Osteoporosis is a condition characterized by low bone mass and deterioration of bone tissue, leading to increased fragility and fracture risk, especially in the elderly and women post-menopause. Various factors, including hormonal changes, dietary deficiencies, and lifestyle habits, contribute to its development, with significant prevalence noted among Indian women due to low calcium and vitamin D levels. Treatments include dietary supplements, bisphosphonates, hormone replacement therapy, and lifestyle modifications to strengthen bones.

1. Osteoporosis

2. What is osteoporosis?
• Bone is a living tissue that undergoes lifelong remodelling (Frost 1969), whereby local
regions of the bone are destroyed and rebuilt in a systematic way .This process serves to
repair microdamage caused by normal body wear and tear and is essential to maintain
strong bones. Bone is lost during the normal aging process. Osteoporosis occurs when a
person has an inadequate amount of bone to provide sufficient strength to perform
normal daily activities. Osteoporosis usually is caused by a chronic imbalance in the bone
remodelling cycle in which bone resorption is not adequately compensated for by
subsequent bone formation (Turner, Sibonga, 2000). Osteoporosis is characterized by
low bone mass with micro architectural deterioration of bone tissue leading to enhance
bone fragility, thus increasing the susceptibility to fracture. Although exact numbers are
not available, based on available data and clinical experience, on estimated 25 million
Indians may be affected. Osteoporotic fractures in India occur commonly in both sexes,
and may occur at a younger age than in the West. (Malhotra, Mittal, 2008)

3. History of osteoporosis:
• One of the worst things for a woman as she grows older is Osteoporosis. However, apart from
being a new disease, it has actually been affecting women since the dawn of our civilization,
dating back over 4,000 years to the Egyptians. The history of Osteoporosis is long. Archaeologists
and researchers have actually found Egyptian mummies with the hump that is a tell-tale sign of
Osteoporosis. However, while this may have been a serious problem in the days of Ancient Egypt,
it is much more manageable these days and many women are able to stand straight and tall, well
into their old age .It was in the 18th century when John Hunter, an English surgeon, discover
something that would play a critical role in Osteoporosis. He found that as a new bone was laid
down in the body, the old bone would be destroyed or absorbed. This is remodelling and it would
be over 100 years before it became a recognized cause of Osteoporosis. Then came Jean George
Chretien Frederic Martin Lobstein, who was a French pathologist in the 1830s, and he found that
some bones in patients had many larger than normal holes. He called Osteoporosis, which meant
Porous Bone, to describe it Over one century later, Full Albright of the Massachusetts General
Hospital found that postmenopausal women were more susceptible to this condition and for
having frail bones. The history of Osteoporosis continued into the 1960s that researchers began
to develop devices which could detect the bone loss.

4. Type of osteoporosis:
Primary osteoporosis:
• It occurs in both genders at all ages but often follows menopause in
women and occurs late in life in men.
• (i). Primary osteoporosis Type I (or) Postmenopausal osteoporosisIt is characterized
by an increased bone resorption that primarily affects trabecular bone and is directly
linked to the decreased production of estrogen that coincides with menopause.
Rapid bone loss is osteoclast-mediated and occurs in women within the first 5 to 10
years after menopause.
• (ii). Primary osteoporosis Type II Proportionate loss of trabecular and cortical
boneoccurs usually due to a decrease in bone cell activity accompanying aging. This
type of osteoporosis predominately affects men and women over the age of 70 years
and is called senile osteoporosis.

5. Secondary osteoporosis
• Secondary osteoporosis is a condition where osteoporosis occurs as a result of an identifiable cause.
There are several causes for secondary osteoporosis which include:
• 1. Endocrine disorders: Acromegaly, adrenal atrophy in Addison disease, Cushing syndrome.
• 2. Eating disorders: Endometriosis, gonadal insufficiency (primary or secondary), hyperparathyroidism,
hyperprolactinemia, hyperthyroidism, hypogonadism, Type 1 diabetes mellitus.
• 3. Nutritional disorders: Tumor secretion of parathyroid hormone-related peptide, gastrointestinal
disease.
• 4. Alcohol-related liver diseases: Celiac disease, chronic active hepatitis, chronic cholestatic diseases,
gastrectomy, inflammatory bowel disease, jejunoileal bypass.
• 5. Malabsorption syndromes: Pancreatic insufficiency, parenteral nutrition, primary biliary cirrhosis,
severe liver disease.
• 6. Marrow-related disorders: Amyloidosis, hemochromatosis, hemophilia, leukemia, lymphoma,
mastocytosis, multiple myeloma, pernicious anemia, sarcoidosis, sickle cell anemia, thalassemia.
• 7. Organ transplantation: Bone marrow, heart, kidney, liver, and lung.

