Assessment of osteoporosis knowledge in perimenopausal females attending outpatient department at tertiary care hospital at central Gujarat

 

 

Abstract              Background: Osteoporosis is a major health issue affecting the perimenopausal women, however not addressed effectively by them due to inadequate knowledge about the condition. Aims and Objectives: Evaluation of knowledge of osteoporosis in female of perimenopausal and menopausal age attending tertiary health care centre. Material and Methods: This is a questionnaire-based survey study. A validated (OKAT) questionnaire was prepared and answered by 300 women (above 40 years.) after consent. Results were tabulated, analysed and presented as frequency and percentage. Association of knowledge score with variables of age, education was analysed. Results: Out of total 300 subjects, 158(52.7%) subjects had poor OKAT knowledge score, whereas 121(40.3%) subjects had average knowledge and 21(7 %) had good knowledge of all aspects of Osteoporosis. There was statistically significant association of good knowledge with age, education level and perimenopausal status, however, strength of association was poor with a subject’s marital status. Conclusion: Inspite of Osteoporosis being common condition, majority of females are still unaware of its inevitable association with age and menopause, modifiable, non-modifiable risk factors. Majority are unaware about the disease status until they develop fractures secondary to Osteoporosis. Beyond adequate amount of calcium, importance of adequate nutrition, sunlight and exercise needs to be stressed upon.  Educative programmes covering preventive and treatment of osteoporosis should be undertaken on routine basis along with other noncommunicable diseases.

Key Word: osteoporosis

 

INTRODUCTION

Most women experience menopause between 40-58years, average age of Menopause being 51 years. Physical changes begin years before menopause. The transition is called as perimenopause. During this period the hormonal changes in the body lead to many physical changes which impact morbidity pattern in the women. Of the many health issues, Osteoporosis has emerged as a common health problem often neglected in perimenopausal women. This disease is a systemic disease of thin bone disease where the bones had weakening of its micro-architecture tissue, low bone mass, fragile bones with a high vulnerability to fractures.¹ It can result in devastating physical, psychosocial, and economic consequences. It is often overlooked and undertreated, however, in large part because it is clinically silent before manifesting as fracture. Fractures secondary to Osteoporosis take long to heal, patients are often bedridden and secondary complications are common. This affects quality of life and increases mortality. The importance of early detection and prevention of Osteoporosis cannot be ignored. This is possible if women themselves are aware of the condition and take proactive steps. According to the International Osteoporosis Foundation, the symptoms of osteoporosis are not clear till the occurrence of the first fracture and it significantly affect old women.² The risk factors for osteoporosis are female gender, old age, low levels of sex hormones, smoking, low levels of vitamin D and menopause.^3,6 Also, bad life style habits and low exposure to sunshine are also important predisposing factors for osteoporosis^4,5

 

MATERIALS AND METHODS

Study design and setting- This is a cross sectional survey study conducted among female patients of perimenopausal and menopausal age group attending the outpatient department of GMERS hospital Gotri over a period of 1 week in the month of May 2019. Selected patients on basis of inclusion criteria were explained regarding the study, verbally in their language and questions asked as per the questionnaire. Data was collected approximately over a period of 1 week in the month of May 2019. Subjects were indirectly identified in order to maintain patient confidentiality.

Selection criteria– All Females in age group of >40years and willing to participate in the study.

Sample size– Sample size of 300 females.

Study tool– A questionnaire is designed on basis of the validated OKAT questionnaire of T.M.

Wizenberg et al⁷. The questionnaire was translated in Gujarati which is the local commonly spoken and understood language. The questionnaire in Gujarati language was validated by 3 local physicians (content validation through experts). The questionnaire had maximum score of 20.It was based on different aspects of Osteoporosis vis- i) Knowledge about non-modifiable risk factors ii) knowledge about symptoms of osteoporosis  iii) knowledge about relation of nutrition with osteoporosis iv)knowledge about modifiable risk factors of osteoporosisv) knowledge about prevention and treatment of osteoporosis. 1 mark given for correct answer and 0 mark for no or don’t know or wrong answer. Demographic information of the females recruited taken in terms of their age, educational level, Marital status.

