Osteoporosis big threat

It has the dubious distinction of being the most common metabolic bone disease in the world. Its progression is slow and silent and its victims invariably end up being hospitalised often for weeks on end. It affects 200 million women world-wide, and half a million women over 50 years of age in Sri Lanka.
With the aging population poised to double by the year 2020 from its present 10% and reach 30% by the year 2050, and women living longer than males in Sri Lanka, managing Osteoporosis is one of the biggest challenges the country will have to face in the future. So huge is its economic burden on health systems globally, that the focus is now increasingly on preventing the disease which health experts say begins even before birth when the female child is still in the mother’s womb.
What is osteoporosis? Who are its victims? What happens to them once they are afflicted with this Non Communicable Disease (NCD)?
A panel of experts on the subject presented papers and fielded questions at a media seminar held at the Health Education Bureau. Stressing the role of the media in raising awareness on this subject, they said that most victims were still ignorant of the simple rules of preventing this debilitating disease and seek treatment only when it has reached an advanced stage

By Carol Aloysius
Osteoporosis, the panel of experts explained to the media, means ‘porous bones,’ and was a disease that causes loss of bone mass which in turn weakens its structure. This results in the bones becoming weak and brittle — so brittle that a fall or even mild stresses like bending over or coughing can cause a fracture.
Often the causes for the bones to become so weak is low levels of calcium and other minerals in your bones. Unfortunately the symptoms of this bone loss prior to the disease becoming acute are not visible in the early stages. However, once bones have been weakened by osteoporosis, you may have osteoporosis signs and symptoms, they pointed out. These symptoms could range from any of the following:

  • Back pain, which can be severe, as a result of a fractured or collapsed vertebra
  • Loss of height over time
  • A stooped posture
  • Fracture of the vertebra, wrist, hip or other bone

A common result of osteoporosis is fractures — most of them occur in the spine, hip or wrist.
Those most at risk are women over 65 years of age, and men over 70 years, post menopausal women and, those older than 50 years with a history of a broken bone, those taking medications such as prednosone or anti-seizure drugs that are associated with osteoporosis.
Since detecting the disease in its early stages is often difficult since it rarely shows signs or symptoms until it reaches an advanced stage, the panel of experts said that this could be done through a bone density test available at all our government hospitals.

The Chances of getting an OP related fracture during lifetime according to sex
30-50% of women
15-30% men
A woman of 50 years has 2.8% risk of death related to hip fracture during her remaining lifetime.

So how can this debilitating disease be prevented?
In her enlightening discussion on the ‘Role of nutrition in preventing osteoporosis’, Dr Renuka Jayatissa, Consultant Medical Nutritionist emphasised the importance of healthy diets as a key tool in preventing the disease.
“Correct feeding practices should commence from the time a child is very young because good nutrition in childhood and adolescence helps to build peak bone mass, thereby reducing vulnerability to osteoporosis later in life. This applies to young and elderly adults as well since a nutritious diet will help preserve bone mass and bone strength with ageing and thereby prevent osteoporosis. Although the maximum bone density in the body is attained when one is in her twenties, at every stage of life, a nutritious, balanced diet promotes strong healthy bones,” she stressed.

Discussing the kind of diet that was essential for strong bone formation she said,
“It should include sufficient calories and adequate protein, fat and carbohydrates,vitamin D and mineral calcium. All these nutrients can be found in our locally grown foods.” For example, kunissa, kelawalla fish, soya beans, kathurumurunga, lotus stem, jaggery, woodapple, gingelly seed, have very high calcium content and leafy green vegetables have plenty of minerals. Legumes such as lentils, green gram, chickpea tofu, grains, nuts and seeds provide vegetable protein, while lean red meat, poultry and fish as well as eggs and dairy foods are excellent sources of animal protein. Fruits and vegetables also contain a whole array of vitamins, minerals, antioxidants and alkaline salts which can have a beneficial effect on bone, she further pointed out.
“We have studies to prove that a higher fruit and vegetable consumption is associated with beneficial effects on bone density in elderly men and women,” she said, adding that all the nutrients we need to prevent osteoporosis are freely available in our gardens and local markets. Unfortunately the target population which really needs to take them such as school going children and adolescents don’t consume enough of these foods and so go on to develop osteoporosis late in life,” she lamented.

How does vitamin D help in preventing osteoporosis?
“Vitamin D plays a key role in several ways. It assists calcium absorption from food, ensures the correct renewal and mineralisation of bone tissue, and promotes a healthy immune system and muscles,” she explained.

And if we don’t have a sufficient amount of this vitamin in our bodies?
“It can lead to a higher risk of osteoporosis and an increased likelihood of falling in older adults whose muscles are already weakened by a lack of this vitamin.”

Answering a question as to how one gets this vitamin into the body, she said it could be obtained from food or supplementary diets in the case of those doing indoor jobs or forced to remain indoors for most of the day. But those who lead an outdoor life can obtain it from sunlight.

