While research continues on osteoporosis, it is not possible to say whether it is due solely to calcium malnutrition, lack of exercise or hormone deficiency, but probably it will be found to be an interplay of all three factors. Each woman is unique with her individual needs and concerns.

There has been a great deal of confusion and controversy concerning hormone therapy to prevent osteoporosis, with research still being carried out and new aspects continually being discovered.

The term ‘Oestrogen Replacement Therapy’ was formerly used, but since it was realized that therapy frequently involves more than oestrogen, the terminology ‘Hormone Replacement Therapy’ (HRT) is preferred by physicians.

If you are at high risk of developing brittle bones in later years, with many of the negative factors that cannot be eliminated, when calcium absorption may be insufficient and exercise impossible, discuss hormone replacement therapy with your physician. HRT is available under the National Health Service, and may be prescribed by your GP or NHS clinic. Your doctor will probably strongly recommend hormone replacement therapy if:

your menstrual periods stopped at an early age; or

you have had surgery to remove your ovaries, effecting a

surgical menopause; or

•    you have had bone-mass tests at regular intervals that reveal

an increasing porosity and risk of fracturing.

Just what is HRT, what are the good points and what are the bad? The ‘balance sheet’ of hormones for bone formation, with oestrogen and progesterone from the ovaries on the positive side. It’s natural for ovaries to start producing hormones at puberty and wind down production at menopause. It’s a misconception that you produce no more natural oestrogen and need full replacement of this hormone at that time. In many menopausal women, ovaries still produce oestrogen, but in insufficient amounts to menstruate. When your ovaries stop making oestrogen, you are not completely lacking this hormone from other sources in your body. Oestrogens come

from the adrenal cortex in the adrenal gland (precursors of \ oestrogens);

indirectly from the body’s fat cells which convert androgens to oestrogens; and

from your ovaries (unless you have had them surgically removed), continuing to manufacture small quantities of androgens which are converted to oestrogens.

While it is true that the quantity of oestrogen drops, the big questions are whether this deficiency needs to be replaced, and if such replacement is safe.

It is important to ask probing questions of your physician if hormone replacement therapy is suggested, so you are aware of all the facts to make an informed decision. Know both sides of the issue and get a second opinion from another physician before reaching any conclusions. A decision made now may need reevaluating years hence if you experience severe deterioration in bone mass or if particular drugs are later produced that may be suitable for you.

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Hip fractures generally affect older people, and are more frequent in women than in men. The hip is the only true ball-and-socket joint in the body, and the largest joint except for the knee. When porous and brittle, the thigh bones are most vulnerable to fracturing, especially in the top at the hip socket where this part of the femur (the ‘neck’) is the narrowest and yet has to carry the full load of the upper body.

Although fractures of the vertebrae can happen spontaneously, hip fractures are usually caused by an accident such as tripping over a small rug or slipping in the bath. Occasionally a hip fracture happens for no apparent reason, which triggers the thought – was the fall caused by a broken hip, or did the hip fracture because of the fall? A woman who has suffered a fractured hip on one side is twenty times more likely to have a subsequent fracture on the other.

Disabilities from such fractures are often the beginning of serious physical decline for the elderly: after leaving hospital, many osteoporotic patients are so afraid of falling that they lead very sedentary lives, depressed and full of despair at the disruption of their lives, remaining in nursing, homes until death. Statistics

can be frightening: 15 per cent of women die shortly after a hip fracture; almost 30 per cent die within a year; less than 50 per cent are able to return to normal life. A wrist fracture can be disabling for two months, but long-term disability is not uncommon. A hip fracture is one of the leading causes of accidental death among elderly white women, reducing life expectancy by 12 per cent. The cause of death is not the fracture itself, but the result of ailments associated with prolonged nursing home or hospital stays – pneumonia, blood clots, or a fat embolism.

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The calcium content of grain products depends upon which kind of flour is used, the extent to which it has been milled, and whether calcium carbonate has been added. White wheat flour uses mainly the inner kernel while wholewheat flour includes the germ and outer husks. Because the composition of flour in the UK is controlled by certain orders and regulations, calcium carbonate (chalk) must be added to all flours except wholemeal and some self-raising flours, at the rate of about 235-390 mg per l00 g. Many breads and cereals have an enriched calcium content with the addition of nonfat dry milk, so read nutrition information labels, talk with the baker, or write to the food manufacturer.

The outer husks of cereal seeds as in bran contain phytic acid, a substance that forms phytates when combined with phosphorus. Phytates, similar to the oxalates in green vegetables, can interfere with calcium absorption if eaten in excessive quantities. Unlike raw bran, when wholegrain wheat or rye bread is being leavened before baking, the enzyme phytase in the flour splits the phytic acid so that it will not bind with calcium – thereby releasing the calcium to be absorbed and making the bread more nutritious.

Because phytate also occurs naturally in other plant material such as coffee beans and tea leaves, strong infusions of coffee, tea and cocoa have the similar potential to inhibit calcium and zinc absorption, or extract these minerals from your body.

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Ordinary table salt is sodium chloride, and sodium is very necessary for us. Sodium attracts water into the blood vessels, keeping the proper blood volume and the pressure within the blood vessels more or less constant, regulated by your kidneys. But, as you probably know, too much salt is unhealthy, increasing blood pressure and the risk of heart disease and kidney problems, and many of us consume salt in far greater quantities than necessary. A high intake of sodium can also lead to an extraction of calcium into the urine, although at the moment it is uncertain what is an excessive amount. But the conservative approach is to maintain a low-salt diet – no more than 2000 mg per day, as recommended by the World Health Organization and the American Heart Association.

Apart from table salt, sodium is found in many other foods, naturally present or as a part of processing and preserving. The wisest course is to eat fresh unprocessed foods as much as possible, seasoning generously with herbs and spices. When eating out, forsake fast foods and choose the salad bar without a large serving of dressing.

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It’s a good idea to keep weight constant, as already-weakened bones may not be capable of supporting an extra 20 or 30 pounds.

In the 1983 report Obesity by the Royal College of Physicians, 8 per cent of women and 6 per cent of men are obese. Chronically overweight women seldom suffer from osteoporosis, probably because they put heavier stress on their bones, with the bone responding by building new tissue to meet the demand for more strength. Or it could be that larger women produce more of the male hormone, androgen, which in turn is converted to oestrogen to reduce the risk of bone loss.

Because of this higher production of androgen hormones after menopause, being obese (or grossly overweight) increases the chances of endometrial cancer (cancer of the lining of the uterus). Obesity also increases the risk of cancers of the cervix, uterus, ovaries and breast, and of developing high blood pressure, heart disease and diabetes.

If you are seriously overweight, ask your doctor to refer you to a trained dietician for expert advice.

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