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Monday, October 21, 2013 C9

HEALTH ELDERLY Asian women can fight back against osteoporosis with diet and lifestyle changes, writes Jeanette Wang

Grey areas that matter ................................................ Sunory Dutt




omen may live longer than men but they may not necessarily be healthier. The International Osteoporosis Foundation (IOF) said during yesterday’s World Osteoporosis Day the quality of life for women would be seriously jeopardised without action to protect their bone health. Osteoporosis can strike anyone but post-menopausal women are most vulnerable. Worldwide, the IOF estimates that 200 million women are affected by osteoporosis and about one in three women older than 50 will suffer a fractured bone due to it. The problem is more pronounced in Asia, not only because populations in the region are ageing rapidly, but also because of physical and lifestyle factors. Asian women tend to have lower bone mass and density, and smaller body frames than the worldwide averages. A traditional Chinese diet also tends to be low in calcium, the key mineral for healthy bones. Average calcium intake in Chinese diets hovered around 400mg in the 1980s and 1990s, and was between about 500mg and 600mg in the 2000s, according to a report by the Osteoporosis Society of Hong Kong, Guidelines for Clinical Management of Postmenopausal Osteoporosis in Hong Kong, published in April. Average calcium intake is further reduced because lactose intolerance, an inability to digest a sugar found in milk and its products, is more common among Asians than Europeans, for example. By 2050, the IOF estimates that half of the world’s osteoporotic fractures will occur in Asia. In the mainland, almost 70 million people over the age of 50 suffer from osteoporosis and the disease causes about 687,000 hip fractures a year. From 2002 to 2006, hip fractures among those over

Tai chi is recommended as one way to prevent falls. Photo: AP

50 year in Beijing increased by 58 per cent in women and 49 per cent in men, according to a study by the Chinese Academy of Medical Sciences published last year in the Journal of Bone and Mineral Research. Urbanisation and lifestyle changes are suggested as the main reasons for such a rapid change. Previous studies in a number of Asian countries have shown the incidence of hip fractures is directly proportional to economic development. The burden is not only physical but financial. In 2006, US$1.6 billion was spent on hip fracture care in China, the IOF says, and this is projected to rise to US$12.5 billion by 2020 and US$265 billion by 2050. Women are a key concern for the IOF. “Around the world it is women over 50 who most often take on the burden of care for elderly parents and disabled or sick family members,” says the IOF in their report Bone Care for the Postmenopausal Woman. Report co-author Professor Bess Dawson-Hughes, the director of the Bone Metabolism Laboratory at the Human Nutrition Research Centre on Ageing at Tufts University in Boston, says: “Although the earlier prevention begins the better, when a woman reaches menopause she must not delay any longer. Menopause is the critical time to take preventive measures against bone loss and muscle weakness that can lead to osteoporosis, falls and fractures.” Oestrogen plays a vital role in regulating the turnover of bone. It is a daily cycle of bone

Menopause is the critical time to take measures against bone loss BESS DAWSON-HUGHES, TUFTS UNIVERSITY, BOSTON


formation the Osteoporosis and bone Society of Hong Daily calcium intake resorption, Kong as an (in milligrams) needed by the breaking “appropriate and post-menopausal women, down of safe exercise for older according to WHO bones. The adults for general process health and fall ensures that prevention”. the skeleton maintains its A review of 47 studies showed structural integrity. the benefits of the Chinese In young people, the body martial art were reported in forms enough new bone to balance and strength, replace what is lost. After age 30, cardiovascular and respiratory bone mass begins to decline and function, flexibility, a healthier for women, the process speeds immune system, relief from the up again after menopause. As symptoms of arthritis, improved oestrogen levels decline, the muscular strength and mental equilibrium in producing and well-being. consuming bones is lost. Osteoporosis develops when Get the right nutrients the body cannot replace bone Calcium: Postmenopausal fast enough. women should get 1,300mg of The disease has no calcium a day, according to the symptoms until a fracture World Health Organisation. One occurs. It can affect any bone in hundred grams of steamed tofu the body but most commonly (510mg of calcium), four figs affects the spine, wrists and hips. (506mg of calcium) and a 150Apart from pain and disability, gram pot of plain low-fat yogurt hip and spine fractures are also (243mg of calcium) will meet associated with a higher risk of that daily need. death – 20 per cent of people In the past few years there who fracture a hip die within has been substantial debate six months. about the efficacy and safety “An individual who has of calcium supplements, but experienced a fracture is at there’s no question that diet double the risk of suffering a should be the primary source second fracture as compared to of the mineral. a person without fractures. In Vitamin D: This vitamin aids postmenopausal women, a bone health in two ways. It helps broken wrist or a spinal fracture calcium absorption and with is often the harbinger of more important bone development fractures to come and should be and maintenance. It also has a taken as a warning that testing direct effect on muscle and preventive treatment is performance and reduces the needed,” says Professor Cyrus risk of falling. Cooper, chairman of the IOF’s The US National Institutes of committee of scientific advisers. Health recommends a daily While there are some risk intake of 600 IU (15 micrograms) factors that cannot be mitigated for adults aged up to 70, and 800 – such as family history, age at IU (20 micrograms) for older menopause and diseases people. A 90-gram serving of such as rheumatoid arthritis – cooked salmon provides about lifestyle and diet changes can 450 IU of vitamin D. lower the risk of osteoporosis Protein: Getting enough protein and fractures. should not be a problem for Here are the suggestions anyone eating a meat-heavy from the IOF report. modern diet, but vegetarians and vegans might want to take Get moving extra care. The Framingham Sedentary people are more Osteoporosis Study from the US likely to suffer hip fractures. found that lower protein intake Women who sit for more than and lower animal protein intake nine hours a day are 43 per cent were associated with loss of more likely to have a hip fracture bone mineral density in the hips than those who sit for fewer than and spines of older people. six hours as day, according to a study in the Journal of Bone and And you know the rest … Mineral Research. Don’t smoke: Smoking is linked Exercise has been shown to to several risk factors for boost bone mineral density by osteoporosis, including early 1-2 per cent in randomised, menopause and excessive controlled trials, but its main thinness. Both current and benefit appears to lie in ex-smokers face an increased increasing muscle mass and the risk of any fracture compared resulting improvement in to non-smokers. balance and strength – both Drink in moderation: Up to two important factors in preventing glasses, 120ml each, of wine a falls and fractures. day does not negatively impact Pick an exercise that suits on bone health. In fact, a Finnish your needs and abilities but study reported that mild to the IOF recommends that moderate alcohol intake was most people should exercise actually associated with greater for 30 to 40 minutes, three to bone mass among four times a week. Exercises postmenopausal women. should be both weight-bearing, Maintain a healthy weight: Being such as dancing, hiking, lean is good – up to a point. jogging and rope skipping, and Excessive thinness, plus the risk muscle-strengthening, including of malnutrition and loss of using elastic resistance bands oestrogen, can be devastating and weights. to bone health. Tai chi is recommended by

