The skeleton, which is made up of bones, is an active organ or part of the body that continuously undergoes change, growth and re-growth. Microscopic damage to the bone tissues happen on a day-to-day basis while macroscopic damage happens when there is a fracture, fall, accident or injury involving the bones. The body constantly replaces or replenishes the lost bone tissue, in a process called as remodeling.
Bone remodeling happens all through our life, right from childhood till death. While in childhood, teenage and early 20s, the remodeling is fast, after the early 20s, the pace gradually reduces in small extents. This means, human bones acquire their maximum density in the early 20s for an average person. Whereas for those individuals who exercise regularly or work in labour-oriented jobs, the pace of bone-tissue replacement and bone density stay healthy even after the early 20s.
When the pace of bone-tissue replacement cannot keep up with the pace of bone-tissue loss, the condition is called Osteoporosis. The inner bone-tissue (trabecular bone) which is spongy in nature with tiny pores, develops larger pores over time. As a result, bones become weak and brittle resulting in constant pain and fractures, especially of the hip, spine and wrists.
Symptoms of Osteoporosis
Loss of height: The person starts getting shorter by an inch or more, gradually.
There is a change in posture. The person tends to stoop or bend forward. In worst cases, the person has a permanently bent back.
Bone fractures[1], bent bones and stiffness in some bones.
Pain in the lower back, and body pain after doing any work.
Also Read: Tips to prevent lower back pain[2]
Risk Factors
Age: Both men and women above 50 years of age are at risk of developing Osteoporosis
Gender: Women, especially post-menopausal women are more at risk than men
Race: Asian and white Caucasians are more at risk than African-Americans and Hispanics
Body-mass index: Thin people are more at risk than those with a healthy BMI
Family medical history: If either of your parents or grandparents had Osteoporosis or had fractured their hip after a fall, you are at risk
Medical conditions: People suffering from an overactive adrenal, parathyroid or thyroid glands, blood diseases such as multiple myeloma, inflammatory bowel disease or Celiac disease, people who have a history of weight-loss surgery or organ transplant, or have had hormone treatment for breast or prostate cancer[3], or women with a history of missed periods, are all at risk.
Lifestyle: People who are not getting a healthy diet rich in calcium and Vitamin D, who live a sedentary lifestyle with very little exercise, who smoke and consume alcoholic drinks or recreational drugs regularly, are all at risk.
Treatment Options
Osteoporosis[4] is confirmed or ruled out using Bone Mineral Density (BMD) test, also known as Dual Energy X-ray Absorptiometry (DEXA/DXA) scan. Unlike regular x-rays, these use very small amounts of radiation to determine the density of bones in the spine, hip or wrist.
Treatment options can be divided into – Medication and Lifestyle changes.
Medication
These can further be divided into 5 categories
Bisphosphonates: These aim at slowing down the pace of bone-loss. For menopausal women, this is the 1st line or most preferred form of treatment. Examples of these drugs include:
Zoledronic acid (Reclast): Given as intravenous infusion, once every year or two years
Alendronate (Fosamax): An oral pill that must be taken daily or once per week
Risedronate (Actonel): An oral pill that must be taken in daily, weekly, or monthly doses
Ibandronate (Boniva): An oral pill that is taken once a month, or an IV injection taken 4 times per year
Antibody or biologic drugs: These aim at controlling or modifying various body-processes that lead to bone loss. Prominent among them is:
Denosumab: This attaches to a protein that is involved in bone-loss and slows down the breakdown of bones, thereby maintaining bone-density. This is an injection that must be taken once in 6 months.
Anabolic or bone-building drugs: These help rebuild bone tissue and thereby reverse bone-loss. Prominent among this type is:
Romosozumab: This is highly recommended for post-menopausal women, especially those who are vulnerable to fracture, have had a fracture before or have not responded to other medications for osteoporosis.
Hormone related drugs: Both the male and female sex hormones – testosterone and estrogen help maintain a healthy bone density in the younger years. With age, hormone levels start dropping, which increases the risk of osteoporosis in both genders. So hormone related drugs manipulate these hormones in one or more ways in order to arrest the bone loss.
