Is stunting in the elderly related to osteoporosis?

At a Glance:

What is osteoporosis?

The bone is regularly broken down and replaced by the body. With osteoporosis, the rate at which new bone is produced fails to keep up with the rate at which it is lost, leading to weak bones. Therefore, patients with osteoporosis are prone to fractures due to brittle bones.

It is more common in women, especially after menopause. To prevent the risk of developing osteoporosis, it is essential to build strong bones before 25-30 years of age when the peak bone density is reached. Consuming adequate levels of calcium helps immensely in the process.

What is bone density?

Bone density or bone mineral density (BMD) defines the amount of bone mineral present in the bone tissue. People with low bone density have porous bones, which are fragile and prone to breaking.

Bone density test helps to determine if a person has osteoporosis. The results are given in the form of T-scores, which compares the person’s BMD with that of a healthy 30-year-old adult. The following are the ranges:

• Normal bone density: -1 and above
• Low bone density: between -1 and -2.5
• Osteoporosis: -2.5 and below

What are osteoporosis symptoms?

Though older women are the most vulnerable, the damage due to osteoporosis tends to begin early in life. There are generally no early signs of osteoporosis. Once the bones have been weakened, the patient may experience low bone density symptoms such as:

• Lower back pain or neck pain
• Stooped posture and loss of height
• Bones that break easily (without trauma)
• Sharp pains that occur suddenly

What are the symptoms and stages of osteoporosis?

Old bone is constantly broken down and reabsorbed (by osteoclasts) and new bone (generated by osteoblasts) takes its place. Before osteoporosis develops, the body goes through a  midpoint, wherein the bones are in between healthy and osteoporotic. While they are weak, they don’t break easily. This stage is called osteopenia or pre osteoporosis.

Early stages of osteoporosis rarely exhibit visible symptoms, while the bone loss symptoms in the later stages are more prominent. Osteoporosis progresses through the following stages as we age:

Stage 1:

By the age of 30, peak bone density is achieved. At this stage, the rate at which new bone is formed and deposited matches the rate at which the bone is broken down. Osteoporosis begins during this state of equilibrium.
Symptoms:  It has no visible symptoms.

Stage 2:

Between the ages of 30-35, the bone breakdown occurs faster than the rate at which new bone is deposited, leading to a loss in bone density. Bone mineral density test may be able to detect low BMD.
Symptoms: Though detectable signs are rare, some people may notice receding gums, weak and brittle nails, or weaker grip strength.

Stage 3:

From the ages of 45-55, especially in post-menopausal women, bones become extremely fragile. Even simple movements like tripping or bending forward may place enough stress on the bones to break them. Most cases of osteoporosis are identified in this stage due to the visible symptoms.
Symptoms: The person may experience pain in the back or neck (osteoporosis back pain) or/and suffer fractures from minor movements or falls.

Stage 4:

Without intervention, osteoporosis may progress into the fourth and last stage. Along with fractures, there may be an increase in pain and the occurrence of deformities in the spine of other areas. The patient may have difficulty performing daily tasks such as sitting down on a chair, climbing the stairs, etc.
Symptoms: The person may lose height or develop a stooped back. Often known as dowager’s hump, it happens due to the compression of the vertebrae, which causes a curve in the spine.

What are the causes of osteoporosis?

Bone renews continuously; as old bone is reabsorbed by the body, new bone replaces it. Some osteoporosis causes are:

• The body fails to form sufficient levels of new bone.
• The body absorbs too much old bone.

This may occur due to:

Low calcium levels:

Bone production requires two essential minerals — calcium and phosphate. Thus, the intake of calcium should be sufficient for not only bone formation but also to drive other body processes. Bones become weak and brittle in the absence of sufficient calcium and can break easily.

Reduced rate of new bone formation:

Up until the 20s, bone mass is high since the body produces new bone faster than it absorbs old bone. Peak bone mass is reached by the age of 30, and the process slows down, making people who don’t have adequate levels of bone mass more prone to osteoporosis.

Lower levels of estrogen/androgen:

The lack of hormones like estrogen (in women) and androgen (in men) can cause osteoporosis. Since menopause is accompanied by lower estrogen levels, older women may develop osteoporosis. 

