Osteoporosis as a silent epidemic

1. Determinants of
Osteoporosis
• Dr.Uma Gupta MD,FICMCH.
Professor,Dept of Obstetrics & Gynecology Era’s
Lucknow Medical College.Lucknow
umankgupta@gmail.com
 Dr.N.K.Gupta,MS,M.Ch.
Professor,Dept of Surgery,Era’s Lucknow Medical
College.Lucknow.
drnkgupta2000@yahoo.com

2. Definition
 Osteoporosis is defined as “a disease
characterized by low bone mass and
microarchitectural deterioration of bone
tissue leading to enhanced bone fragility
and a consequent increase in fracture
risk”
Simon S. Lee. Osteoporosis. Clin Geriatr Med 2005; 21: 603-629
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4. Magnitude of problem
 It is a global problem affecting 150 million
men and women worldwide.
 In USA over 10 million individuals are
affected by osteoporosis and 18 million
have osteopenia
Osteoporosis prevention, diagnosis and therapy. NIH consensus statement
2000; 17(1): 1-36.
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5. Magnitude of problem
 Osteoporosis is emerging as a major
health problem in view of the increasing
number of older people in India. It is
estimated that in India 61 million people
are affected by osteoporosis out of which
80% are female
Joshi VR, Mangat, G, Balakrishnan C and Mittal G. Osteoporosis
approach to Indian scenario. J Assoc Physicians India 1998; 46(11):
965-967.
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6. Magnitude of problem
 Above 65 years of age, 50% of females
are affected by osteoporosis. One in
every third post-menopausal woman is at
risk of fracture. Projections in Asia for
the year 2050 indicate that this figure will
rise from 26% in 1990 to 45%.
Consensus statement of the expert group meeting convened by the Osteoporosis Society of India
at All India Institute of Medical Sciences, New Delhi on 10th February, 2003 President Dr. A.B.
Dey., Secretary General- Dr. Rohini Handa.
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7.  Due to morbid consequences,
prevention of osteoporosis is considered
essential. Post menopausal osteoporosis
is common and is preventable. It’s
worldwide health concern & economic
burden of osteoporosis is likely to
increase with improvement in life
expectancy.
WHO scientific group on the assessment of osteoporosis at primary health care
level. Summary Meeting Report. Brussels, Belgium, 5-7 May 2004.
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8.  WHO definition of osteoporosis
is based on BMD levels :
Normal bone mass: T score greater
than, equal to -1.0.BMD is above 1
standard deviation below the
average young adult value.
Osteopenia:T score between -1.0 and -2.5
BMD is between 1 and 2.5 standard
deviation below the average young adult
value.
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9. Osteoporosis: T score less than -2.5
BMD more than 2.5 standard deviation
below the average young value.
Severe osteoporosis: T score less than -2.5
or established osteoporosis BMD
more than 2.5 standard deviation below
the average young adult value and at
least one osteoporotic fracture.
World Health Organ Tech Rep Ser 1994; 843: 1-129.
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10. Pathophysiology - osteoporosis
 Bone is a dynamic organ which remodels
itself throughout life. This process
involves removal or resorption of bone.
Factors that participate in modulating
these processes include systemic
hormones and local paracrine factors
Simon S. Lee. Osteoporosis. Clin Geriatr Med 2005; 21: 603-629
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11. Pathophysiology - osteoporosis
 The specialized cells that perform
remodeling include osteoblasts and
osteoclasts. The osteoblasts are the cells
that form bone. The organic matrix
synthesized by osteoblasts includes
proteins in addition to type I collagen.
There are also noncollagenous proteins
within the organic structure
Heinegard D, Hultenby K, Oldberg A et al. Macromolecules in bone matrix. Connect
Tissue Res 1989; 21: 3.
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12. Pathophysiology - osteoporosis
 The osteoclasts are the bone resorbing
cells. Macrophages also participate-
through phagocytosis and by producing
cytokines. The cytokines participate in
increased osteoclast recruitment,
differentiation, and function. Systemic
hormones and local factors regulate
osteoblasts and the osteoclasts.
Raisz LG, Kream BE. Regulation of bone formation. N Engl J Med 1983; 309: 29.