Fourteen per cent of Hong Kong’s population is aged 65 or older, a figure that is expected to increase to 30 per cent by 2040. With urbanisation and modernisation changing the roles of older people, seniors face a new set of pressures. Some older adults feel isolated by a greater focus on the individual. They feel they are cut off from younger members of the family who have different values, a greater affinity for global values compared to traditional values, and may not even share the same language or dialect as their elders. The elderly face other life transitions too: losing friends or loved ones, a diminishing support system, moving into long-term care, coping with economic hardship, facing ill health and mortality, and the burden they feel they impose on loved ones. These adjustments can challenge their mental health. Counselling has always existed to help individuals cope with life transitions. It was once more informal, directed by religious practitioners, physicians and community elders. It has now become much more formalised and professional. Gerontological counselling is an integral part of palliative care for the elderly in Hong Kong. With its bio-psycho-spiritual approach, it has proven an effective intervention in helping the elderly address psychological and emotional issues, and to help them develop the skills necessary for better mental health. In fact, researchers at the Chinese University of Hong Kong have shown that grief therapy can relieve emotional distress in elderly people facing terminal illnesses, enabling them to maintain a good quality of life. While the literature documenting the effectiveness of counselling often concentrates on younger populations, there is a growing body of work examining gerontological counselling. A report for the Singaporebased the Tsao Foundation, an aged-care research and lobby group, found “the elderly benefitted significantly from counselling through a combination of supportive care and interventions which allowed them to deal with deep-seated emotional pain, accept unchangeable situations, find

new direction and gain new meanings and perspectives to their struggle.” Bob Knight, professor of gerontology and psychology at USC Davis School of Gerontology, says depression and other psychological problems in later life can have serious effects on health if they are not treated. “In less psychologically minded people, emotional distress often presents as physical symptoms,” he says. “Depression, anxiety, and so forth can also interfere with medical treatment for existing physical health problems.” According to the Coroner’s Court, the suicide rate among people older than 60 years was as high as 20.9 per 100,000 people, the highest among all age groups in Hong Kong. It is assumed that the elderly, with greater levels of education and higher socioeconomic status, are more likely to seek counselling. But Dr Raymond Lo, from the Department of Medicine and Therapeutics, Chinese University of Hong Kong says more research is required. “Age should not be a barrier per se. The oldest patient who received counselling from my experience is 107 years old. Education and literacy are not barriers either,” he says. “Problems do arise with

Older patients can be stronger but they often have a smaller social support network

The elderly face significant challenges. Photo: Felix Wong

cognitively impaired or dementia patients, however, where verbal comprehension is affected. In these circumstances, simple non-verbal interventions like soothing music can help relieve anxieties restlessness, sadness and fear. “It needs to be emphasised that care and attention from caregivers is a great form of support. Simple skills and approaches can be practiced by caregivers, while difficult cases can be referred.” Lo’s research on palliative care patients shows that older patients can be psychologically stronger than the young, but they often have a smaller social support network. Often the old are caring for the very old. Educated adults may need more counselling, partly because they were previously more autonomous in their decision-making and find it difficult to accept a dependent role. Counsellors face numerous challenges in getting the elderly to commit to counselling due to social norms, the cost, a poor understanding of the process, and, importantly, the relative lack of access to geriatric counselling support. Societal pressure partly stems from the stigma of seeking psychological help. More training for professionals, wider promotion in the media and public education are needed to correct the stigma directed at elders who need counselling. Gerontological counselling takes many forms and should be tailor-made. Lo says counselling may need to include family or a form of family-wide therapy, not just to the patient. Another approach involves validation of the client’s life history and achievement to raise self-esteem. The details do not have to be spectacular, but can be anything with meaning and significance, such as a mother successfully raising a family. Another example is helping the client to find meaning and a purpose in life. In one scenario, an elderly man rediscovered a zest for life after talking to a student. The student learnt from him and can now help other elderly people adjust. From a public policy standpoint, good psychological services can reduce health care costs by improving adherence to medical treatment and by reducing overuse of medical treatment for emotional problems. The elderly deserve a comfortable old age, where their emotional needs are better understood.

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