Results were tabulated on Microsoft excel, analysed by SPSS software and presented as percentages and frequencies. The strength of association between the demographics and knowledge was checked by chi-squared test to check p value significance. The study was approved by institutional ethics committee.

 

RESULTS

Demographics of studied subjects: As per table 1 ,49 patients (16.3%) were from age group 40-44years, 74 (24.6%) patients were in age group of 45-49 years,and55 (17%) patients in 50-54 years age group,55-59 age group consists of 33(11%) while total of 93 patients (30.9%) were more than 60 years old. Educational status of subjects in our study showed majority 113(37.7%) were illiterate with no education followed by equal number of subjects 113 (37.7%) with primary education till 7^th standard.62 (20.7%) subjects were schooled till secondary schooling education till 10^th std.8(2.7%) were educated till 12^th and 4 (1.3%) were graduates. Out of included subjects, 92.7% subjects were married females and 7.3% were widows. Menopause was attained by 153 patients (51%) and 147 patients (49%) were in premenopausal status.

DISCUSSION

Risk of Osteoporosis is high, affecting the quality of life in women of menopausal age group. People at large are aware about the cancer risks associated with Ovary, breast and Cervical cancer, but Osteoporosis as a condition characterised by thinning of bones which can be prevented, is often overlooked. This study highlights the awareness of the women of different demographic background towards Osteoporosis. Backache, leg pains with or without joint pains are thought to be due to Arthritis. Medications like Steroids commonly prescribed for such “arthritic” pain, proton-pump inhibitors for gastritis and even taken over the counter contributing further to osteoporosis. In our study though 236(78.6%) subjects were aware of osteoporosis as a condition characterised with bone thinning, only 107(35.6%) were aware of the association of aging and menopause has with osteoporosis.221(73.6%) of the subjects knew that bone thinning increases risk of fractures, but 285 (95%) didn’t knew about the symptoms to be identified with it. Various factors are involved in the aetiology of osteoporosis among Indian women. The non modifiable factors include female gender, advancing age, ethnicity, and genetic factors. Women have a smaller body frame size, are more likely to have lower portions of calcium-rich foods and for socio-cultural reasons are likely to have poor sunlight exposure. This has been reported to be a significant risk factor for the development of osteoporosis in Indian women.^8,9 Numerous studies have reported increasing prevalence of osteoporosis with advancing age, and this trend had been observed to a great extent among Indian women than men.⁹ Nutritional factorsplay an important role in development of osteoporosis. calcium and vitamin D, the two main nutrients involved in bone health, play a major role in influencing the risk of osteoporosis.

Calcium: calcium in the form of hydroxyapatite crystals is deposited in the bone matrix and is responsible for the hardness of bone. Calcium is obtained from the diet through dairy as well as non-dairy sources. The bioavailability of calcium from dairy sources is much higher than non-dairy sources. Several studies have reported that Indian diets do not meet the recommended dietary allowances of 600 mg/d of calcium for adult women, which has been recommended by the Indian Council of Medical Research.¹⁰ One of the reasons for this is the poor consumption of dairy products. According to the reports by Harinarayan et al Indian diets have a higher ratio of phytates to calcium, especially among rural Indians.¹¹ Phytates may hinder calcium absorption from the already calcium-deficient diets. Thus, bone remodelling may be retarded, resulting in lower BMD, increasing the risk of osteoporosis.

