The Fall That Changes Everything
Mrs. Lakshmi was 68, a retired teacher, active and independent. She was walking to her morning kitty party when she stumbled on an uneven pavement. She put her hand out to break the fall — a reflexive action we've all done a hundred times.
Her wrist shattered.
Not a crack. Not a hairline fracture. Her radius bone collapsed like it was made of chalk. Surgery followed, then weeks of physiotherapy, and even now, two years later, she can't make rotis properly because of limited wrist movement.
Her bone density had been tested 5 years earlier. The report showed osteopenia — early bone loss. It was filed away without action. No calcium prescribed, no vitamin D checked, no follow-up arranged.
Mrs. Lakshmi's fracture was preventable. She just needed someone to take her bone health seriously before the fall.
The Silent Disease
Osteoporosis is called a "silent disease" because bone loss happens without symptoms. You don't feel your bones getting weaker. There's no pain, no warning sign. The first indication is often a fracture — a fracture from a fall that shouldn't break a bone, or worse, a vertebra that collapses while you're simply lifting something.
The statistics are sobering:
- India has 50 million people with osteoporosis — one of the highest numbers in the world
- One in three women and one in eight men over 50 will have an osteoporotic fracture
- Hip fractures carry a 20-30% mortality rate in elderly Indians within the first year
- Survivors often lose independence — 40% can't walk independently afterwards
This isn't about living longer. It's about living better — maintaining independence, mobility, and quality of life as we age.
FRAX: Predicting Fractures Before They Happen
FRAX (Fracture Risk Assessment Tool) is a WHO-developed algorithm that calculates your 10-year probability of having a major osteoporotic fracture. It takes into account clinical risk factors — with or without a bone density scan — to predict your risk.
Think of it as a weather forecast for your bones. It doesn't tell you for certain that you'll fracture, but it tells you how likely it is — allowing you to take shelter before the storm.
What FRAX Predicts
- 10-year probability of major osteoporotic fracture (hip, spine, wrist, or shoulder)
- 10-year probability of hip fracture specifically (the most devastating type)
The Risk Factors That Matter
FRAX uses several clinical factors, each with a biological reason behind it:
| Risk Factor | Why It Matters | How Much It Increases Risk |
|---|---|---|
| Age | Bone remodeling becomes less efficient with age | Risk doubles every 7-8 years after 50 |
| Sex | Women lose bone rapidly after menopause | Women have 4x higher risk than men |
| Low body weight | Less mechanical load on bones, less bone built | BMI below 19 significantly increases risk |
| Previous fracture | Prior fracture indicates already-weakened bone | Doubles the risk of future fractures |
| Parent hip fracture | Genetic component to bone strength | Increases risk by 50-100% |
| Current smoking | Directly toxic to bone cells, impairs vitamin D | Increases risk by 20-30% |
| Glucocorticoids | Steroids rapidly destroy bone | Most potent modifiable risk factor |
| Rheumatoid arthritis | Inflammation damages bone independent of steroids | 1.5x increased risk |
| Alcohol (3+ units/day) | Directly toxic to osteoblasts (bone-building cells) | Significantly increased risk |
FRAX+ (2024 Update) — New Factors
The updated FRAX tool now includes additional risk factors:
- Falls history: Falling frequently means more opportunities for fracture
- Recent fracture (within 2 years): The period right after a fracture is highest risk
- Type 2 diabetes: Diabetic bone is structurally weaker despite normal density
- Lumbar spine T-score: Spine bone density now factored in
Understanding Your FRAX Score
10-Year Major Osteoporotic Fracture Risk
| FRAX Score | Risk Category | What It Means | Recommendation |
|---|---|---|---|
| Below 10% | Low | Less than 1 in 10 chance in 10 years | Lifestyle measures, reassess in 5 years |
| 10-20% | Moderate | 1-2 in 10 chance in 10 years | Get DEXA if not done, optimize lifestyle |
| Above 20% | High | More than 1 in 5 chance in 10 years | Medication strongly recommended |
10-Year Hip Fracture Risk
| FRAX Score | Risk Category | Recommendation |
|---|---|---|
| Below 3% | Low | Continue preventive measures |
| 3% and above | High | Treatment recommended regardless of DEXA |
The 3% Hip Fracture Threshold:
A 3% 10-year hip fracture risk is the treatment threshold in many countries. This isn't arbitrary — at this risk level, the benefit of treatment clearly outweighs the risks. If your hip fracture risk is 3% or higher, medication should be strongly considered.
DEXA Scan: The Gold Standard
While FRAX can be calculated without a bone density scan, adding DEXA results makes it more accurate.
What Is a DEXA Scan?
