Bone weary | Yves Muscat Baron

Osteoporosis is a disease of bones that leads to an increased risk of fracture, known as a silent disease, because people often don't show outward symptoms.

In osteoporosis the bone mineral density (BMD) is reduced, bone micro-architecture deteriorates, and the amount and variety of proteins in bone is altered.

Osteoporosis is defined by the World Health Organisation (WHO) as a bone mineral density that is 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by DXA while the term "established osteoporosis" includes the presence of a fragility fracture.

So what has led a gynaecologist like Muscat Baron conduct clinical studies on the illness?

"Some people say there's a big divide between gynaecology and osteoporosis. However, there is a connection. 

"I'll take your readers back to 1942. There was a professor by the name of Fuller Albright who had noticed that out of 48 patients he was treating in his ward for a hip fracture, 42 turned out to be post-menopausal.

"It's a bit of a coincidence to have 90% of a ward suffering from a fractured hip and being of a particular gender and age.

"Therefore, Albright linked post-menopause surgery to the weakening of the bones. Later, Albright started to realise that patients who underwent a hysterectomy (and at that time it was common for women who underwent a hysterectomy to have their ovaries removed too) developed a surgical menopause (quite a severe menopause) and the professor noticed that these women were susceptible to more frequent fractures.

"So that is where the connection was made: that due to menopause the bone weakened. And with increasing age the bones weakened even further until they became extremely fragile."

"One can have fragile bones which fracture by themselves like in the vertebrae (spinal column) for instance. The vertebrae weakens in women to such an extent that the ratio is 12:1 - a striking female predominance. And this explains why basically a female's bones fracture more easily than those of males."

So what really leads to osteoporosis?

"After menopause the levels of estrogen drop significantly, and after surgical menopause an even greater drop occurs.

"In the first 10 years after menopause, one can get an accumulative loss of about 1.5 to 2% per year, so within 10 to 12 years a woman can lose about 20 to 30% of her bone mass, quite an excessive amount. As a result, this brings about a greater risk of fractures."

So what is the problem with these fractures, I ask Muscat Baron?

"If one suffers a fracture in the upper limb, it's accompanied with pain and a patient may not regain her full function and the fracture may not heal as we wish. The most serious of fractures are the ones that occur in the hip. "Mortality rates are high following a fracture of the hip. Twenty-five per cent of those with fractured hips are operated upon immediately. Allowing the fracture to heal by itself without surgical intervention may leave us with a bedridden patient and one must keep in mind the patients we are dealing with are over 75 years old and if left in bed for too long can end up with bedsores, infections, you name it.

"Therefore, we operate to help mobilise the patient as soon as possible. But even after undergoing an operation, 25% still die during the first year, 25% end up bound to a wheelchair or bed, 25% end up with limited mobility while the rest of the other 25% of patients only regain their previous quality of life.

"So we have a situation which involves a costly operation since prosthesis are very expensive coupled with the risks of operating on elderly women."

So what is the key to this problem, I asked the gynaecologist?

"Prevention is the key. The main reason why we are seeing more patients diagnosed with osteoporosis more than ever is due to an aging population. Women end up spending 30 to 35% in a menopausal state, meaning that if the average age of the start of menopause is at 51, and one lives to age 84, this means that today's women will spend around 30 to 35 years in post-menopausal phase. So this is a very important phase that one must take good care of and which can leave a significant impact on the quality of life of a person."

The aging population is a reality because people are living longer, so what one must do is act on preventive measures. What preventive measures do you suggest one undertakes to avoid being diagnosed with osteoporosis in the future?

"First and foremost, we all need to know that bone mass (bone density) is associated with mobility, so it's important that we remain mobile. A perfect example of immobility can be observed in astronauts who experience the effect of weightlessness - the absence of gravity. This leaves them with no loading on the bones, developing osteoporosis as a result, no matter the age.

"I recently watched Apollo 13 and this factor came to mind. In fact, on watching the movie, one could easily see that the astronauts could hardly walk and were very weak on landing back on earth - a clear example.

Apollo 13 is based on a true story of a moon landing mission that went terribly wrong.

"It is very important to walk at least 20 minutes a day. A recent US study revealed that if a person jogged for an hour a week, it added six years to his or her life. Today, mobility has decreased due to our lifestyle and we are quickly resorting to our cars instead of walking."

It is a well-known fact that most runway models meet the anorexia criteria and in today's world there's the physical appearance obsession: that of having the perfect body index (BMI). According to Muscat Baron this can contribute to osteoporosis.

"Having a low BMI is typically an indicator of malnutrition. If women are anorexic for instance, this leads to a low body mass. One of the most serious effects of anorexia is hormonal changes, which can have severe health consequences. Reproductive hormones, including estrogen, are lower. Therefore, anorexics can induce fractures, eventually leading to osteoporosis.

 "And it's the same with menopause, where, as I mentioned earlier, the levels in estrogen start to lower."

Osteoporosis is known as a silent disease, because people often don't show outward symptoms. How does one find out that he or she has the illness?

"Osteoporosis is referred to a silent disease because a person's bone tissue starts to deteriorate without feeling anything. One may realise following a fracture but it can be too late in the day since deterioration would have already reached its toll."

So isn't there some sort of screening a person can undergo to measure bone density?