6. Risk factors in women
• 1. Steroids:Taking steroids over a long period of time can lead to osteoporosis.
• 2. Estrogen deficiencies:Women who have had an early menopause (before the age of 45) or a hysterectomy where one
or both ovaries have been removed are at greater risk. Removal of the ovaries only (ovariectomy) is relatively rare but is
also associated with an increased risk of osteoporosis. Excessive bone loss resulting from estrogen deficiency is believed
to be the most important of the many factors that determine the overall risk for osteoporosis in women (Richelson et
al., 1984).
• 3. Lack of exercise:Moderate exercise keeps the bones strong during childhood and throughout adulthood. Anyone who
does not exercise, or has an illness or disability which makes exercise difficult, will be more prone to losing calcium and
more likely to develop osteoporosis. Exercise is therefore very important in preventing osteoporosis. (However, there is
one case in which this is not true: for the small number of people who exercise very intensively, particularly women
who exercise so much that their periods stop, the risk of osteoporosis may actually be increased.)
• 4. Poor diet:A diet that does not include enough calcium or vitamin D can make osteoporosis more likely to occur. A
case-control interview-based study on postmenopausal women showed that a history of fractures in relatives, weight
<60 kg, height <155 cm are significant risk factors for osteoporosis, and regular consumption of milk, almonds, and
fruits are protective factors (Keramat, Mithal, 2005).
• 5. Heavy smoking:Tobacco lowers the estrogen level in women and may cause early menopause (Turner, 2000), which
increases the risk of osteoporosis.
• 6. Heavy drinking:A high alcohol intake reduces the ability of the body’s cells to make bone. Overwhelming evidence
from human and laboratory animal studies shows that chronic heavy drinking has detrimental effects on the skeleton
(Turner, 2000).

7. Effects of menopause and effects of estrogen
on osteoporosis
• Menopause is characterized by the loss of estrogen production by the ovaries. This may occur by
natural means or by the surgical removal of both ovaries. This loss of estrogen accelerates bone loss for
a period ranging from 5 to 8 years.In terms of bone remodeling, the lack of estrogen enhances the
ability of osteoclasts to absorb bone. Since the osteoblasts (the cells which produce bone) are not
encouraged to lay down more bone, the osteoclasts win, and more bone is lost than is produced. The
accelerated bone loss during menopause has little relationship to the amount of calcium intake. After
age 60, however, proper attention to calcium intake is very important and has been shown to increase
bone density.
• Estrogen deficiency accompanying menopause leads to bone loss, which in turn predisposes women to
osteoporosis later in life. Estrogen deficiency accelerates bone remodeling, which is the process by
which small areas of bone are destroyed and rebuilt, and leads to an imbalance whereby bone
resorption—the part of remodeling consisting of breaking down and assimilating—exceeds bone
formation (Turner, Sibonga, 2001).Estrogen influences virtually all aspects of bone physiology
throughout life. The hormone plays an important role in maintaining bone mass in adult women, in
part by slowing bone remodeling and in part by maintaining the proper balance between the activity of
bone-forming cells (osteoblasts) and bone-resorbing cells (osteoclasts) (Turner et al., 1994).

8. Osteoporosis in Indian women
• In childhood and adolescent period, bone formation exceeds resorption, resulting in continued
skeletal growth and denser, stronger, longer, and heavier bones. This process slows down in
adulthood, and peak bone mass is attained at about 30 years of age. After this, resorption begins
to exceed formation. Normal bone loss averages 0.7 percent per year. It gets accelerated at the
time of menopause to 2-5 percent per year, which may continue for up to 10 years (Francis et al.,
1997).
• Calcium and vitamin D nutrition play an important role in determining bone health. Recent data
demonstrated a high prevalence of vitamin D deficiency in different subgroups of the Indian
population, despite the availability of abundant sunshine. This includes urban and semi-urban
Indians, postmenopausal women, pregnant women, school children, and newborns (Sachan et al.,
2005; Marwaha et al., 2005; Harinarayan et al., 2007).
• Studies have shown that the majority of urban office workers have moderate to severe vitamin D
deficiency, which is asymptomatic (Goswami et al., 2000; Arya et al., 2004). Arya et al. used a
serum vitamin D level of 15 ng/ml as a cut-off and found 66.3 percent of subjects to be deficient.

