Preventing osteoporosis: Exercise and nutrition are key

Staying physically active, getting an adequate amount of calcium and vitamin D, and getting a dexa scan post menopause, can help women in the prevention of osteoporosis, says orthopaedic and joint replacement surgeon Dr. Abhishek Kumar Mishra.

Osteoporosis, a condition that makes bones fragile and more susceptible to breaking or fractures, impacts both men and women but women are thrice as likely to get osteoporosis compared to men.

In India, osteoporosis impacts as many as 46 million women above the age of 50. “Women have a lower peak bone mass, which is compounded by the hormonal changes that occur at the time of menopause. It is a silent disease until fractures occur, which causes important secondary health problems and even death,” says a study.

We spoke to Dr. Abhishek Kumar Mishra, an orthopaedic and joint replacement surgeon at the Apollo Spectra hospital in New Delhi, about the symptoms, causes and prevention of osteoporosis. He also spoke to us about the importance of calcium and vitamin D, which are essential for maintaining bone health. Edited excerpts:

• What is osteoporosis and what are its main causes?
• How does menopause increase the risk of osteoporosis?
• What can women do to prevent osteoporosis post menopause?
• What are some of the best sources of calcium?
• What are the symptoms of calcium and vitamin D deficiency?

What is osteoporosis and what are its main causes?

Osteoporosis comes from two words, osteo meaning bones and porosis which means weakness. Literally speaking, it just means the weak bone disease. It is also referred to as the brittle bone disease. In this disease, the propensity of the bone to get a fracture, even with a minor injury, increases. Its causes are manifold — age, sex, race, which are the predisposing factors. The older you get, the higher the chance of you having osteoporosis.

Women  are more predisposed to getting osteoporosis than men. Caucasians and Asians are also more likely to get osteoporosis, as compared to black people. Apart from these predispositions, a lack of physical activity, lack of vitamin D in the diet, and a short physical frame or stature, make you more prone to osteoporosis. Petite women are more likely to get osteoporosis as compared to those who are tall and heavily built.

There are also certain medicines like antiepileptic drugs, steroids, which can cause osteoporosis if taken over a long period of time. There are also certain diseases and conditions from which you can get osteoporosis. Women who undergo hysterectomy, which reduces the impact of the estrogen hormone which strengthens the bones, are also more prone to osteoporosis.

We have read that women can lose up to one-fifth of their bone mass after menopause. Could you talk to us about that? How does menopause increase the risk of osteoporosis?

Both men and women build their bone stock only till the age of 30 or so. Bone is a living tissue, which is in constant need of repair like any other tissue in the body. What happens is that till the age of 30, the rate at which you form the bone is more than the rate at which the bone tissues are depleting. Let me give you an analogy. Compare it to a bank account, the problem in the bank account of bones is that you deposit money till the age of 30, after that you are only withdrawing. The deposit is much less post the age of 30, and the account is going to get weaker day by day. The same happens with bones. If you don’t have enough bone stock to begin with, you are more likely to deplete your account.

This holds good not just for women but also for men. But because of biology, post menopause, women’s estrogen levels fall which impacts the strength of their bones. Estrogen plays a strong role in keeping the bones strong and keeping the metabolism of calcium to the bones adequate.

And, if this is added to other factors like a smaller build or a lack of physical activity, or taking medication for thyroid and steroids or antiepileptic drugs, the risk of osteoporosis increases manifold.

So what can women do to prevent osteoporosis especially post menopause?

Women must keep themselves physically active, it keeps the bones stronger. They also have to take care of their diet needs. If you think that your dietary intake does not have sufficient calcium and vitamin D apart from other nutrients, you should take supplements in consultation with a doctor. Now, calcium supplement can be associated with the risk of forming kidney stones. So what you can do is, take calcium for about 3-4 months, and then give it a break of a month to avoid any side effects.

After 55, women should undergo the dexa scan or the bone density test at least once to determine the baseline level of the strength of the bones. And if they are diagnosed with osteoporosis and osteopenia, there have to be corrective measures. Ostopaenia is a lower degree of osteoporosis. It is a harbinger of osteoporosis, it can lead to osteoporosis if not corrected.

However, I must add that just taking calcium or vitamin D is not sufficient, there are so many other factors. There is genetic predisposition and level of physical activity. If you are found to be osteopenic or osteoporotic in the scan, your doctor will prescribe you medication to make your bones stronger and stop the further depletion of bones and reduce the risk of fractures.

Talking of calcium and vitamin D deficiency, there are studies that tell you that you don’t need to drink milk as an adult. Should we drink milk to fulfil our daily calcium requirement? What are some of the other sources of calcium?

There are certain things which have been proven over time. You cannot refute that milk, milk products and green vegetables are very important if you want to keep your stock of calcium full. Other foods which contain calcium are seafoods, which are not that easy to procure. So everything boils down to what you can get easily. Easier than trying to procure seafood is take supplements. If your tests show that you are low on calcium and you are of a short build, or post menopausal etc, then apart from your calcium intake in your diet, you might need supplements. A 1000 mg a day is adequate, if your food is not rich in calcium. But if you are taking enough in your food and your dexa scan is normal, then 500 mg of calcium supplement is sufficient.

Since osteoporosis is linked to vitamin D and calcium deficiency, tell us about the symptoms of calcium and vitamin D deficiency?

Vitamin D deficiency is extremely common in India. Let me talk about calcium deficiency first.  You can get bloodwork to check your calcium and vitamin D deficiency. But the calcium we see in the blood work doesn’t have much to do with the calcium in your bones or the strength of your bones. The calcium in your  blood work might be okay, but you still might have osteopenia or osteoporosis.

This also makes a dexa scan very essential for post menopausal women. I recommend getting a dexa scan once at least in your 50s. If the scan shows osteoporosis, you should start therapy and get follow up checkups as recommended by the doctor.

Calcium deficiency in the blood is very rare and it can happen in certain conditions. It also has a different set of symptoms as compared to a deficiency of calcium phosphate or deficiency of calcium and mineral in the bone. The deficiency of calcium in the bone is mostly asymptomatic in the initial phases, and that is where the danger lurks. You might feel everything is okay but you still might have osteoporosis and osteopenia.

Talking of vitamin D, Indians are very low on vitamin D.  The symptoms are usually fatigue, bodyache, and malaise. A mild deficiency can be found in people with no symptoms as well. It has very vague symptoms, which is why taking vitamin D supplements is not a bad idea at all. You can take supplements weekly for the initial two months, and after that monthly. Once a month is a dose that you can take throughout your life.

More about the diagnosis and treatment of osteoporosis will be published in the next part of the interview.

Sources:

1. Prevalence of osteoporosis in peri- and post-menopausal women in slum area of Mumbai, India. Omna Shaki, Sanjay Kumar Rai, Manoj Kashid, Barun K Chakrabarty
2. Postmenopausal osteoporosis – An Indian perspective. Remya Rajan, Jinson Paul, Nitin Kapoor, Kripa Elizabeth Cherian, Thomas V Paul. Department of Endocrinology and Metabolism, Christian Medical College, Vellore, Tamil Nadu, India
3. Epidemiology and treatment of osteoporosis in women: an Indian perspective. Anuradha V Khadilkar and Rubina M Mandlik

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