Osteoporosis … quietly ticking timebomb People don’t realize they have it until it strikes

IT’S NOT a very well known disease, though its incidence is similar to diabetes: osteoporosis, a disease that can erode your bone to the extent of causing breakages from a sneeze. In this interview, Dr Kashif Rizvi of Specialized British Medical Unit in Mazaya Clover Center explains all about the disease and deems it important to create awareness on it as it’s a silent disease and can go unnoticed until the patient suffers from excruciatingly painful fragility fractures. That’s why he likes to call it the ticking timebomb. Interestingly, among the top reasons for its prevalence in Kuwait is the general aversion for sun among the population. Read on and find out how sunlight and bone strength are related, and what you can do to prevent the disease.

Question: What is Osteoporosis?
Answer: Osteoporosis is literally translated into ‘porous bones.’ It means that the bones are lighter, softer and more vulnerable to breaking. What we call fragile bones.
The important thing to note is that just like most cases of Type 2 Diabetes, it’s clinically silent. So, people don’t realize they have the problem until they suffer a so called ‘fragility fracture’

Q: What are fragility fractures?
A: The bone can break in two ways. Either from a direct hit, the so called ‘traumatic fracture’ and depending upon the magnitude of the injury any bone is susceptible. Or it can break without trauma even by a minor movement, sneeze or a cough or even by lifting a slight weight as in the case of osteoporosis. Those fractures are referred to as fragility fractures.

Q: A bone breaking from a sneeze, that’s really extreme. So, it must be the sternum that breaks while sneezing, right?

A: In osteoporosis the bones which are most vulnerable are the lumbar spine, the lower part of the vertebral column, the two hip bones referred to as neck of the femur and the wrist bone. You may have come across elderly people, mostly ladies, who lose their height as they get older, that’s because their vertebral bones collapse upon themselves, and spine becomes shorter as a result.
The science behind bone disease is simply understandable by using the following analogy. It is that the bone is a very active tissue; contrary to popular belief bone is an ever changing, remodeling, reshaping structure. Within a year or so, everybody replaces their entire bone bank.
There are mainly two types of cells within the bony skeleton, the builders and the destroyer cells. When we are younger the bone is building and the skeleton is growing, so the cells which are building the bones outnumber the cells which are resorbing the bone. Consequently more bone is laid down than is being eaten away. Factors which facilitate this process would be a good balanced diet rich in calcium and vitamin D, regular weight bearing exercise like walking, jogging and weight lifting, abstinence from smoking and alcohol, all of which deposit more bone in the bone bank so to speak.

Q: By this you mean that the bone density increases?

A: Yes and the equation is tilted in the favor of the ‘builder cells’ till we reach our mid 20s. Then it starts to taper off, and the destroyer cells and builder cells become almost equal. And gradually the destroyer cells become a little bit more active reversing the outcome, and we start to lose more bone than we are laying down.
This is the so called age related bone loss, which is in a slow, predictable gradual manner. In women however there’s an additional and very important component of menopause. When they enter the stage of menopause, they lose the protection of estrogen the female hormone on their bone and lose a significant amount of density within a short span of time. That’s referred to as the ‘post menopausal bone density loss’, and combined with the ‘age related loss’ makes the ladies bone density more vulnerable to osteoporosis compared to men.
If osteoporosis results then it could lead to this cycle of fragility fractures, pain, deformity and depression, dependence upon painkillers and so on.
The key thing is trying to establish a good bone density in the younger age and protect your bone once you become older.

Q: What are the important things to remember for patients of osteoporosis?

A: There are certain factors which are ‘fixed’ like the family history, but most others are variable and correctable, including diet, lifestyle, walking, not smoking not drinking and being careful with appropriate and judicious use of cortisone treatment, which should not be for a long duration. In addition certain drugs used for epilepsy and blood thinning could also affect bone density adversely.
In Kuwait, there is a significant caveat affecting the bone density now and particularly in the future and that is the enormous prevalence of vitamin D deficiency. This is a vitamin which is pivotal in absorbing calcium and keeping the level of parathyroid hormone low, which absorbs the bone in people lacking vitamin D. People, here in Kuwait, should know that the importance of Vitamin D, that it is a very important substance for laying down the mineral on the bone. As a huge number of Kuwaiti residents are lacking in Vitamin D, this makes them vulnerable to osteoporosis. Now and as they get older.

