Why young Indians are developing brittle bones

Mayank (17) was deep into preparations for his engineering entrance examinations. The long study hours meant sitting for long durations. And when boredom crept in, he would reach for a packet of chips and a bottle of soft drink. Most of the time, this combo replaced his usual meals.

He would often complain of back pain, pain in his legs and arms and feel fatigued despite no physical exertion. He had been also taking anti-epileptic medication for the past two years. When he finally reached my OPD, X-rays and DEXA scan to measure his bone mineral density (BMD) revealed that he was suffering from adolescent osteoporosis due to a combination of risk factors, including poor nutrition, vitamin D deficiency, low sun exposure, low dietary calcium intake and limited physical activity.

He was prescribed calcium and vitamin D supplements, regular exercise and a healthy, balanced diet, and was advised to ask his doctor to change his epilepsy drug, if possible.

Classically, osteoporosis is a disease affecting the elderly, especially postmenopausal women (due to low oestrogen levels) and men over 60 (low testosterone levels). It is characterised by reduced bone mass leading to increased susceptibility to fractures.

Inadequate nutrition since childhood, junk foods replacing traditional Indian diets leading to poor nutrition, increased indoor living limiting sun exposure and causing vitamin D deficiency, low calcium intake, sedentary lifestyle, long working and sitting hours, etc, are contributing to the early onset of osteopenia (when the bone mass starts shrinking but is still asymptomatic) and osteoporosis (low bone mass causing brittle bones) among young adults in their 20s and adolescents.

In a recent case in Pune, an 11-year-old boy was found to have osteopenia, discovered after a femur fracture from a minor trauma. Factors included poor dietary calcium intake, less skin exposure to sunlight and limited physical activity.

Nearly 90 per cent of peak bone mass is achieved during adolescence and young adulthood, a critical determinant of lifelong skeletal strength.

Factors like a calcium and protein-rich diet, exercise and adequate vitamin D from regular skin exposure to sun act as stimulants for the bone forming cells, osteoblasts. On the contrary, sedentary lifestyle, increasing consumption of junk/processed food, smoking, alcohol, poor physical activity, inadequate exposure to sunlight, certain chronic diseases and long-term use of certain drugs suppress the osteoblasts and stimulate the osteoclasts (bone cells that resorb or break down old and damaged bone tissue), thus leading to bone resorption and osteoporosis.

The initial symptoms of osteoporosis are mild and vague like lethargy, easy fatigability, intermittent backache and pain in extremities. Persistent pain may reflect micro-fractures in the vertebrae due to weakened bones or muscle fatigue from weak structural support. In undiagnosed/untreated osteoporosis, minimal trauma can cause vertebral compression fractures or long bone fractures.

Thus, since osteoporosis is mildly symptomatic until a fracture occurs, the subtle signs in the young should be seen as red flags for this metabolic bone disease, especially in persons on long-term medication or with poor lifestyle habits. Early diagnosis, intervention and lifestyle changes can help check the disease.

Diagnosis is based on symptoms supported by blood tests like serum calcium, phosphate, alkaline phosphatase, parathyroid hormone (PTH), and vitamin D levels; X-rays of the painful bones and DEXA scan or BMD test.

Management involves addressing underlying cause(s) and lifestyle modifications.

In case of vitamin D and calcium deficiency, take oral calcium (1000–1200 mg/day) and vitamin D supplement (800–1000 IU/day).

If serum vitamin D levels are low, loading (either daily/weekly/monthly) doses of oral or injectable vitamin D are advised.

A daily 30-minute skin exposure to direct sunlight (of 30 per cent bare skin surface area, usually arms and legs, not covered with clothes) provides adequate vitamin D. Sunlight coming through glasses/curtains does not provide vitamin D. Daily diet should include milk, dairy products, green leafy vegetables, eggs, pulses, fruits and nuts. Junk/processed foods high in phosphates and salt and sugary drinks must be avoided.

Exercise (30-40 minutes) for at least 5-6 days a week. Include weight-bearing exercises (walking, jogging, stair climbing) and resistance training. These stimulate bone formation and strengthen muscles.

Balance study/work schedules with physical activity and take adequate rest and proper sleep.

People on certain drugs that can cause osteoporosis should consult their doctor to switch to newer drugs with less impact on bone metabolism.

Prevention and awareness

Prevention of osteoporosis must start early — during childhood/adolescence, the period of peak bone mass acquisition. Health education in schools and colleges should emphasise the importance of balanced nutrition, regular physical exercise; awareness about ill-effects of smoking and alcohol on health; safe medication practices and awareness of drug-induced side effects; and screening for bone health in adolescents on long-term drug therapy.

— The writer is Chairman, Orthopaedics, Joint Replacement and Sports Injuries, Paras Hospital, Panchkula

These can potentially cause osteoporosis

Steroids: Prednisolone, Dexamethasone, Methylprednisolone

Anti-epileptic drugs (AEDs): Phenytoin, Phenobarbital, Carbamazepine, Valproate

Antacid drugs: Omeprazole, Pantoprazole, Esomeprazole

Drugs acting on central nervous system: Fluoxetine, Sertraline, Paroxetine

Anti-cancer drugs: Methotrexate, Cyclophosphamide

Anti-HIV Drugs: Tenofovir, Zidovudine

Anti-coagulants (Long-term): Heparin, Warfarin

Hormonal drugs: Levothyroxine, Leuprolide, Goserelin, Flutamide, Letrozole, Anastrozole

Diuretics: Furosemide

Immunosuppressants: Cyclosporine, Tacrolimus

Substance use: Alcohol, smoking

Chronic diseases that are risk factors for osteoporosis

— Cushing’s syndrome, hyperthyroidism, hyperparathyroidism, diabetes mellitus, hypogonadism

— Celiac disease/ malabsorption syndromes, Crohn’s disease/ulcerative colitis, chronic liver disease

— Chronic kidney disease (CKD)

— Rheumatoid arthritis, systemic lupus erythematosus (SLE)

— Cerebral palsy/Spinal cord injury

— Thalassemia major, multiple myeloma

— Chronic obstructive pulmonary disease (COPD)

— Anorexia nervosa/malnutrition

— AIDS

— Chronic immobilisation (bedridden state, paralysis)

— Organ transplantation (post-transplant bone disease)

Factcheck

Studies in India indicate the prevalence of osteoporosis in people in their 30s, though less prevalent than in older age groups. An article in a journal of Science Direct reported 3% prevalence of osteoporosis in women and 0% in men at the lumbar spine in the 30-39 age group. A review article in a journal of the National Institutes of Health found that around 8.5% of women in this age bracket had osteoporosis and 45.7% had osteopenia.