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13. Pathophysiology - osteoporosis
 The remodeling process in the adult
skeleton is continuous throughout life,
peak bone mass is reached in the middle
of the third decade of life, a plateau
period –
 Following this plateau phase there begins,
a period of net bone loss equivalent to
about 0.3% to 0.5% per year
Simon S. Lee. Osteoporosis. Clin Geriatr Med 2005; 21: 603-629
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14. Pathophysiology - osteoporosis
 Accelerated bone loss is the dominant
effect in postmenopausal osteoporosis.
With the progressive loss of estrogen,
levels of these cytokines rise and enhance
bone resorption by increasing the
recruitment, differentiation and activation
of osteoclast cells
Hurwitz MC. Cytokines and estrogen in bone: anti-osteoporotic effects. Science
1993; 260: 623.
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15. TYPES OF OSTEOPOROSIS:
 A. Primary Osteoporosis:
(i) Type I osteoporosis: It occurs in
hypogonadal individuals. Postmenopausal
women and women with oligo-menorrhoea,
develop net bone loss directly related to the
loss of gonadal function. Patients present with
fractures of skeleton where trabecular bone is
predominant; e.g.,distal forearm and vertebral
bodies.
Prior JC, Vigna YM, Schechler MT et al. Spinal bone loss and ovulatory
disturbances. N Engl J Med 1990; 323: 1221.
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16.  (ii) Type II osteoporosis: It is associated
with the normal aging process and is seen in
individuals typically after the age of 60 to 70
years. Normal aging is associated with a
progressive decline in the supply of
osteoblasts and a decrease in their activity.
This results in net loss of bone. Fractures of
cortical bone, such as in the femur, femoral
neck, proximal tibia, and pelvis, are more
common in this group.
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17.  Secondary Osteoporosis:
 It can occur due to endocrine diseases
(hyperparathyroidism, hypothyroidism,
chronic renal failure, diabetes mellitus),
hypervitaminosis A, immobilization,
malignancy, rheumatoid arthritis and drug
induced (corticosteroid, ethanol,
barbiturates, etc.).
Shah Rashmi S, Savardekar Lalita S. Postmenopausal osteoporosis in India: Growing Public Health Concern.
National Institute for Research in Reproductive Health, (ICMR). Presentation made at Forum 9, Mumbai, India,
September 2005; 12-16.
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18. DIAGNOSTIC MODALITIES FOR
TESTING BMD:
Dual Energy X-ray Absorptiometry
(DEXA)
Quantitative Computerized
Tomography
Quantitative Ultrasonography
(QUS)
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19. IMPORTANT RISK FACTORS
AFFECTING BONE MINERAL DENSITY:
 Increasing Age - Perimenopause and
Menopause: Oestrogen deficiency is
important factor in the pathogenesis of bone
fragility.
 Prior to menopause, bone loss occurs at the
rate of 0.5% to 1.0% per year which accelerates
at the rate of 2% to 5% per year due to decline
in estrogen levels and is maximum in the first
3-6 years after menopause.
Riggs BL, Kholsa S and Melton LJ III. A unitary model for involutional osteoporosis: estrogen deficiency
causes both type-1 and type-2 osteoporosis in postmenopausal women and contributes to bone loss in
aging men. J Bone Miner Res 1998; 13: 763-773.
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20. Weight :
Low body weight is associated with low BMD.
In obesity, there are several mechanisms that produce higher
bone mass including the weight bearing effect of excess soft
tissue on skeleton, the association of fat mass with the
secretion of bone active hormones i.e. estrogens, leptins
and adiponectin from the adipocytes, and the secretion of
bone active hormones from other organs such as the gut
and the pancreas.
It is suggested that improved vitamin D status due to storage
of vitamin D in fatty tissues also improves bone mass.
Kroger H, Tuppurainen M, Honkanen R. et al. Bone mineral density and risk factors for
osteoporosis – a population based study of 1600 perimenopausal women. Calcif Tissue Int
1994; 55: 1-7.
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21. Parity and Lactation :
 Pregnancy and lactation - predisposing factors
for osteoporosis.
