In India, awareness of osteoporosis is low, since there has been relatively little effort to publicize the disease. Various small-scale surveys indicate that awareness of the disease in the urban population is about 10%-15%. A larger survey to assess public attitude and physician awareness is required - India will be one of 18 countries included in a major IOF research study How Fragile is Our Future, which will be completed by January 2006.

It is clear that a large-scale public awareness effort is required to bring the issue of osteoporosis to the attention of individuals, health care professionals, and government health officials.

Osteoporosis is serious, but it is a ‘good’ disease to promote because people can take steps to prevent the disease (to a certain extent through proper nutrition, exercise and lifestyle choices), it is easy to diagnose, and many treatments are available which can reduce the risk of fracture by up to 50%.

With increasing longevity of the Indian population, it is now being realized, that, like in the west, osteoporotic fractures are a major cause of morbidity and mortality in the elderly. Osteoporosis is a silent disease, reflected only in a low bone density, till a fracture occurs. Much in the manner that asymptomatic conditions like hypertension and dyslipidemia predispose to stroke and myocardial infarction respectively, a low bone density (reflecting poor bone health) predisposes to osteoporotic fractures. The fracture prevention strategy consists of increasing peak bone mass in the growing years and reducing subsequent bone loss throughout life.

Although solid epidemiological data are lacking, hospital data suggest that hip fractures are common in India. Available data suggest that:

While these are reasonable conclusions, we must keep in mind that there is no epidemiological data on fracture prevalence, although most clinicians would agree that hip fractures are common. The male female ratio may be distorted because of men being more likely to be brought for hospital care. The lower peak age as compared to the west may be simply linked to a shorter life span, as also to the inclusion of traumatic/non-fragility fractures in the analysis. Perhaps it is best to simply conclude that osteoporotic fractures are common in India and occur in both sexes.

Dual energy X Ray absorptiometry (DXA) technology, the gold standard for diagnosing osteoporosis by measuring bone density, became available in India only in 1997 at the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow. Subsequently several other machines became available and the last 3 years have seen their number grow to almost 140. However, these are still mostly localized to the larger cities- Delhi and Bombay alone account for more than 30 of these installations. Thus while certain segments of the Indian population do have access to diagnosis and treatment, these techniques remain inaccessible to the majority of Indians. Overall the BMD at all sites seems to be 5-15% lower than Caucasians. However, there are differences in BMD between different centres, and a very recent study involving healthy subjects presenting for a preventive health check in Delhi has suggested that BMD differences with western populations may be minimal, and could be related to the smaller skeletal size of Indians. The issue of appropriate BMD normative data for Indians remains open. There is need to study the BMD- fracture relationship in Indians (fracture threshold) to determine the ideal normative data for Indian population. If Indians fracture at the same level of BMD as Caucasians, there would be no reason to have separate normative data for Indians.

Recent data indicates a high prevalence of vitamin D deficiency in urban Indians, despite availability of abundant sunshine. Studies have shown that the majority of urban office workers and hospital staff have moderate to severe vitamin D deficiency, which is usually asymptomatic. Inadequate calcium intake was proposed as an additional factor contributing to the low BMD. Thus low vitamin D levels (and low calcium intakes) could also be major contributing factors to poor bone health and osteoporosis in India.

Poor sunlight exposure, skin pigmentation and a vitamin D deficient diet are some obvious causes for this finding. Atmospheric pollution has also been suggested as a contributor to vitamin D deficiency in children from Delhi. The spectrum of vitamin D deficiency in India extends from asymptomatic deficiency, to frank osteomalacia, a crippling disorder. Recent data also suggest that a healthy lifestyle (diet, exercise and sunlight exposure) can have a major positive impact on the bone metabolism and bone health of Indians.

Overall, it appears that typical urban (“white collar”) Indians have poor bone health, and osteoporosis is common in India. However, adequate calcium intake, regular physical exercise and sunlight exposure can go along way in improving Indians’ bone health and potentially reducing fracture risk. There is thus an urgent need for spreading public awareness in this regard, particularly about the benefits of sunlight exposure.

Most current therapies for osteoporosis, like the bisphosphonates risedronate and alendronate, raloxifene, and teriparatide (PTH) are now available in India. Awareness about appropriate use of these agents, as well as proper interpretation of bone densitometric findings remains major issues. Cost, also, remains a factor to be tackled. There has been some improvement in the reimbursement and insurance facilities for these agents, but sustained effort will be required to bring osteoporosis diagnosis and treatment into the mainstream of healthcare.