
• You have a medical condition associated with secondary osteoporosis: Such as hyperthyroidism, rheumatoid arthritis, or gastrointestinal malabsorption issues.

• Am I at risk for osteoporosis? What are my specific risk factors?
• Do you recommend a bone density (DEXA) scan for me? If so, when and where can I get one?
• What are my current bone mineral density results (T-score/Z-score)? What do they mean for my bone health?
• What are my options for treatment or prevention? What are the benefits and potential side effects of these?
• How much calcium and vitamin D do I need each day, and what are the best ways for me to get it (diet vs. supplements)?
• What type of exercises are safe and beneficial for me to strengthen my bones and improve my balance?
• What steps can I take to prevent falls in my home and daily life?

• Learn about osteoporosis: Educate yourself on the condition, its challenges, and its treatments. This helps you understand their experience and respond with empathy.
• Help create a safe home environment: Proactively identify and remove fall hazards such as loose rugs, clutter, and poor lighting. Ensure bathrooms have grab bars and non-slip mats.
• Encourage adherence to treatment and appointments: Gently remind them about medication schedules and the importance of regular dental check-ups and follow-up appointments with their bone specialist. Offer to accompany them if they wish.
• Support their activity and nutrition: Encourage participation in safe, bone-strengthening exercises (e.g., walking, Tai Chi) and help ensure their diet is rich in calcium and vitamin D. You can even participate with them to make it more enjoyable.

Osteoporosis is a chronic and progressive skeletal disorder characterised by diminished bone density and increased bone fragility. Often silent until a fracture occurs, it poses a significant global health burden, particularly affecting older adults and postmenopausal women. While ageing and genetic predisposition play roles, numerous modifiable factors and underlying medical conditions contribute to its development. Early diagnosis is, therefore, important for timely intervention.