FRAX Score: Understanding Your Fracture Risk

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

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

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

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

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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.