SERMs: Selective Estrogen Receptor Modulators imitate the bone-preserving effects of estrogen. One such example of Raloxifene (Evista) that is taken as an oral pill once a day.
Calcitonin: Natural calcitonin is a hormone produced by the thyroid gland and helps regulate calcium levels in the body, thereby maintaining bone density. Synthetic calcitonin is the 1st choice for post-menopausal women who cannot take bisphosphonates. It is also used to relieve pain in people with spinal compression fractures. This is given as an injection or taken as a nasal spray.
Parathyroid hormones (PTH): Natural parathyroid hormones regulate calcium and phosphate levels in the body thereby maintaining bone density. Synthetic PTH imitate the same effect and help promote bone growth. Examples include teriparatide (Forteo) and abaloparatide (Tymlos) that are taken as self-administered injections. Since these are costly, they are only recommended for people with severe osteoporosis who are not responding to other drugs.
Hormone therapy: These include synthetic versions of estrogen, progesterone or a combination of the 2. These are available as an oral tablet, a skin patch, an injection or a cream, that must be used daily, once or twice a week. Examples include: Premarin, Climara, Menest, Vivelle-Dot, Estrace and Minivelle.
Supplements: Calcium is the building block of bone-tissue and Vitamin D is what helps the body absorb calcium from food consumed. So people suffering from a deficiency in either or both of these nutrients will develop osteoporosis sooner or later. That is why, Calcium or Vitamin D tablets are prescribed after a blood-test confirms deficiency.
Side-effects: It’s important to note here that each of the above medications come with their own side-effects. However, your doctor will be aware of the same and choose the best medication for you. Further, he/she will also educate you on the side-effects.
Lifestyle changes
Healthy Diet: As explained above, calcium and Vitamin D are important for bone density. So it’s important to consume a diet rich in sources of calcium such as dairy (milk, yoghurt, cheese), nuts & seeds, salmon and sardines, whey protein, leafy green vegetables, beans & lentils, rhubarb and figs. Vitamin D primarily comes from exposure to sunshine, while dietary sources include red meat, liver, egg yolks and oily fish such as sardines, salmon, mackerel and herring. You can also consume foods that are artificially fortified with calcium or vitamin D.
Exercise: Exercise helps improve or sustain bone mass thereby helping slowdown or reverse bone loss. This is true at any age, although best results are obtained in younger years. It’s important to perform exercises where bones are put through stress and strain, such as weight-training or strength-training, or bones are moved against gravity, as in jogging, running and certain other exercises. If you suspect that you have weak bones, get a bone-density test done and then join a gym or a health club. Engage a trainer and create an exercise regimen with particular attention to weight/strength training.
Quit smoking: Smoking[5] is known to affect bone-mass and cause bone-loss in 3 ways. Firstly, lungs that are choked with nicotine or tar pump less blood than before. So there is reduced blood supply to all tissues of the body including bones. Next, nicotine in cigarettes slows down the production of one type of bone-cells called osteoblasts. Finally, smoking reduces the absorption of calcium by the body.
Quit alcohol: Like smoking, alcohol too affects bone-mass and causes bone-loss in 3 ways. Firstly, high levels of cortisol found in alcoholics accelerates bone breakdown and slows down bone formation. Secondly, parathyroid hormone levels in the body increase and this causes calcium to be leeched or drained out of the bones. Finally, alcohol kills osteoblasts, a type of bone-cell.
Quit Drugs: Recreational or psychedelic drugs contain innumerable toxic compounds that interfere with metabolic activities such as bone-rebuilding, nutrient absorption from food, etc. In the long run, this leads to ailments of the skeleto-muscular system such as osteoporosis, osteomyelitis, temporomandibular joint disorder (TMJ) and arthritis[6].
Reviewed by Dr Suresh S Venkita, Group Medical Director, Kauvery Hospitals
NOTE: Take medications only when prescribed by your doctors, self-medication must be avoided under any circumstances.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai, Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.