Johnny had always been an exuberant and friendly old chap, taking his usual morning walk at 7am daily without fail. Adored by many, he is often known as “Uncle Johnny” in his community. Following a routine of tai chi after his morning walk, he would indulge in hearty conversations at a nearby coffee shop while having tea. After all, an uncle of over 70 years old certainly do have much experiences to share. It is up to one moment on a sunday morning, Uncle Johnny tripped over a gravel on the park path and fell in an uncontrolled manner. He was unable to get up and suffered excruciating pain in his groin area. Passersby took notice and immediately sought medical help. He was eventually immobilised and taken to a nearby hospital for a suspected hip fracture.

As it turned out, it was a mildly displaced intertrochanteric hip fracture which warrants for surgical intervention. Unfortunately, there had been a shortage of hospital staff with the hospital operating at full capacity. While surgery is ideally recommended to be immediate, it was postponed to 5 days later with Uncle Johnny being immobilised, and he had to lay in bed over the next few days. Over time, pain and swelling symptoms developed on the lower leg due to preoperative Deep Vein Thrombosis (DVT). Surgical management was proceeded with caution, and it was deemed stable during the perioperative period with successful surgical outcome. Uncle Johnny subsequently lay rested in bed with oral blood thinning medications and was ultimately discharged after some time.

As Uncle Johnny was one that engaged in frequent walking and outdoor enjoyment, he was growing anxious from resting at home. Each time he started putting his body weight on his legs, he felt pain on his leg, at times swelling occurred. Traumatised from his previous DVT episode, he chose to rest further at home. It was to a point where it affected his psyche and he was constantly feeling down. The growing sedentary lifestyle led to more health issues, and over time it impacted his social wellbeing as well. He constantly held a fear of uncertainty, where he was not only afraid of another potential fragility fracture, but also fearing that he might end up in a serious or fatal Pulmonary Embolism (PE). He further hated the fact he had to rely and depend on relatives for help on daily necessities, which further soured his temperament leading to negative behavioural changes.

The above illustrated a sequence of events stemming from a single event involving fragility fracture. Though it could be properly managed through surgical means and perioperative care, it underscores the increasing problem of bone health in our societies today. Osteoporosis represents a major public health problem, and fragility fractures, such as hip fracture, continue to rise due to increasing disease prevalence and ageing population (Cooper, Campion & Melton, 1992). Often neglected, bone health is more important today than ever before. The rise of sedentary lifestyle, along with people getting older and frail, invariably leads to the increase in risk of osteopenia. Fortunately, all is not lost with the ability for us to influence modifiable factors stemming from calcium intake, vitamin D deficiency, physical inactivity, cigarette smoking and alcohol (Poole & Compston, 2006).

Physical Activity

The concept of Wolff’s Law states that bones adapt to the forces placed upon them. In other words, when stress or mechanical load is applied to bones, they respond by becoming stronger and denser over time (Rowe, Koller & Sharma, 2023). As such, there are numerous publications and clinical evidences supporting the lifestyle of physical weight bearing exercises to improve bone mineral density (BMD). Ng et al. (2023) ran a meta-analysis of randomised controlled trials (RCTs) studying the effects of moderate to high impact exercise training on bone structure. It is found that impact exercises significantly improved volumetric BMD for postmenopausal women at the distal tibia (shin bone) area which reliably predicts fractures at clinically relevant sites such as the hip and spine. The review of study on older men has also noted consistent reports of significant improvement in femoral neck BMD, along with positive outcomes when supplemented with calcium- and vitamin D3-fortified milk. As we get older, the lifestyle adaptation of incorporating tolerable weight bearing exercises into our routine is important. It is thus often encouraged at a national public health interest to adopt active ageing through consistent mobility and exercises well into the late stages of our lives.

Calcium & Vitamin D Intake

We all would understand by now that calcium is the key building block for bone formation, with vitamin D playing a crucial role in the absorption of calcium. However, we often fall short to understand that calcium is not naturally produced by our bodies and we would require it from the food we eat. As such when there’s insufficient calcium intake, our bodies turn to the next calcium-rich source: our bones.

According to the Bone Health & Osteoporosis Foundation (BHOF), our requirements would be as follows:

Calcium rich food sources include dairy products such as milk, yogurt and cheese. Some green vegetables such as broccoli, kale, and bok choy are good choices of foods for calcium intake as well. Vitamin D, on the other hand, is found in very few food sources. It is recommended by BHOF for age 50 and older to consume 800-1000 IU daily. Several sources recommended by BHOF include wild caught mackerel, salmon, and tuna. Otherwise, fortified foods can be considered as well, such as fortified milk which may have calcium and vitamin D added. Alternatively, supplementation could also be a viable option to meet daily requirements. However, caution must be exercised to choose brands with proven reliability. When in doubt, speak to your healthcare provider.

Call to Action

Contrary to popular misconceptions surrounding ageing and fragility where often it is an easier option to rest at home and stave off exercises that may be inherently risky, it is encouraged that we should involve in at least 150 minutes of moderate-intensity physical activity. This could be achieved with a 30-minute brisk walk, 5 days a week (CDC, 2024). This triangulates with an earlier article posted in relation to the number of MET-minutes required for healthy ageing. Though a life well-lived, one shouldn’t rest on his laurels when it comes to maintaining activity and proper diet intake. Hence, the spirit of a community would be essential not only for social wellbeing, but also a community that drives a sense of purpose to stay active together.

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References

Cooper C, Campion G, Melton LJ. (1992). 3rd Hip fractures in the elderly: A world-wide projection. Osteoporos Int. 2:285-9. Doi: 10.1007/BF01623184.

Poole K., Compston J. Osteoporosis and its management. BMJ. 2006;333:1251–1256. doi: 10.1136/bmj.39050.597350.47.

Rowe P, Koller A, Sharma S. Physiology, Bone Remodeling. [Updated 2023 Mar 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499863/

Bone Health & Osteoporosis Foundation. (2023). Calcium and Vitamin D. (Online). Available at: https://www.bonehealthandosteoporosis.org/patients/treatment/calciumvitamin-d/

U.S. Centers for Disease Control and Prevention. Older Adult Activity: An Overview. (Online). Accessed at: https://www.cdc.gov/physical-activity-basics/guidelines/older-adults.html#:~:text=Every%20week%2C%20adults%2065%20and%20older%20need%3A&text=At%20least%20150%20minutes%20at,at%20moderate%20and%20vigorous%20intensity.