The goal should be to diagnose osteoporosis before the first fragility fracture occurs
steoporosis is one of the common age-related diseases. Bones become porous, fragile or less dense and fracture easily. It is a preventable and treatable condition.
What makes bones dense? Minerals deposited in bones, like calcium, phosphorus, carbonate, magnesium, strontium and sodium, make them thick. Loss of these minerals makes bones fragile.
Why do bones become thin or less dense? What are the risk factors; how are they recognised; and what can be done to prevent or treat them? Are we identifying osteoporosis early, particularly among the at-risk population?
Both men and women can develop osteoporosis. Some of the contributing factors include advancing age, being underweight, post-menopausal or having premature menopause (oestrogen has a protective effect on bones), smoking, alcohol intake, low levels of calcium and vitamin D, use of steroids (recurrent or long term), having a family history of osteoporosis or fractures, past history of fractures, conditions like rheumatoid arthritis or inflammatory bowel diseases etc.
A systematic review published on JSTOR in 2021 indicated that the global prevalence of osteoporosis among women was 23 percent; in men it was more or less half that, i.e. 11.7 percent. In Pakistan, approximately 9.9 million people have osteoporosis out of which 7.2 million are females (JPMA, Aug 2013). A milder form of bone loss is called osteopenia. It develops slowly over several years and is often only diagnosed when a patient presents with a fragility fracture from a non-significant fall. The fractures occur after minor trauma or fall.
Patients with osteoporosis can undoubtedly fracture their bones with minimal mechanical stress/ force compared to a person with no osteoporosis. Low bone marrow density (BMD) can cause fractures of the spine, forearm, wrist, hip and shoulder. Patients can also present with back pain which persists or changes in posture like bending on a side. A thorough history by primary care physicians
identifying risk factors contributing to the development of osteoporosis is the first step in establishing the diagnosis. The first fracture is a major risk for subsequent fractures, so the ultimate goal should be to diagnose osteoporosis before the first fracture occurs.
In order to diagnose osteopenia or osteoporosis, a scan called dual-energy X-ray absorptiometry (DEXA) scan is required. This bone density scan compares the patient’s bone density with a healthy adult of the same age, gender and ethnicity. The difference between the patient’s values and the expected values is calculated in terms of standard deviation (SD). It is represented as Z score or T score, the more negative a number is for example, T score <-2.5 the weaker bones are and the more likely to break.
In Pakistan, investigations and treatment of osteoporosis in a patient presenting with fragility fracture is not well documented.
Further research is required in our society to create and identify local evidence that will then help in the development of treatment guidelines.
A potential barrier could be the cost of therapy, time, cost of investigations and side effects of medication etc. It is difficult to have a systemic approach to preventing this potentially treatable condition due to a lack of trained family physician-led primary care who could take responsibility of long-term care and follow-up of these patients.
Further research is required in our society to create and identify local evidence, which will then help in the development of treatment guidelines. This may change screening and diagnostic criteria in our population.
As it is a progressive disease, it is important to address modifiable risk factors like smoking, alcohol intake, poor nutrition and low body weight. Any co-existing conditions like diabetes or liver disease or use of medications like steroids or long-term injectable contraceptives must be looked at.
Like many conditions, osteoporosis is asymptomatic; therefore, management should focus on preventing fragility fractures, also called fractures due to low-energy trauma. Early identification, particularly in high-risk population is essential. As primary care physicians, it is important to be aware that fragility fractures are associated with high morbidity and mortality.
In terms of managing or preventing osteoporosis, remember that it is a combination of maintaining a healthy lifestyle, taking a nutritious diet, incorporating exercise in your daily plan and taking measures – like hand railing, use of a stick, ensuring proper lighting in the room etc – to reduce falls. The following steps should be taken to keep bones healthy:
1- If individuals at risk of osteoporosis are smokers, then encourage and counsel for smoking cessation.
2- Ensure alcohol consumption is reduced. Provide information leaflets to support your argument.
3- Regular weight-bearing exercises like walking, stair climbing, aerobics etc
4- Healthy eating, including foods rich in calcium and vitamin D, like eggs, red meat and oily fish.
5- Supplements (daily) containing 10m (micrograms) of vitamin D. These supplements should be considered in pregnancy too.
6- Assess patients for risk of falls and consider hip protectors for high-risk patients.
7- Reduce polypharmacy in the elderly, particularly those causing sedation, as it increases the risk of falls.
8- Ensure that post-menopausal women and older men are taking calcium and vitamin D supplements.
People should be more aware of their health, particularly if there are long-term underlying medical conditions requiring regular medication. They should stay physically active and eat healthy foods. Such investments pay off in the long run.
Dr Hina Jawaid is an assistant professor in family medicine at the University of Health Sciences, Lahore
Dr Abdul Jalil Khan is an assistant professor in family medicine at Khyber Medical University, Peshawar