 During pregnancy, mineralization of fetal
skeleton requires approximately 30 g of
calcium from maternal sources. Furthermore,
abundant calcium is lost from the mother
during lactation.
 BMD may change during and after pregnancy.
Lactation causes bone loss of upto 5%.
Sowers MF. Pregnancy and lactation as risk factors for subsequent bone loss
and osteoporosis. J Bone Miner Res 1996; 2: 1052-1060.
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22. Menstrual Function
 Age at menarche and menopause seem to
be of important in determining endogenous
estrogen.
 Onset of hypothalamic amenorrhoea is
extremely important in determining its impact
on bone density. Estrogen deficiency in
puberty is -devasting b’s adolescence is a
crucial time for bone formation and for
eventful attainment of peak bone density.
Miller KK and Klibanski. Amenorrhoea bone loss. Journal of Clinical
Endocrinology and Metabolism 1999; 84(6): 1775-1783.
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23. Menstrual Function
 Delayed menarche and amenorrhoea
during adolescence are associated with
decreased peak bone mass.
 Untreated hypothalamic amenorrhoea is
associated with progressive bone loss during
first 5 years of amenorrhoea after which bone
loss may significantly decline.
Miller KK and Klibanski. Amenorrhoea bone loss. Journal of Clinical
Endocrinology and Metabolism 1999; 84(6): 1775-1783.
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24. Diet
Nutrition is an important factor in the
development and maintenance of bone mass.
Approximately 80-90% of content is
comprised of calcium and phosphorous.
 Other dietary components - protein,
magnesium, zinc, copper, iron, fluoride,
vitamin D, A, C and K .
Ilich JZ, Kerstetler JE. Nutrition in bone health revised: a study beyond calcium.
Journal of American College of Nutrition 2002; 19: 715-737.
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25. Calcium Supplementation
 The adult human body contains about
1000 to 1500 gm of calcium of which 99%
is found in the bone.
 Dietary calcium requirements are
determined mostly by skeletal needs.
Skeletal response occurs only when
calcium is increased from the deficiency
level to a threshold zone.
Ilich JZ, Kerstetler JE. Nutrition in bone health revised: a study beyond calcium. Journal
of American College of Nutrition 2002; 19: 715-737.
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26. Intake of Magnesium
 There is approximately 25 mg of Magnesium
in human body.
 Magnesium plays an important role in calcium
and bone metabolism. Magnesium deficiency
alters calcium metabolism resulting in
hypocalcemia.
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27. Genetic Factors affecting BMD :
 Race and familial predisposition are
non modifiable risk factors for
osteoporosis10.
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28. Effect of lifestyle on bone mass
 Low physical activity leads to increased bone
loss, decreased BMD and increased fracture
risk.
 Osteoclasts are sensitive to mechanical
loading and reduced loading as in immobility
leads to bone loss.
 Moderate exercise of 5-10 hours per
week or high exercise of 10 hours per week
produces a better improvement in BMD.
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29. BIOCHEMICAL PARAMETERS
AFFECTING BMD
 Markers of bone formation include –
serum calcium, serum inorganic
phosphate, serum alkaline phosphatase
(total and bone specific), serum
osteocalcin, serum procollagen I carboxy-
terminal extension peptide.
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30. FSH
 Sowers et al performed a longitudinal , Study of
Women Health Across the Nations (SWAN).
 Participants were 2311 premenopausal or early
postmenopausal women.
 Baseline FSH values were > 35-45 mIU/ml and
lower follow up of FSH (40-50 mIU/ml) predicted
a 0.05 gm/cm2 four year spine BMD loss.
 The study results gave evidence that FSH may
have direct effect on bone.
Sowers M, Jannausch M, McConnell D, Little R, Greendle G, Finkelstein J, Neer R, Johnston J and
Ettinger B. Hormone predictors of bone mineral density changes during the menopausal transition:
Journal of Clinical Endocrinology & Metabolism 2006; 91(4): 1261-1267.
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31. Take home message
 Bone mineral density and biochemical
parameters measurement is helpful in
assessing bone health in women. Timely
intervention can prevent bone loss and its
associated complications
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