Osteoporosis is one of the impending epidemics as the population around the world ages. It is usually considered a “silent disease” until a fracture occurs. Osteoporotic fractures are defined as fractures associated with low bone mineral density (BMD) and include clinical spine, hip, forearm and shoulder fractures. Based on 2001 census approximately 163 million Indians are above the age of 50; this number is expected to increase to 230 million by 2015. Even conservative estimates suggest that of these, 20 percent of women and about 10-15 percent of men would be osteoporotic. The total affected population would, therefore, be around 25 million and the figure can increase to 50 million. Osteoporosis leads to nearly 9 million fractures annually worldwide.
There have been studies around the world for prevalence of osteoporosis and its related risk factors but there have been limited studies which discuss the incidence of risk factors and osteoporosis in the Indian population. In this study, the incidence of osteoporosis and the associated clinical risk factors was studied in the urban Indian population of New Delhi. Bone mineral density of 445 individuals (223 males and 222 females) using qualitative ultrasound was assessed. The patients were also questioned regarding the presence of the various clinical risk factors as per the FRAX tool of WHO. The incidence of osteoporosis was found to be very high in the urban Indian population of New Delhi.
There is an urgent need for a comprehensive national program to screen for osteoporosis in India. More care and attention should be targeted towards elderly, especially the ones with the risk factors as discussed here to prevent the future epidemic of osteoporosis.
Recently, a WHO scientific group proposed that the 10-year probability of fracture calculated using information on clinical risk factors.The FRAX tool developed by the WHO is used in assessment of both clinical fracture risk and BMD. The risk of fracture is calculated in men or women from age, body mass index (BMI) computed from height and weight and independent risk variables comprising; a prior fragility fracture, parental history of hip fracture, current tobacco smoking, long-term use of oral steroids, rheumatoid arthritis, other causes of secondary osteoporosis and daily alcohol consumption of 3 or more units daily.
Information on age and Clinical Risk Factors was obtained using a standardized questionnaire administered face to face. The community out-reach programme was organized by the efforts of an NGO (Arthritis Care Foundation) in this study. The senior citizen forum and the resident welfare associations in the areas of central and east Delhi were contacted and those who volunteered for the camp were included in the study. Fourteen camps were organized in total and every third person attending the camp was included in the study. The study duration of the study was from October 2012 to March 2013. This study was conducted in Sukhdev Vihar, Ishwar Nagar, Sarita Vihar, Jasola, Kalkaji, East of Kailash, New Friends Colony, Maharani Bagh, Lajpat Nagar – I,II,III,IV, Nizzamuddin and Mayur Vihar. The cluster of subjects mainly belonged to the middle and upper class.
The 445 individuals in this study were in the age group of 38 years to 68 years (mean: 59.68 years). There were 223 males and 222 females in this study. Females were found have the significantly high incidence of osteoporosis. A very high incidence of osteoporosis (69%) was found in the studied population, with about 69% and only 31% people had normal BMD scores. It was found that the association of parent history of fracture, rheumatoid arthritis and secondary osteoporosis was associated with high incidence of osteoporosis.
The major osteoporotic fracture risk ranged from 0.70% to 25% and the risk of hip fracture ranged from 0 to 21%. The number and percentage of the population needing treatment were out of a total population of 445 was 113 (25.39%).
The problem of osteoporosis will soon be of greater importance in developing countries due to the increase in life expectancy. Identification of patients who are at risk of developing osteoporosis and adequate treatment can prevent long-term morbidity due to osteoporotic fractures. Unfortunately, osteoporosis receives low attention in the primary health care programs in most underdeveloped and developing countries where most population is largely unaware of the serious complications associated with osteoporosis.
The ideal management of osteoporosis is two-pronged, 1) by minimizing the risk of acquiring the disease by modification of individuals’ lifestyle to combat related risk factors and 2) by identification of patients at high risk to reduce future fractures. Many risk factors, some are modifiable (like low BMD, steroid intake etc.) and others non-modifiable (like advanced age, personal and parental history of fracture) are associated with osteoporosis.
When the risk factors are studied in the context of the Indian population, some points are worth mentioning. The average age at menopause has been reported to be slightly lower than the average Caucasian female. This decreased exposure to estrogen in a female in her lifetime is a major risk factor for osteoporosis. There are other described modifiable risk factors which have been associated with the low BMD in the Indian population. The most important factor is the low dietary intake of calcium and vitamin D. The causes of poor dietary intake of calcium include a large vegetarian population and the absence of government guidelines regarding fortification of food. Moreover, due to the increasing costs of dairy products, a large population is unable to afford them. An increased intake of phytates in the Indian diet (in chapatti) as another major contributing factor for the poor absorption of dietary calcium. Even though India is a sun-rich company, still a large population is vitamin D deficient. The causes of vitamin D deficiency include the use of traditional dresses like sari, burqa which limit the direct exposure of the skin to the sun. Other contributing factors include highly pigmented skin and overall low sun exposure.
The 10-year probability of MOF and HF was significantly associated with higher age and female gender. Parent history of fracture, presence of secondary osteoporosis and rheumatoid arthritis were also significantly associated with a 10-year probability of HF and MOF. Similar results were found in null by some authors in other populations30,31,32. The results are consistent with results published in literature where a null significant association between risk of osteoporosis and such variables was found30,43. This present study can be generalized to upper and middle class of an urban population.
Steroid intake was not found to be significantly associated with lower T-scores. The reason for this could be the selection of a possible “healthy cohort”. The cohort attending our health camps were a comparatively healthy population as depicted by only 15 total patients found to be using steroids. We were also unable to find a significant association between alcohol intake and smoking with T-scores.
We found a very high incidence of osteopenia and osteoporosis in the urban Indian population. Out of the population studied, 25.39% of the population needed treatment on the basis of FRAX score. Significant association of sex, parent history of fracture and secondary osteoporosis was identified in the present study whereas alcohol and steroid intake was not found to be statistically associated with the low T-scores. This study may predict a future epidemic of hip and major osteoporotic fractures in the aging population of India and might pose a serious challenge to the health planners. There is an urgent need for a comprehensive national program to screen for osteoporosis in India. We propose that more care and attention should be targeted toward elderly and especially postmenopausal female with respect to preventive measures. Further research and studies regarding fracture rates, the null component of osteoporosis, and evaluation of the applicability accuracy and feasibility of universal use of FRAX in Indian population are needed.
Dr. (Prof.) Raju Vaishya , a surgeon of international repute, is best known for his swift surgical skills in the field of Orthopedic & Joint Replacement. He has been working at Indraprastha Apollo Hospitals, New Delhi as a Professor and Senior consultant. He is the founder president of Arthritis Care Foundation. Apart from his distinguished clinical work in the field of arthroscopic and joint replace¬ment surgery, he is well known for his academic contributions. He has more than 150 published articles in various International and national peer-reviewed medical journals and has been regularly invited to give lectures, chairing sessions,etc. in Orthopaedic conferences around the world. He has been awarded for the best paper publication on nu¬merous occasions by Delhi Orthopedic Association and Apollo Hospitals. His work was recognized in the Limca book of records in 2012, 2013 & 2015 for do¬ing bilateral Total Knee Replacement in 93 years old gentleman, bilateral Total Knee Replacement in the oldest couple in a single sitting, ACL reconstruction on oldest man.