Q: Why is there a deficiency of Vitamin D in Kuwait?

A: Humans don’t make vitamins within their bodies, which are required in small amounts for normal metabolism. Hence we have to include them in our diet. Vitamin D is unique as we can actually synthesize it in our bodies but it requires the trigger from exposure to sunlight. It is found is some foods, but predominantly it is made from exposure of the skin to the ultraviolet rays of the sunlight. 
In any country where there’s an aversion to the sun, like here in Kuwait where the sun is very fierce, Vitamin D deficiency is likely to be high. This aversion could be direct so we don’t like to be outdoors, or indirect as once outdoors we put a sun block on. We also have cultural and religious reasons to dress conservatively. So, they cover up our faces and arms, the surface area of the skin that is usually required to be exposed to form Vitamin D.
Thirdly, and equally importantly, is the color of the skin and the weight of the body. If people have dark skins, they process Vitamin D poorly. And if they are overweight and obese, which is common within Kuwaiti residents, they also process Vitamin D poorly.
So, obesity, dark skin, aversion to the sun, usage of sun blocks, indoor lifestyle, dressing modestly, lacking in healthy balanced foods, all combine to create this ‘perfect storm’ of low Vitamin D, which is endemic in the Kuwaiti population as a consequence.

Q: How long does it take to make this vitamin D?

A: Just half an hour’s exposure of the face and limbs to the sun is good enough to process Vitamin D. We need to exercise caution about the heat index of the sun. It can be the dawn or the dusk sun given the temperatures in Kuwait, we must ensure don’t burn the skin as a balance must be struck
Every sun protection cream will also block Vitamin D conversion. So, people when they put any factor to protect themselves from the sun, they are impeding the production of Vitamin D. again the balancing act has to be precise.

Q: What about the oral intake of Vitamin D, is it through normal food or tablets?

A: There are some fish that are rich in Vitamin D, some milk and vegetables have added Vitamin D on to it. But the big chunk of Vitamin D comes from sunlight rather than the food, so you have to combine the two. If you belong to one of those groups of people prone to Vitamin D deficiency, then you have to supplement it with tablets or injections. However, supplementation on a long-term basis should preferably be with tablets or lifestyle modifications rather than injections. But if you have got severe deficiency, then your doctor may give you injections in usually a course of three, which will boost Vitamin D in your body. Generally, given the way we live in Kuwait, all of us are programmed to develop Vitamin D deficiency sooner or later and to varying degrees. The thing is how to recognize it. The key lessons are: be aware of the processes required to process Vitamin D as discussed above. If we think that we have deficiency, we need to get it checked, and in the first instance to encourage increasing the oral intake of Vitamin D, which should be in the region 600 international units per day. (Between 400 to 800 IU).

Q: What symptoms if any can arise from vitamin D deficiency?
A: Vitamin D deficiency usually creates a syndrome of tiredness, fatigue, aches and pains in the limbs, if it is very severe or if it is responsible for conditions like rickets in children or other bone diseases like osteomalacia (soft bones) in adults.
Vitamin D correction is now linked with improvement in many quality of life parameters like sleep quality, mood adjustment, non-specific symptoms improvement and reduced muscle aches and pains. But more importantly, it helps you to build your bones and protect what you have already built.

Q: From your mid twenties, it’s only about preserving the bone density that you have already built, and you can’t build further from there, can you?
A: You can’t build after mid twenties, because by then you have built enough bone to last a lifetime. Not everybody will develop osteoporosis unless the factors mentioned were present.
If you suspect that you may have reduced bone density, then it’s easy to have your bone density measured via a very simple test called a DEXA scan. It does not involve any invasive technique and is a simple quick scan, taking only a few minutes. It checks your bone density in the most vulnerable areas of your body like the spine, hips and wrist.
Once you know there is a problem, you can take steps to correct it, and tilt the balance to start protecting your bones.

