Osteoporosis in India.

GR Sridhar, Endocrine and Diabetes Centre, Vishakhapatnam-530 002.
Shastri NV
Natl Med J India 1997 Jan-Feb;10(1):48-9 (correspondence)

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Gupta has highlighted a silent, progressive and potentially catastrophic condition that, in India, has not yet received the attention it deserves (1)Osteoporosis increases the risk of bone fracture. This relationship is similar to hypertension and stroke, and hypercholesterolemia andmyocardial infarction.To carry the analogy further, like hypertension and hypercholesterolemia,osteoporosis is both preventable and treatable (2)While accurate epidemiological data for Indians is not available, the reports quoted by Gupta show osteoporosis is common, at least in those who sustained fractures (1)Teotia stated that osteoporosis was the commonest metabolic bone disease in postmenopausal women, which occurred in 35% of their cases.(2)According to both projections (2), and clinical impression (3), osteoporosis is likely to become more common in India and other Asian countries.

We had assessed the degree of osteoporosis in 80 patients with fracture neck of femur(4), using conventional radiography; osteoporosis was evaluated at the hip [Singh's index(5)], and at the calcaneus [calcaneal index (6)]. Lower the score on the indices, higher was the degree of osteoporosis. Our results showed that fractures occurred with increasing age, with female preponderance in the older age group. Both indices, as surrogates of osteoporosis, decreased with increasing age. The mean age of patients with intracapsular fracture neck of femur (ICNF) was 49.7 years (SD 11.1 y), and of extracapsular fracture (ECNF) 57.9 years (SD 9.8 y). Men below the age of 50 had fractures resulting from severe injury, whereas women above 50 sustained fractures from trivial to moderate injury.

The sex ratio (female:male) varied from 1.3:1 in ICFN and 2:1 in ECFN. Unlike the West, where women comprise a much greater proportion with osteoporotic fractures, Indian series (1, and the present one) reported a different sex pattern, this could also be linked to bias in presentation, where males are more often brought to medical attention (4,7), a lower life expenctancy in women, or perhaps other factors (1). It is worthwhile to investigate whether greater prevalence of insulin resistance(8), resultant steroid hormonal abnormalities and hyperandrogenism in Indians could confer relative protection against early bone loss and fractures in women.

Similarly, the earlier peak incidence of fracture neck of femur in Indians (1,4) could also be due to low peak bone mineral content (4) and perhaps lesser soft tissue that can dissipate the effect of trauma (2).

Given that bone mineral density is accurately measured by sophisticated techniques such as bone densitometry (single and dual photon absorptiometry, dual wavelength x-ray absorptiometry, quantitative computed tomography), are conventional radiographic procedures irrelevant ? Universal screening of women about the time of menopause may be sensible, but is impractical in most countries (2). In the meantime, semi-quantitation of bone density at the calcaneum could be carried out in high-risk individuals; calcaneal index has the advantages compared to the Singh's index at the hip (4): rotation of limb does not limit the accuracy of grading, difference in soft tissue is similarly less around the calcaneus, and finally, the gonads are not exposed to irradiation.

Osteoporosis at the calcaneus is a predictor for future hip fracture. Calcaneal pattern reflects radiological changes present in the femoral neck (4). Broad band ultrasonography (8) and single photon absorptiometry (9) have also confirmed the ability of calcaneal osteoporosis to predict future hip fracture.

Even granting that we use the best possible available method to document osteoporosis, there is a lesson in prevention. Dietary supplement of calcium and healthy active life-style in the pre-adolescent years, calcium supplementation in adults and weight-bearing exercise (2) are all possible, safe, effective and inexpensive.

Until a consensus is reached about hormone replacement therapy (2,3), and safe, effective, inexpensive pharmacological interventions are universally available, we could make a beginning by recognising that osteoporosis exists in India and that it can be managed with long-term planning.


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  4. Sastry NV, Sridhar GR, Reddy GN, Davidraju S, Madhavi G, Nagamani G. Evaluation of osteoporosis in patients with fracture neck of femur using conventional radiography. J Assoc Physicians India 1992;42:209-11
  5. Singh M, Nagrath Ar, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg (Amer) 1970;52A:457-67
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  7. Sridhar GR. Gender differences in childhood diabetes. Intl J Diab Dev Countries (Diab Bulletin) (in press) 1997
  8. Yajnik CS, Shelgikar KM, Sardesai BS, Naik SS, Bhat DS, Joshi VM, Raut KN,Mandore SA, Deshpande JA. Association of obesity with clinical, biochemical,metabolic and endocrine measurements in newly diagnosed NIDDM patients. In (ed)Kapur A. Proceedings of the 2nd Novo Nordisk Diabetes Update. Health Care Communications, Bombay 1993; pp139-146
  9. Porter RW, Miller CG, Grainger Dr, Palmer SB. Prediction of hip fracture in elderly women: a prospective study. BMJ 1990;301:638-41
  10. Cummings Sr, Black DN, Nevitt MC et al. Appendicular bone density and age predict hip fracture in women: the study of osteoporotic fracture research group. JAMA 1990;261:665-8

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