Vitamin D: vitamin D is synthesized in the human skin upon exposure to sunlight. Although India has abundant sunlight, several reports state that Indians suffer from vitamin D deficiency.^11,12,13,14 Some of the reasons for vitamin D deficiency among Indians may be low sun exposure, traditional clothing (saris, salwar suits), inadequate dietary intake, poor vitamin D fortification of food. Vitamin D deficiency results in ineffective calcium absorption from the gut. Reports suggest that risk of osteoporotic fractures in subjects taking calcium and vitamin D supplements were less.¹⁵In our study81% of the subjects realised that consumption of dairy products necessary for improving bone strength but majority 244(81.4%) subjects didn’t know how much is enough to meet daily requirement of calcium. This leads to false assurance that adequate calcium is being consumed. Modifiable risk factors like lifestyle, daily exercise and type of exercise, smoking alcohol consumption etc also influence development of osteoporosis. Need to control these factors for control of disease like Diabetes, Hypertension Ischaemic heart disease is very well known however knowledge about these factors affecting osteoporosis is varying. Urbanization has resulted in a sedentary lifestyle, decreased sun exposure, and lesser physical activity, which are detrimental to bone health.¹⁴Physical exercise, especially weight-bearing exercise, helps to improve and maintain muscle and bone strength and also helps to improve body balance Lack of exercise has been found to be significantly associated with lower BMD in Indian women.^15,16 In our study only77(25.6%) were aware that sedentary lifestyle increases chances of osteoporosis and only 13 (4.3%) realised that routine household work is not enough to prevent osteoporosis. Cigarette smoking, while being a major risk factor for osteoporosis, has been found to be too low among Indian women to majorly increase their risk of osteoporosis. On average 50% of our study subjects were aware of detrimental effects of smoking and alcohol consumption has on osteoporosis. However, whether they were aware of specific implications it has on osteoporosis or they considered smoking and alcohol as a bad influence on health in general could not be ascertained. Long-term glucocorticoid use by elderly population has also been reported as a major contributor to the increasing prevalence of osteoporosis in elderly Indian population.¹⁷Many women as stated earlier take over the counter medicines for “bone pains” but in our study only 11(3.6%)are aware of its side effects which can cause osteoporosis. Osteoporosis can be prevented was asserted correctly by only 68(22.6%) subjects ,141(47%) knew that treatment is available once diagnosed with it. None were aware of the availability of hormone therapy available along with Calcium and Vit D supplements to prevent further bone loss. More than 50% of the subjects had poor overall knowledge of Osteoporosis in our study and it showed statistically significant association   with age and educational level of the subject. Women in age group 45-55 years (N=125), 62(51.6%) had good knowledge score with p<0.05. Also women with secondary schooling and above (N=74), 40 (54.05%) had good knowledge score and women with primary schoolong or no schooling(N=226), only 81 (35.84%) had good knowledge score with p<0.01.In the study by Pandeetal 2005¹⁸ showed poor knowledge score even in educated women. Osteoporosis is a silent disease. However, once fractures occur, they result in pain and disabilities; fractures are also an enormous economic burden. Hence, prevention is critical in this disorder. In postmenopausal women, testing for BMD is based on the risk profile, while for women older than 65 years, measurement of BMD is recommended. Yearly measurement of height is also advised (for vertebral fractures). Suggested lifestyle changes include a diet rich in calcium (up to 1,000–1,200 mg/d) and exposure to sunlight to make or vitamin D supplementation to achieve 800–1,000 IU/d. Regular weight-bearing and muscle-strengthening exercises are also advocated. Further, avoiding behaviours such as smoking that impair bone health and prevention of falls to avoid fragility fractures are important.

 

CONCLUSION

Inspite of Osteoporosis being common condition, majority of females are still unaware of its inevitable association with age and menopause, modifiable non modifiable risk factors. Majority are not knowledgeable about the disease status until they develop fractures secondary to Osteoporosis. Over and above adequate amount of calcium, importance of adequate nutrition, sunlight and exercise needs to be stressed upon.  Educative programmes covering preventive and treatment of osteoporosis should be undertaken on routine basis along with other non communicable diseases.

 

REFERENCES

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