DEXA (Dual-Energy X-ray Absorptiometry) measures bone mineral density at the hip and spine — the sites most prone to osteoporotic fractures. It's quick (10 minutes), painless, and uses minimal radiation.
Understanding T-Scores
Your T-score compares your bone density to a healthy 30-year-old adult of the same sex:
| T-Score | Diagnosis | What It Means |
|---|---|---|
| Above -1.0 | Normal | Bone density within healthy range |
| -1.0 to -2.5 | Osteopenia | Lower than normal — "pre-osteoporosis" |
| Below -2.5 | Osteoporosis | Significantly reduced bone density |
| Below -2.5 with fracture | Severe Osteoporosis | Established disease with fracture history |
Who Should Get a DEXA Scan?
- All women at 65 and all men at 70
- Postmenopausal women under 65 with risk factors
- Anyone with a fragility fracture (fracture from minimal trauma)
- Anyone on long-term steroids (more than 3 months)
- Anyone with conditions causing secondary osteoporosis
Why Indians Are at Special Risk
Several factors make osteoporosis particularly concerning for Indians:
Vitamin D Deficiency
Despite abundant sunshine, 70-90% of Indians are vitamin D deficient. Cultural practices (avoiding sun exposure, covering skin), skin melanin content, and air pollution all contribute. Without adequate vitamin D, calcium absorption is impaired, and bones weaken.
Lower Peak Bone Mass
Indian children and young adults tend to have lower peak bone mass compared to Western populations. Since bone loss begins from your peak, starting lower means hitting the danger zone earlier.
Vegetarian Diet Challenges
While a vegetarian diet can be bone-healthy, it often falls short in protein and vitamin D. Many vegetarians also avoid dairy, eliminating the primary calcium source.
Early Menopause
Indian women reach menopause 4-5 years earlier than Western women on average. This means earlier estrogen loss and earlier onset of accelerated bone loss.
Genetic Factors
Certain genetic variants affecting vitamin D metabolism and bone structure are more common in South Asian populations.
The Fracture You Must Prevent: Hip Fracture
Not all fractures are equal. Hip fractures are in a category of their own.
Mr. Krishnamurthy was 74, a retired bank manager who prided himself on his independence. He lived alone, did his own shopping, and walked 3 km every morning. One evening, he tripped on his bathroom mat.
His hip fractured.
Surgery was scheduled for the next day, but he developed a hospital-acquired pneumonia while waiting. The surgery was delayed by a week. Post-surgery, he developed a blood clot. Three weeks in hospital turned into two months. He never walked independently again. He moved in with his son. Six months later, he passed away from complications.
This isn't an unusual story. Hip fractures are devastating:
- 20-30% mortality within one year
- 50% never regain their previous level of function
- 25% require long-term care
- Most never live independently again
This is why preventing hip fractures specifically is so critical — and why FRAX calculates hip fracture risk separately.
Building and Maintaining Bone
Here's what actually works for bone health:
Weight-Bearing Exercise
Your bones respond to mechanical stress by getting stronger. But not all exercise is equal for bones:
Best for bones:
- Walking, jogging, stair climbing
- Resistance training (weights, resistance bands)
- Dancing
- Sports with jumping or impact
Good but not bone-building:
- Swimming (great for fitness, but no bone stimulus)
- Cycling (same — excellent cardio, minimal bone impact)
Calcium — From Food First
Target: 1000-1200 mg per day (more if postmenopausal or over 70)
| Food | Calcium (mg per serving) |
|---|---|
| Curd (200g) | 300 |
| Milk (1 glass) | 250 |
| Paneer (100g) | 480 |
| Ragi (100g) | 350 |
| Sesame seeds (30g) | 280 |
| Rajma (cooked, 1 cup) | 80 |
| Methi leaves (100g) | 395 |
If you can't get enough from food, supplements are reasonable — but don't exceed 500 mg per dose (absorption drops at higher doses).
Vitamin D — The Essential Cofactor
Without adequate vitamin D, you only absorb 10-15% of dietary calcium. With sufficient vitamin D, you absorb 30-40%.
Target levels: 30-60 ng/mL (75-150 nmol/L)
Most Indians need supplementation. Common regimens:
- 60,000 IU weekly for 8 weeks (loading dose if deficient)
- 60,000 IU monthly or 2000 IU daily (maintenance)
Protein — The Forgotten Factor
Bone isn't just calcium — it's 50% protein by volume. Adequate protein intake (1.0-1.2 g/kg body weight) is essential for bone health and muscle strength (which prevents falls).