“Vitamin D is made in our skin from exposure to the sun’s ultraviolet B rays. So it is free. In children and adults, casual exposure of the face, hands and arms for as little as 10-15 minutes a day outside peak sunlight hours before 10 a m and after 2 pm, is usually sufficient for most individuals.”
As to what kind of foods can decrease our calcium intake, she said that caffeine and salt can increase calcium loss from the body and should not be taken in excessive amounts. Two teaspoons of salt per day was sufficient intake for an individual.
“However, in Sri Lanka most people ingest as much as 10 teaspoons on an average,” she pointed out.

Fact file on Osteoporosis (OP)

OP affects 200 million women worldwide.
- 1/3 of women aged 60-70
- 2/3 of women aged 80 or older
In Sri Lanka 45% of women over 50 years are likely to have OP
Approximately 20-25% of women over 50 have one of more vertebral fractures.

What about alcohol and soft drinks?
“These too should be taken in moderation (not more than 2 standard units per day) as it diminishes one’s bone health and has been linked to increased risk of hip and other osteoporotic fractrures from falls as when a person who has consumed too much liquor loses his balance and falls. As for soft drinks, while there is no conclusive evidence that fizzy soft drinks (e.g. cola drinks) weaken bones , here too it’s best not to overdo it – especially as such drinks tend to ‘displace’ calcium-high drinks such as milk in the diets of children and teenagers,” Dr Jayatissa observed.

Physical exercise
Dr Lalith Wijayaratne, Counsultant Rheumatologist, National Hospital, who was the next speaker, drew attention to what he said was one of the most powerful tools for preventing osteoporosis: physical exercise.
“If you don’t use a machine it will become rusty and become unusable. Similarly, if you don’t exercise your arms, legs, feet, and body, their bone mass will diminish to an extent when you will be unable to use them. That’s why I tell my patients, ‘Move your limbs or lose them’. The more you use your bones, the stronger they will be. Bone density increases with more loading on bones and with muscles working on bone.”
Fielding a question on the kind of exercises he could recommend to prevent osteoporosis, he said, that exercises to improve bone strength fell into two categories: weight bearing exercises and weight training exercises. The former included running, walking, climbing steps, dancing and racquet sports such as tennis, badminton, squash, table tennis. Non weight bearing exercises included swimming and cycling. Weight training exercises included dumbell, exercise bands and use of exercise machines such as one finds in any gym. Any kind of sports too should include weight bearing and weight training exercises, he noted.
“All these exercises should be done continuously on a long term basis, because if you stop half way, you will lose what you have gained,” he warned.

Prevalence of OP in different countries

Western communities

- 30% in European whites
- 45% in UK
- 39% in Thailand
- 56% in Japan
- 45% in Korea

For how long should one do these exercises?
“One session of moderate intense exercises for a minimum of 30 minutes at least five times a week. Less than that would have less benefits.”
Are these exercises only to prevent osteoporosis, or can they also be used to treat the disease once you have got it?
“They are for both- prevention and treatment.”

To prevent osteoporosis, whom should we target?
“School going age groups are the most important target groups — especially school girls, because women are more prone to the disease. The second group are those below 30 years of age, while the third group are premenopausal women between 40 – 50 years.

Why women are more at risk
The panel of experts also explained why women were more at risk of getting the disease. They said that it was because their oestrogen level dropped after menopause. Since oestrogen was essential for bone strength, fractures from brittle bones were twice or even three times higher than in the case of men.
Also responding to a question from the audience as to why osteoporosis was more common among Asian women than European women, the speakers explained that generally Asian women were slimmer and smaller made than their European counterparts and thus had less bone mass to draw from as they age. We were told that those with anorexia nervosa or bulmia were also at higher risk of lower bone density. Hence, women who are exceptionally thin (with a body mass index of 19 or less) or have small body frames tend to have a higher risk of getting the disease as they age. Those with a family history of fractures and having a parent or sibling with osteoporosis could also put one at risk of the disease.
The speakers summed up their discussions with the following key messages to the public:

  • Ensure an adequate calcium intake that meets the relevant dietary recommendations at all stages of your life. A good diet to prevent osteoporosis must contain sufficient protein, fat and carbohydrates as well as vitamin D.
  • Osteoporosis can start from birth if a child is born underweight and has a low bone mass. In childhood and adolescence good nutrition helps build peak bone mass with maximum bone density attained in the 20s.
  • Maintain a sufficient supply of vitamin D through adequate safe exposure to the sun, through diet or through supplements.
  • Safeguard a healthy body weight, as being underweight is a strong risk factor for osteoporosis (body mass index less than 18.5 kg/m2)
  • Avoid smoking as it hampers the work of bone building cells and increases risk of fracture.
  • Avoid excessive alcohol consumption.
  • Use salt and caffeine in moderation as these can promote calcium loss from the body especially if calcium intake is inadequate.
  • Physical exercises are good to prevent and treat osteoporosis.
  • Exercises should be weight bearing or non weight bearing types. One session of moderate intensity exercises for a minimum of 30 minutes at least five times a week can produce the best result.
Risk factors

A number of factors can increase the likelihood that you’ll develop osteoporosis — some you can change, others you cannot.
Risk factors you can change

  • Low calcium intake
  • Tobacco use

Eating disorders

Those with anorexia nervosa or bulmia are at higher risk of lower bone density. Hence, women who are exceptionally thin (with a body mass index of 19 or less) or have small body frames tend to have a higher risk of getting the disease as they age.
Family history: Those with a family history of fractures and having a parent or sibling with osteoporosis could also put one at risk of the disease.