Q: Stopping further erosion is the only thing you can do, is it?
A: In severe cases there are some medicines you could use to build bone. But that is very expensive and is reserved for severe cases where there are lots of fractures or established osteoporosis. But for less severe conditions, a commonly used medicine is the Bisphosphonates. They are used as once weekly or once monthly tablets and are now available as once-a-year injections, which are quite safe and effective offering a very simple way of arresting this problem.
Osteoporosis is very common, with incidence by the way similar to diabetes. Like for example, if there were 30 % people with Type 2 diabetes in Kuwait, there will be similar number of people with osteoporosis as well. But because osteoporosis does not have any symptom, most of them will not start to take any preventative / corrective measure or treatment until they actually break a bone. If you have recognized and assessed the situation before that painful point is reached then you could reduce the suffering in the future.

Q: Is osteoporosis always a gradually occurring process, or can it happen all of a sudden?
A: In most cases it is gradually occurring. Either age related or post menopausal. But if something else is added on it, like if you’ve had steroid treatment for a long duration, if you smoke heavily, if you’ve a family history, and if you didn’t do any weight bearing exercise, and you didn’t eat enough calcium and your Vitamin D was severely depleted, causing a rise in parathyroid hormone level, you will of course add an accelerator to that loss. So combined with the normal bone loss, you will now have accelerated bone loss.
So you could rapidly lose a lot of bone in a short space of time if those factors are also present.

Q: Tell us how genetic factors and lifestyle factors work in the occurrence of the disease?
A: It’s usually a combination of both. Genetic factors you can’t change. But if you are aware of it, then you need to do simple things, which are walking as number one priority, 30 minutes a day brisk walk will also protect you against diabetes. You should not smoke or drink. You must ensure enough Vitamin D in your body through adequate diet and exposure to sunlight. That will set you for a good bone bank. It’s not anything special that you have to do. You just have to follow simple rules of a healthy life.
As you get older, if you recognize that you are part of one of those groups prone to Vitamin D deficiency, like you are living in Kuwait, you have dark skin, you have extra weight on you, you have aversion to sun etc, then it’s better to get Vitamin D checked and replaced. That can be easily done by your health care provider.
It’s not something that’s complicated. The key element lies in its recognition and awareness as once you reach a stage where you suffer fragility fractures then it becomes very difficult, because they are very painful, lower your self esteem, your body shape changes etc.

Q: Earlier you mentioned about destroyer cells. What exactly are they? Why are they there in our body, are they going to cause us harm?
A: These are the cells that responsible for eating the bone so that new bone can be built in the place of lost bone. In our body, things are always remodeling, reshaping themselves. You see, we have a bone which has an outer shell which is the strong area called cortex giving us our upright posture and protecting our soft tissues, there we have relatively less turnover. This is why you sometimes find skeletons that are a hundreds of years old and their outer shell is still intact. It’s the inside of the bone that is very spongy and is very alive with a lot of blood vessels and nerves running through it. Most of the changes are taking place within that bone, the so called trabecular bone. It is mostly within that bit of the bone that osteoporosis takes place.
The destroyer cells and the builder cells are always working in harmony with each other, as they lay down the bone and remove the bone. The acquired factors like smoking, steroid use, lack of exercise, Vitamin D deficiency etc. will help the destroyer cells more than the builder cell.

Q: Is this the cell, the destroyer cell, responsible for aging in us?
A: No. I am using this term for simple understanding. The cells which eat the bone are called Osteoclasts and the ones which make the bone are called Osteoblasts, There is always this little struggle going on between them. The Osteoblasts win while you are in your youth, and the Osteoclasts win, for the want of a better term, as you get older.

Q: What is the purpose of the Osteoclasts?
A: Their function is to repair and remodel the bone. Every year, almost the entire skeleton is replaced. You don’t live with the same bone as when you were a young boy.

