13th February 2000
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Time to save your bones

Osteoporosis Society launched

The Osteoporosis Society of Sri Lanka held its foundation meeting last week at the Sri Lanka Medical Association Auditorium. 

President of the Society, Prof. Devaka Fernando said the aim of the society is to make the public aware of the problem as well as to bring it to the notice of those who plan health services, so they can prepare now for the large number of Osteoporosis-related illnesses in the next 20 years.

They also hope to provide a forum for those who share their concerns and to collect and disseminate information about Osteoporosis. The members feel it is necessary to lobby for the inclusion of Osteoporosis as a significant public health problem in Sri Lanka.

By Hiranthi Fernando
In the next twenty years, many hip fractures are expected to be reported in Sri Lanka, as has happened in many Western countries. With increased life expectancy, the proportion of elderly people is increasing in the country and it has been found that one in two women and one in eight men over 50 years, are likely to have a fracture in their lifetime.

"This is due to Osteoporosis, a condition where the bones are brittle and more likely to fracture," said Prof. Devaka Fernando, Professor of Medicine at the University of Sri Jayawardenepura, who chaired the Osteoporosis Research Group. As the name suggests, Osteoporosis is caused by porous bones. 

"It can be compared to a tree, where termites have bored holes. It makes the tree more fragile although the damage is not seen externally," Prof. Fernando explained. "It is a condition that may not give dramatic symptoms."

Prof. Fernando said that fractures commonly occur in people over 60, but the disease occurs in those who are younger as well. It often remains undetected until a fracture occurs. 

"Those who have fractures are only the tip of the iceberg," he said. The large majority do not show symptoms but are susceptible to fractures. According to the World Health Organization (WHO) definition, Osteoporosis is caused by a reduction in bone mineral density. The elderly have low bone mass, and so are at a greater risk of Osteoporosis.

Osteoporosis has been found to affect mainly elderly women. Explaining the incidence of the disease, Prof. Fernando said that by the age of 30, we develop peak bone strength. From 30 onwards, bone strength declines. At menopause in women, the decline is much greater. Although the female sex hormone, oestrogen and the male hormone testosterone are very similar, in females there is a dramatic halt in oestrogen production levels at menopause. A similar fall occurs in men but it is a slower process, spread over years. 

Fractures caused by Osteoporosis occur mostly in the hip, spine or wrist. Of these hip fractures cause the greatest disabilities. It has been seen that after a hip fracture, 10% to 20% die during the following six months, 50% are unable to walk without assistance and 25% require long-term care. 

Yet fractures due to Osteoporosis need not be an inevitable consequence of aging. They are largely preventable. Health services need to be prepared to meet the additional demands of a disease that is likely to be a serious health problem in the near future.

"Right now, in Sri Lanka, Osteoporosis and its related fractures are a totally neglected aspect of health care," Prof. Fernando said. "So much so that let alone providing services, even research studies are carried out by just four people from the Universities of Sri Jayawardenepura and Ruhuna."

"Osteoporosis being a disease that affects the elderly, is neglected by health care planners and policy makers," Prof. Fernando said. They are undemanding as a group and tend to be ignored. 

"Even on a personal level, Grandma is expected to be fragile, hunched and have aches and pains. It is not treated as an illness but rather as part of growing old. However, a marked stoop or loss of height is a manifestation of Osteoporosis."

According to Prof. Fernando, fractures are an end point of Osteoporosis and are preventable. Prevention should start in younger age groups. Adolescents and teenaged girls should be encouraged to develop and maintain bone health by an active lifestyle, regular physical exercise and an adequate intake of dietary Calcium. The greatest benefits of such a programme will be seen between the ages 10 to 15. After puberty the effects are not so significant. However, maintaining regular physical exercise even at the adult stages can prevent to a certain extent, a drop in bone density. 

"The greatest benefit is seen in older women if Hormone Replacement Therapy (HRT) is given immediately after or with menopause," Prof. Fernando said. He dismissed the risk of cancer of the womb commonly associated with HRT as not being significant. "The risk of cancer is only in those who have a particular type of HRT. There are many varieties of HRT not associated with cancer. HRT is a group of treatments. If used appropriately under medical supervision there is no danger. When a scientific study shows a risk, one has to consider, whether the benefits outweigh the risks. Even if there is a risk, it can be overcome. Crossing the Galle Road can also be a risk," he remarked.

Prof. Fernando stressed that continuation of a healthy lifestyle into old age would have beneficial effects. More than effects on the bone, by improving their postural control, people would be fitter, more coordinated and less likely to fall and incur a fracture. There is also evidence to show that adequate intake of calcium and Vitamin D even in this age group slows down the rate of declining bone structure. He advised post menopausal women to have HRT and physical exercise, provided they do not have any other disease such as heart ailments. Adequate intake of calcium is also important. Foods such as milk, greens and sprats are rich in calcium. Medical advice should be sought to determine the amount of supplementary Calcium needed. Although one may feel well, it is advisable for women in the menopause stage to go for screening specifically targeted for women. A family doctor could advise on this, he said.

Prof. Fernando, who has been involved in several studies on Osteoporosis since 1985, says that significant efforts should be made by government departments and NGOs at addressing this serious threat to the health of the nation. Clinical research on Osteoporosis should be encouraged and supported and facilities developed for its treatment.

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