Other conditions that lead to osteoporotic bones may include:

• Bone cancer
• Overuse of corticosteroids
• Thyroid problems
• Genetic disorders

What are the types of osteoporosis?

Based on the cause of osteoporosis, doctors distinguish between primary and secondary osteoporosis. 

Primary osteoporosis:

It is linked to the aging process, wherein the rate at which bone is lost is linked to changing hormonal levels (due to age) or deficiencies in the body.

• Type 1: A drop in the level of estrogen in women and testosterone in men can lead to the loss of bone mass due to an increased rate of absorption of bone by the body. Osteoporosis in women occurs between the ages of 50-70. It can also occur in men over 70 years of age.
• Type 2: Calcium deficiency leads to the loss of bone structure. This can occur either due to insufficient intake of calcium and vitamin D or overactivity of the parathyroid glands.

Secondary osteoporosis:

As discussed previously, certain medications and medical conditions can also increase the risk of osteoporosis. This is known as secondary osteoporosis, which is caused due to the disruption of bone reformation due to external factors. Diabetes, thyroid problems, etc. can lead to the condition.

What are the risk factors for osteoporosis?

There are various factors that can influence your chances of developing osteoporosis. A few are discussed below. 

Genetic factors:

• Gender: Osteoporosis occurs more commonly in women than in men.
• Family history: Having parents or siblings with osteoporosis (especially a fractured hip) increases the risk.
• Body frame size: People with small body frames may develop osteoporosis as they age since they have lower reserves of bone mass to draw from.
• Age also plays a role. The risk of osteoporosis increases as a person ages.

Medical problems:

Medical conditions that increase the risk of osteoporosis are:

• Cancer: Cancer patients are at risk of bone cancer both due to the disease and side-effects of cancer therapies.
• Lupus: A systemic autoimmune disease wherein the body’s immune system attacks its tissues and organs.
• Rheumatoid arthritis: A systemic autoimmune disorder that affects the joints throughout the body.
• Pituitary gland disorders: Conditions like Cushing’s syndrome affect hormonal levels, causing secondary osteoporosis.
• Celiac disease: People with celiac disease may be deficient in calcium even if they consume sufficient levels, which affects their bone density.

Medications:

Long-term use of certain medications such as corticosteroids can affect bone growth. Other medications which are used to treat the following conditions have also been linked to osteoporosis:

• Cancer
• Transplant rejection
• Seizures
• Depression

Hormone levels:

Less or more levels of certain hormones can affect bone density. Some of these hormones are:

• Sex hormones: Lower levels of sex hormones weaken the bone. Post-menopausal women are, therefore, likely to develop osteoporosis due to reduced levels of estrogen. Men may also have reduced levels of testosterone as they age, making them more prone to the condition.
• Thyroid hormone: An overactive thyroid gland can lead to osteoporosis. Excessive medication to treat an underactive thyroid may also increase the risk.
• Adrenal and parathyroid glands: Overactivity in any of these two glands is associated with an increased risk of osteoporosis.

Dietary issues:

Certain issues related to one’s diet can also affect bone density.

• Low intake of calcium: A lack of calcium in the diet over a prolonged period reduces the amount of calcium available to the body, leading to low bone density.
• Eating disorders: Restricting one’s intake can affect the level of certain important nutrients, including calcium.
• Gastrointestinal surgeries: Some surgeries may reduce the size of the stomach or remove parts of the intestine, reducing the surface area available for the absorption of essential nutrients.

Lifestyle:

Certain lifestyle habits can increase the risk of lower bone mass:

• Alcohol: Regular and excessive consumption of alcohol affects bone density.
• Tobacco: The use of tobacco contributes to weaker bones as well.
• Sedentary lifestyle: Sitting for long hours and lack of exercise adversely affects the bones.

What are the complications of osteoporosis?

Some of the complications of osteoporosis are:

• Fractures: Hip and spinal fractures can be caused very easily, which increases the risk of heightened pain and disability. Sometimes, bones may even crumple, leading to back pain, stooped posture, and loss of height.
• Limited mobility: Osteoporosis can make it extremely difficult to perform daily activities such as walking or getting out of bed. In the absence of exercise, people can gain weight, which increases the risk of cardiovascular diseases and diabetes.
• Depression: A poor emotional state can be caused due to the lack of physical activity and an inability to perform tasks (that the patient could previously do). However, it is essential to maintain a positive mindset when combating any disease, including osteoporosis.