Fall Prevention
Most fractures happen because of falls. Preventing falls is as important as strengthening bones:
- Remove loose rugs and cables at home
- Ensure adequate lighting, especially at night
- Install grab bars in bathrooms
- Review medications that cause dizziness
- Check vision regularly
- Consider balance exercises (yoga, tai chi)
When Medication Is Needed
Lifestyle modifications aren't always enough. Here's when medications are recommended:
- FRAX 10-year major fracture risk above 20%
- FRAX 10-year hip fracture risk above 3%
- T-score of -2.5 or below at hip or spine
- T-score between -1.0 and -2.5 PLUS a fragility fracture
- Long-term steroid use (more than 3 months)
The Medications That Work
| Medication Class | Examples | How They Work | Notes |
|---|---|---|---|
| Bisphosphonates | Alendronate, Risedronate, Zoledronic acid | Slow bone breakdown | First-line treatment; taken weekly/monthly/yearly |
| Denosumab | Prolia | Blocks bone-resorbing cells | Injection every 6 months; must not miss doses |
| Teriparatide | Forteo | Stimulates new bone formation | For severe osteoporosis; daily injection for 2 years |
| Romosozumab | Evenity | Both builds bone and slows breakdown | Newest option; monthly injection for 1 year |
The Bisphosphonate Reality:
Many patients fear bisphosphonates because of rare side effects like jaw osteonecrosis. The perspective matters:
- Risk of jaw osteonecrosis: 1 in 10,000 to 1 in 100,000
- Risk of hip fracture if untreated: 1 in 5 to 1 in 3 over 10 years
The risk of NOT treating far exceeds the risk of treatment in those who need it.
Secondary Osteoporosis: The Hidden Causes
Sometimes osteoporosis isn't just about aging — there's an underlying cause:
| Condition | How It Affects Bones |
|---|---|
| Hyperthyroidism | Excess thyroid hormone accelerates bone loss |
| Hyperparathyroidism | High PTH literally leeches calcium from bones |
| Celiac disease | Malabsorption of calcium and vitamin D |
| Chronic kidney disease | Disrupts vitamin D activation and calcium balance |
| Type 1 diabetes | Bone quality is impaired |
| Inflammatory bowel disease | Inflammation + malabsorption + often steroid use |
| Anorexia nervosa | Malnutrition + low estrogen |
| Chronic steroid use | Most potent drug-induced cause |
If you have osteoporosis at a young age, or if it's severe despite no obvious risk factors, your doctor should investigate for secondary causes.
Monitoring and Follow-Up
If You're on Treatment
- DEXA scan every 2 years to assess response
- Vitamin D level check annually
- Monitor for medication side effects
If You Have Osteopenia
- FRAX calculation to determine actual fracture risk
- DEXA scan every 2-3 years to assess progression
- Aggressive lifestyle optimization
- Consider medication if risk crosses threshold
Back to Mrs. Lakshmi
After her wrist fracture, Mrs. Lakshmi finally had a proper bone health evaluation. Her DEXA showed a T-score of -3.1 at the hip — severe osteoporosis. Her FRAX calculated a 35% 10-year major fracture risk and an 8% hip fracture risk.
She was started on zoledronic acid (once-yearly infusion), her vitamin D was optimized (she was at 12 ng/mL — severely deficient), and calcium was added. A home safety assessment was done and she started balance exercises.
Two years later, her bone density has improved by 5%. More importantly, she hasn't had another fracture. She's back at her kitty parties — just more careful about uneven pavements.
"I wish someone had explained this to me five years ago," she reflects. "Before I broke my wrist."
That's the point. Bone health shouldn't be an afterthought. By the time a fracture happens, you're playing catch-up.
Your Bone Health Action Plan
For Everyone Over 50:
- Know your risk: Calculate your FRAX score (online at sheffield.ac.uk/FRAX)
- Check vitamin D: Get tested, supplement if low (most Indians are)
- Optimize calcium: 1000-1200 mg daily from food + supplements if needed
- Load your bones: Weight-bearing exercise most days
- Prevent falls: Home safety, balance training, vision checks
- Consider DEXA: If you have risk factors or are over 65 (women) or 70 (men)
| Your Situation | What To Do |
|---|---|
| Postmenopausal woman with no risk factors | Calculate FRAX, get DEXA at 65 |
| Anyone on steroids more than 3 months | DEXA now, likely need medication |
| History of fragility fracture | DEXA now, likely need medication |
| Parent with hip fracture | Earlier screening, FRAX calculation |
| Low body weight (BMI under 19) | Consider earlier screening |
Track your bone health with ExaHealth. Upload your DEXA scan results and monitor your T-scores over time — because preventing a fracture is infinitely better than recovering from one.