Q: Tell us about this extreme case where you break a bone when you sneeze. Can bones become that fragile?
A: When you do a DEXA scan, you are given a set of figures which is called the T score. It refers to your bone density compared to a perfect or peak bone density. As you get older, your T score is usually expected to be less than the perfect due to the age related and in women additionally post menopausal loss. So from 0 (the perfect) to -1 is normal bone density. If you are further below, say from -1 to -2, you get into what we call the half-way stage, which is the grey area between the normal bone and osteoporosis.  This stage is called Osteopenia. If you go further below -2, then you get into osteoporosis, which could be silent or could be established. Silent is when you haven’t broken any bone yet, but potentially may. Established is when you have already broken a bone and you have displayed your condition.
When you are in the range of -2 and below, then you could break a bone without any overt trauma. If you have a sneeze or cough, or if you lift a slight weight, or without any of these things, you could just fracture one of the bones. This could be very painful, and one of the symptomatic elements of osteoporosis comes into play.
Osteoporosis is harder to treat than Osteopenia, because at half way stage you can actually reverse the process relatively easily and go back to normal bone density and your risk of fragility fractures is not increased. Of course that will only happen if you are aware of it in the first place.
We see within Kuwait, there is a very effective drive for raising awareness of diabetes. It is paramount to raise awareness of bone disease too as it is equally common and equally important in terms of quality of life and threat to life. If an elderly person breaks a bone, he is hospitalized, and they are vulnerable to life threatening problems.

Q: You said spine is also a very vulnerable bone. That should make osteoporosis very dangerous, isn’t it?
A: Spine is very serious because of multiple factors. Spinal fractures usually are treated conservatively. It’s difficult to repair the bone there, as the vertebral bone collapses upon itself, causing very severe sharp pain present on literally every movement, even breathing and increasing substantially with coughing, sneezing etc. in addition you lose your height. This leads to all your abdominal contents getting crammed up, which causes your lungs to become smaller. So you can’t breathe very well. Further, as the pain would be very high in such cases, the person could develop painkiller addiction and constipation, poor sleep, low self esteem etc.

Q: Before we end, what is the key message you have for our readers?
A: Be aware, be proactive. Ensure diet rich in Vitamin D, inclusive of fish and fortified milk, cheeses etc, engage in half an hour a day exposure to the sun, (a walk outdoors will do the trick) to the body surface area of face and arms at least, with the proviso that the sun burn is avoided, try to do weight bearing exercise i.e. walking, jogging, weight training etc for 30 minutes a day. Avoiding/stopping smoking and alcohol and risks of fall will protect. Awareness of the paucity of symptoms and getting the levels of Vitamin D checked if nonspecific problems. If found to be Vit D depleted, getting a simple bone scan called DEXA to assess bone density and acting positively to encourage bone health, with simple changes to lifestyle, seeking medical help for replacing Vitamin D and correcting the osteoporosis.

Q: Finally, tell us about your centre please.
A: Our centre, the specialized British Medical Unit is at Mazaya Clover Centre. We are adhering to international protocols for good medical practice and clinical governance providing a multidisciplinary team of professionals which delivers a wholesome management of all endocrine disease including diabetes and metabolic bone disease. We have all the facilities for diagnosing and managing within this place and also fulfill our social corporate responsibilities with general public awareness, engaging via print and electronic media. Many thanks for providing us with this very useful, meaningful discussion indeed.


Dr Kashif Rizvi is the Consultant Physician and Endocrinologist at Specialized British Medical Unit, Mazaya Clover Center. He was the former Director of New Mowasat Hospital Diabetes & Medical Centre, Kuwait. Prior to that he was the Head of Department of Endocrinology and Diabetes – Kettering, UK.

Dr Kashif has the following credentials: Certificate of Completion of Specialist Training – UK, Accredited Endocrinologist General Medical Council – UK, Member of Royal College of Physicians (London - UK), Member of British Diabetes Association, Member of British Endocrine Society, Member of Association of British Clinical Diabetologists.

He is the author of Several Peer Reviewed Research Papers presented in International Meeting of British Diabetes Association. He is also a Tutor of Royal College of Physicians.

By Valiya S. Sajjad - Arab Times Staff

By: Dr Kashif Rizvi

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