When to seek medical help for osteoporosis?

Some cases we recommend seeking medical attention for are:

• Constant pain in the neck or back in post-menopausal women.
• Severe pain in the joints or muscles that affects mobility.
• Trauma to the hip, spine, or wrist or suspected fractures in these areas. Visit the emergency ward in such cases.

Doctors will perform a bone density scan to assess whether the pain/fracture is a result of osteoporosis. 

Which doctor treats osteoporosis?

There is no particular osteoporosis doctor. It may be treated by doctors from various specialties. For an initial assessment, a person can visit as an orthopedician, endocrinologist, rheumatologist, geriatrician, gynecologist, generalist, internist, orthopedic surgeon, or physiatrist. 

How to diagnose osteoporosis?

The doctor will carefully evaluate the patient’s medical history, family history, and lifestyle habits while checking for osteoporosis. This helps to determine if blood tests are required to check for the levels of calcium, phosphate, testosterone, etc. in the body. 

The doctor will request a bone density scan in case osteoporosis is suspected. The specialized test is done with the help of dual-energy X-ray absorptiometry (DEXA). It measures the bone density in the spine, hip, or throughout the body.

The result of the test is derived by comparing the patient’s bone mineral density with two standards:

• Age-matched: The patient’s reading is compared to the usual bone density of someone their build and age.
• Young normal: The patient’s reading is compared to the bone density of a healthy young adult of the same gender.

If the patient’s score is below young normal, it is an indication of osteoporosis and susceptibility to its accompanying risks. 

What is osteoporosis treatment?

Recommendations for treatment are based on the results of the bone density test through which the risk of breaking a bone in the next decade is derived. If the risk is low, low bone density treatment may not involve medication. Generally, it is aimed at achieving the following objectives:

• Slowing down/preventing the development of osteoporosis
• Reducing osteoporosis pain
• Preventing the possibility of fractures
• Maintaining healthy bone mineral density

Medical treatment may employ the use of drugs to improve bone density, stimulate bone growth, regulate hormonal levels, etc. 

Other treatments that aim to modify the risk factors for bone loss and falls focus on lifestyle modification. This includes:

• Dietary changes: Young adults are encouraged to consume sufficient levels of calcium in their everyday diet to achieve peak bone density. Foods such as milk, other dairy products, and leafy greens are essential for this purpose.
• Exercise: Regular exercise such as jogging, walking, swimming, etc. reduce the risk of fractures associated with osteoporosis. Exercises that require the muscles to pull on the bone also help bones to retain and may even increase their density.

Is follow-up required for osteoporosis treatment?

Yes, follow-up treatment is required for patients undergoing long-term treatment for osteoporosis.

Patients on various medications may require long-term care and constant review of their response to the medication. This helps to evaluate if continuing treatment is the best option or if it needs to be changed. The patient’s response to medical treatment can also determine if it needs to be stopped completely.

How to prevent osteoporosis?

We recommend the following practices to ensure a healthy lifestyle that supports building and maintaining bone density for osteoporosis prevention:

• Calcium intake: Calcium is essential for healthy bones. Adults over the age of 19 require 1000 mg of calcium per day. Meanwhile, women over the age of 51 and all adults over 71 years of age require 1200 mg of calcium per day. Some good sources of calcium are dairy products, leafy greens, and seafood. Calcium supplements are also good options.
• Sufficient levels of Vitamin D: Vitamin D helps the body to absorb calcium, thereby helping to increase bone density. Vitamin D deficiency is common in people who have a vegan diet (i.e. no milk and meat) or have limited exposure to sunlight. Some good sources are cheese, egg yolks, and cod liver oil.
• Avoiding smoking: Smoking has two negative effects. It reduces the growth of new bone. It also reduces estrogen levels in women, which can lead to osteoporosis. Thus, avoiding smoking helps to promote healthier bones.
• Avoiding alcohol: Alcohol and osteoporosis make a bad combination. Excessive alcohol consumption i.e. more than two drinks per day can impact the rate of bone formation. This adversely impacts bone density. Avoiding alcohol also helps to prevent falls, which may lead to injuries and fractures.
• Exercising regularly: Regular exercise promotes healthy bones and increases the support that they receive from the muscles. Practicing yoga and other similar exercises also help to improve flexibility and balance, which reduces the risk of falls.