  • Sedentary lifestyle
  • Excessive alcohol consumption
  • Corticosteroid medications

Risk factors you can’t change

  • Being a woman
  • Getting older
  • Race
  • Family history
  • Frame size
  • Thyroid hormone

Too much thyroid hormone also can cause bone loss. This can occur either because your thyroid is overactive (hyperthyroidism) or because you take excess amounts of thyroid hormone medication to treat an underactive thyroid (hypothyroidism).


Ninety per cent reduction of cases

Breakthrough with new polio vaccine

A new vaccine against the polio virus has helped reduce the number of cases by more than 90%.
Research published online in the journal The Lancet, shows that the new vaccine is significantly better at protecting children against polio than the current popular vaccine.
It has already been used in Afghanistan, India and Nigeria.
The scientists behind the work believe this new vaccine could help to finally eradicate the disease.
Mass vaccination campaigns have led to the number of polio endemic countries falling from 125 in 1988 to just four in 2005.

This meant an actual drop in cases from 350,000 to just 1,606 in 2009.
Polio is caused by one of three versions of the polio virus: type1, type 2 or type 3.
Until recently, vaccines targetting either all three forms of the virus or just one of them were used to immunisie children.

The last case of type 2 polio was recorded in India in 1999, so it’s the other two types that need to be targeted to finally eliminate the disease.
The authors of the study carried out a trial in India comparing the commonly used old vaccines to the new one, which is taken orally.
In total, 830 newborn babies received either the new vaccine or one of the old vaccines in two doses – one at birth and one 30 days later.

Blood samples were taken before vaccination and after the first and second doses to measure seroconversion – the rise in antibodies produced by the immune system against polio.
It appears that the new vaccine is about 30% more effective in protecting against polio than the most commonly used vaccine to date.
The new vaccine has already been used in immunisation campaigns in Afghanistan, India and Nigeria.
In India the number of cases this time last year was 464. Over the same period this year, there have only been 39 cases.

Nigeria has seen an even greater difference, with cases falling by 95%.
The new vaccine and improved immunisation programmes appear to be responsible for this significant decrease, according to the World Health Organization (WHO).
Dr Roland Sutter, from the WHO and the lead author of the study, told BBC News: “This (new) vaccine could get us over the top and get us to the finish line for eradication.”
“The dramatic drop in the number of polio cases in India and Nigeria is attributable to the new vaccine and better coverage during immunisation campaigns.”
The private sector manufacturers played a key role in its development, says Dr Bruce Aylward, the Director of WHO’s Global Polio Eradication Initiative.

“They’ve held the price to the same price of what we are paying for the older polio vaccine,” he says.
The new vaccine can be administered in the same way as the previous one. “That’s why there is so much promise with this product,” says Dr Aylward.
Commenting on the research, Nigel Crawford and Jim Buttery from the Murdoch Children’s Research Institute (SAEFVIC) in Melbourne, Australia, said that the new vaccine had shown great promise.
However, they cautioned that the global financial crisis had resulted in a massive funding gap for immunisation programmes worldwide, including polio. (BBC Health)


Blood group ‘affects fertility’

A woman’s ability to conceive in early middle age may be influenced by her blood type, according to research.
The US study of 560 women undergoing fertility treatment found that those with type “O” blood had chemical signs linked to low egg numbers.
There is no clear explanation for the results, presented to the American Society of Reproductive Medicine conference in Denver.
Approximately 44% of the UK population has type ‘O’ blood.
The researchers, from Albert Einstein College of Medicine in New York, and Yale University, looked at the levels of a chemical called follicle-stimulating hormone (FSH) in the women, who had an average age of 35.
A woman has a fixed number of eggs, her ‘ovarian reserve’, which are released gradually over her fertile life.
High levels of FSH are thought to be an indicator that this reserve is diminishing more quickly – which can reduce chances of conception once a woman reaches her 30s and 40s.
Analysis of blood samples revealed that the women with type ‘O’ blood were more likely to have higher FSH readings.
Those with type ‘A’ blood – the other major blood group in the UK – had lower FSH levels.
Dr Edward Nejat, who led the study, said: “A woman’s age remains the most important factor in determining her success of conceiving.
“The baseline FSH gives us an idea of the quality and quantity of a woman’s eggs.”
Whether or not this will make any difference to women in the general population is not clear – all the women in the trial were already seeking fertility treatment.
Tony Rutherford, chairman of the British Fertility Society, said the research was ‘interesting.’
He said that further larger-scale research would be needed to both confirm the result, and see if any effects could be spotted in women with no diagnosed fertility problems trying to conceive.
“This is the first time that I’m aware of that the researchers have shown a link between blood group and potential for fertility.
“We really need to look at it with other, more up to date tests of ovarian reserve – and to look at a prospective group of women to see if blood group affects your chance of getting pregnant.”
(BBC Health)