"Nowadays, we have what we call a bone densitometer - a very accurate tool that measures the amount of bone density, whereas in the past we used to rely on X-ray machines - which, in my opinion, was a very inaccurate way of measuring bone mass. Women would have had to lose 30% of their bone mass by the time it was noticed through an X-ray.

"In Malta we are very fortunate when it comes to the investment of health-related equipment and other health-related issues, among which is educating the public about preventive measures. We currently can boast of having around 14 to 16 bone densitometer machines spread across the public and private sectors when compared to Scotland, which until a couple of years, had only two of these machines. This shows the importance both the Maltese government and the private health sector gives to health in general in this country."

Muscat Baron recalls: "A Scottish professor almost envied us for having so many densitometers when compared to his country - with a far bigger population - and this came from a man who dedicated his life to studying the illness.

"It's important that we keep investing in such equipment since undoubtedly the aging population is increasing like in other western countries and is becoming a massive burden on our national health service.

"We must invest in education where obesity, hypertension, diabetes, arthritis, smoking and alcoholism are concerned. These are all precursors which precede the actual disease. Hypertension and high blood pressure equals heart attacks and strokes, obesity equals diabetes. We must emphasise on prevention because our health services aren't going to cope with the influx of patients.

"Everyone should be informed of the basic elements of maintaining bone health and preventing bone disease and paying attention to the basics is critical for everyone, especially those who have, or who are at risk of developing, osteoporosis."

Can a bad posture lead to osteoporosis?

"No, not really, however there's another angle to your question. Bone isn't a hard object, it can easily be molded. If a person is bending forward many a time it can eventually lead to molding of the bones. When a fracture occurs in the the interior front part of the vertabrae, the front part ends collapses. Women in particular end up kyphotic, meaning bent forward. In the same way, a bad posture doesn't help due to abnormal pressures in the joints."

What about extreme exercise?

"Any extreme thing we may do in life can lead to problems. Whether it's exercising heavily or not exercising at all. It's good to keep the right balance."

What age group is normally associated with osteoporosis?

"Osteoporosis normally starts off in a person's fifth decade and aggravates in the sixth. The first fractures occur mainly in the back.

"And as I previously mentioned, a typical fracture of the vertebra occurs on leaning forward frequently. A typical example is that of a grandmother who constantly leans forward to carry her grandchild. This puts an amount of pressure on the front interior part and that is when the bone gives way.

"And once you suffer a fracture the whole system starts to lean forward piling an amount of pressure on other bones. This leads to a collapse in the rest of the spinal column's bones.

"In both the fifth and sixth decade there's also a greater risk of falling due to a imbalance in our system which may be affected by menopause. This is when the risk of fracture increases."

Osteoporosis is classified as primary and secondary. What is the difference?

"Primary is when it occurs for no reason whatsoever or due to aging while secondary refers to the presence of other disorders or the use of medications that can cause harm to bone, such as steroids used to treat inflammatory illnesses like asthma."

Is there a high incidence of osteoporosis in Malta?

"Well, when our team actually looked at the prevalence of the illness it turned out to be low. We published this research as part of our ongoing studies on the illness, and found a very interesting pattern.

"Hip fractures are three times more common in Scandinavian countries when compared to Mediterranean countries. In the UK and Germany for instance, the ratio of fractures is twice as much compared to Mediterranean countries like Malta. So there's a latitude effect.

"This can also be due to the stature of Scandinavian people who are taller and the taller the bone the easier it fractures. There could also be a genetic element as well. The bone is not only made of calcium but also made of collagen which acts like glue, helping keep the calcium in place. The amount of collagen found in Mediterranean people is genetically higher than people in Scandinavian countries.

"I have, alongside colleagues Professor Mark Brincat and Dr Ray Galea conducted studies on this issue, where we looked at the collagen aspect. Contrary to the perception of many people, that the majority of our bones are made up of calcium, one third of bone is in fact made up of collagen, i.e. connective tissue.

"When a person loses collagen he or she eventually starts losing the glue-type effect and that is where calcium starts to be lost.

"As part of our research on osteoporosis, we are also looking at the vital role the intervertebral discs in the spine play. Everybody is looking at the aspect of the bone but forgets to delve into the subject of the intervertebral discs in between the bones."

Muscat Baron says that according to the results of trials conducted on 900 women, those who have a low disc (meaning a disc that is low in height) are more susceptible to fractures, comparing the intervertebral disc to a vehicle's shock absorber.

Muscat Baron and his colleagues have been asked by leading pharmaceutical organisations to conduct multi-centre trials on a number of volunteers on the illness including a major study involving 900 volunteers.

"No matter how strong the vehicle is, if it doesn't have good shock absorption, the structure of the car will eventually break down. And it's the same with a person's structure."

On medical treatments, I asked Muscat Baron if any were proving successful?

"A particular treatment involves an injection which is administered every six months and seems to be helping reduce such fractures. Hormone replacement therapy (HRT) is also prescribed to patients diagnosed with the illness which come in forms of creams or patches.

"Patients are also administered bisphosphorates, in oral or injection form. However, we tailor the treatment according to the needs of every patient. Strontium, a powder formula, SERMS (Selective estrogen receptor modulators) like Raloxifene, calcium and vitamin D are also prescribed to patients with osteoporosis."