It is also essential to prevent the possibility of falls. Here are some useful tips:

• Remove objects which cause tripping such as toys.
• Install bars in the bathroom.
• Ensure plenty of light in all rooms.
• Get regular eye check-ups and wear up-to-date eyewear.
• Wear low heeled shoes with a good grip.

Which foods should be avoided with osteoporosis?

Certain foods can negatively impact bone density. These include:

• High-sodium food: Food that is high in salt causes the body to lose calcium and bone mass.
• Alcohol: Drinking more than two drinks a day negatively affects bone density.
• Caffeine: Foods containing caffeine include coffee, soda, and tea. It reduces calcium absorption, and thereby, bone mass.

We recommend reducing or eliminating their consumption from the diets of people who are at risk of or suffer from osteoporosis.

Living with osteoporosis and managing it

Osteoporosis is a progressive condition and can be managed and treated with the right medication and lifestyle habits. It is, therefore, always recommended to modify your lifestyle and accommodate the changes that osteoporosis brings to it. As we have recommended earlier:

• Have a healthy diet: Include sufficient sources of calcium and vitamin D, which can also be in the form of supplements for osteoporosis, and reduce the consumption of alcohol and tobacco.
• Exercise regularly: Include both weight-bearing exercises and exercises that promote balance and flexibility. The former improves bone mass and the latter helps to prevent falls.
• Prevent falls: This can be done by removing extra clutter from the rooms, wearing up-to-date prescription eyewear, keeping rooms well-lit, etc.

While one cannot reverse osteoporosis, it is possible to curb its effects and prevent fractures.

What is the prognosis for osteoporosis?

While osteoporosis cannot be reversed, its progress can be slowed down and contained if it is detected in the early stages and treated accordingly. Patients can increase their bone mineral density with medication, appropriate diet, and regular exercise, and the risk of fractures can be decreased with appropriate environmental modification as well. Thus, it is very important to detect and treat osteoporosis as early as possible. Appropriate measures should also be taken from an early age to prevent osteoporosis.

Conclusion:

Osteoporosis is a serious medical condition linked with decreasing bone mass that makes patients prone to fractures. It is especially common in post-menopausal women.  If left untreated, it can also lead to a loss of height and stooped posture. Therefore, it is essential to detect and treat osteoporosis early. It can be managed by changing one’s diet, such as consuming a sufficient amount of calcium and vitamin D and by adopting healthier lifestyle habits. Medications can also be given to spur new bone growth, increase bone mineral density, or manage the pain.

References:

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4. Kellet, Jennifer. “The stages of osteoporosis”. Hawker Place Physiotherapy & Pilates, 5 October 2017, hawkerplacephysio.com.au/newsletter/the-stages-of-osteoporosis. Accessed 5 September 2019.
5. MacGill, Marcus. “What to know about osteoporosis”. Medical News Today, Healthline Media, July 2019, www.medicalnewstoday.com/articles/155646.php
6. “Osteoporosis”. Mayo Clinic, Mayo Foundation for Medical Education and Research, June 2019, www.mayoclinic.org/diseases-conditions/osteoporosis/symptoms-causes/syc-20351968. Accessed on 4 September 2019.
7. “Osteoporosis complications”. Healthline, Healthline Media, www.healthline.com/health/osteoporosis-complications#complications. Accessed 4 September 2019.
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About Author –

Dr. Shashi Kanth G, Sr. Consultant Orthopedic Surgeon, Yashoda Hospitals, Hyderabad
He is specialized in arthroscopy, sports medicine, and orthopedics. His expertise includes Lower Limb Joint Replacement Surgery, Lower Limb Arthroscopy, Sports Injuries, Foot and Ankle Surgery, & Management of Complex Trauma.