9. Of the women suffering from osteoporosis
• 20.6 percent had severe vitamin D deficiency (<5 ng/ml)
• .31 percent had moderate deficiency (5-9.9 ng/ml).
• 18.5 percent had mild deficiency (10-14.9 ng/ml).
• Inadequate calcium intake was proposed as an additional major factor contributing to poor
bone health in Indian women from low-income groups who consumed inadequate calcium,
calories, and proteins (Shatrugna et al., 2005).Poor sunlight exposure, skin pigmentation, and
vitamin D-deficient diets are also contributing factors. Atmospheric pollution has been
suggested as a contributor to vitamin D deficiency in children from Delhi (Puliyel et al., 2000).A
cross-sectional study of 159 pre- and postmenopausal women was performed at the
Department of Biochemistry, S.D.M College of Medical Sciences and Hospital, Dharwad, during
the period of May 2005 to September 2005. The study group consisted of 75 postmenopausal
women aged 46-65 years and 84 premenopausal women aged 25-45 years. Serum was
separated and analyzed for total calcium, ionized calcium, phosphorus, total protein, albumin,
alkaline phosphatase, hydroxyproline, and creatinine.

10. Results of studies conducted
• Serum total calcium and ionized calcium showed a significant decrease
in postmenopausal women compared to premenopausal women.
• Serum ALP levels increased significantly in postmenopausal women.
• Nearly 35% of women lose bone density faster during the late
perimenopausal period.
• Summary of key values:
Serum ALP (U/L): 32.44 ± 6.09 (Pre) vs. 56.88 ± 7.91 (Post)
Urinary Hydroxyproline (mg/g Cr): 10.21 ± 3.19 (Pre) vs. 22.35 ±
10.88 (Post)

11. Prevention of osteoporosis(diet)
• There is a great deal that can be done at different stages of life to
guard against the condition of osteoporosis.
• Healthy diet recommendations:Milk, cheese, and yogurt
• Broccoli, Dark green leafy vegetables
• Canned fish with bones
• Fortified bread and cereal products
• Vitamin D dietary reference intakes:
• 1-70 years of age: 600 IU/day
• Pregnancy and lactation: 600 IU/day
• >70 yrs of age: 800 IU/day

12. Prevention of osteoporosis(exercise)
• Strengthen bones and muscles
• Improve posture
• Increase muscle strength
• Improve balance
• Relieve or decrease pain
• Enhance the sense of well-being

13. Effect of smoking on bones
• Cigarette smoking is a risk factor for osteoporosis. Studies show that smokers are at an
increased risk due to:
• Lower body weight
• Early menopause
• Poor diets and physical inactivity
• The longer one smokes and the more cigarettes one consumes, the greater the risk of fractures in old age.
• Smokers who experience fractures may take longer to heal.
• Significant bone loss has been observed in older women who smoke
• Effects of smoking on bones:
• Smoking releases free radicals that damage cells, including osteoblasts (bone-forming cells).
• It disrupts the balance of hormones (like estrogen), worsening bone loss during menopausal years.
• Smoking increases cortisol levels, which contributes to bone breakdown.It impedes the hormone
calcitonin, which helps build bones.
• Smoking damages blood vessels, reducing oxygen and nutrient supply to bones, leading to poor healing
and increased fracture risk.Smokers face double the risk of fractures compared to non-smokers.

14. Effect of drinking alcohol on bones
• Drinking too much alcohol should be avoided. The recommended
daily maximum is 2-3 units.
• Effects of alcohol on bones:
• Chronic heavy drinking has detrimental effects on the skeleton (Turner, 2000).
• Alcohol use produces bone with reduced strength (Hogan et al., 1997).
• Alcoholics of both genders may experience diminished bone strength, beyond
what is predicted by bone mass measurements.
• Limited studies on the effects of alcohol use during childhood and
adolescence show alcohol negatively affects bone remodeling in growing
individuals.

15. Treatments for osteoporosis
• In addition to preventative measures, pharmacological agents are available to slow bone loss or
reduce fracture risk. These treatments include:
• 1. Calcium and Vitamin D:People over 60 may benefit from taking daily amounts of vitamin D and 1500 mg of
calcium.
• 2. Bisphosphonates:Slow bone loss and increase bone density.Alendronate (Fosamax) and Risedronate (Actonel)
reduce hip and spine fractures.Available as daily-dose or weekly-dose tablets, but they must be taken on an
empty stomach.Etidronate (Didronel) is a weaker alternative, taken in 3-month cycles.
• Hormone Replacement Therapy (HRT):
• May be beneficial for bones during menopause but should only be used to manage menopausal symptoms.HRT
is associated with reduced fracture risk but increases risks of venous thrombosis, cardiovascular issues, and
breast cancer.Benefits and risks must be carefully weighed.
• Other treatments:
• Selective Estrogen Receptor Modulators (SERMs) like Raloxifene (Evista) mimic estrogen's effects on bones while
reducing breast cancer risk.
• Calcitonin can be administered via injection or nasal spray to reduce vertebral fractures and alleviate pain,
though side effects like nasal irritation may occur.