Osteoporosis

What is Osteoporosis?

This subsequently increases the risk of fractures even with minor trauma. It is the result of the body losing more bone than it makes, resulting in an absolute loss of bone density and thus strength. 

Much like other metabolic diseases, osteoporosis is a “silent disease.” Much like how high cholesterol does not have symptoms till a stroke or heart attack occurs, osteoporosis progresses without symptoms until a fracture occurs. These fractures commonly occur in the hip, spine or wrist. Due to its location, and fragility, these fractures can lead to chronic pain, disability, and reduced quality of life, particularly in older adults. Hip fractures can actually lower life expectancy with a 20 to 30 percent increase in mortality a year after fracture. 

How common is Osteoporosis in Singapore?

In Singapore, osteoporosis is a growing health concern, especially with the ageing population. In fact, 1 in 3 women, and 1 in 5 men over the age of 50 years old are at risk of developing an osteoporotic fracture in their lifetime.

Hip fractures, in particular, have increased significantly in recent decades. What is even more concerning is that Singapore has one of the highest hip fracture rates in Asia, with projections indicating a continued rise unless preventive measures are taken.

What causes Osteoporosis?

Bone cells continuously break down and build-up bone tissue in our bones. This continuous process occurs throughout such that our bones are completely replaced every 10 years. When the rate of the bone breakdown exceeds new bone formation, bone mass decreases. Over time, this imbalance leads to osteoporosis.

What are the symptoms of Osteoporosis?

Osteoporosis is asymptomatic in its early stages. As such, many individuals remain unaware of their condition until a fracture occurs.

However, as the disease progresses, symptoms may include:

• Loss of height over time – a gradual decrease in height of more than 3cm may indicate osteoporosis.
  
• Persistent back pain due to spinal fractures – chronic or recurring back pain can result from tiny fractures in the vertebrae, often caused by osteoporosis. Dr Dinesh comments that most lower back pain is due to osteoarthritis (degeneration) of the spine but osteoporotic crush fractures of the spine should not be missed especially if there was preceding trauma.

• Stooped or hunched posture (kyphosis) – a forward-curved spine, commonly seen in older adults with osteoporosis, caused by collapsed or weakened vertebrae.

• Sudden fractures from minor falls or routine activities – fragile bones can break easily during simple actions such as bending, lifting or minor slips, and trips. Dr Dinesh has even seen many patients with severe osteoporosis having fractures without any trauma. This is why screening for osteoporosis prior to fracture is important so these events can be prevented. 

Who is at risk of Osteoporosis in Singapore?

There are several risk factors that contribute to osteoporosis, many of which are prevalent in Singapore’s ageing, and urban population.

These risk factors include:

• Age – as we age, bone renewal slows down. After 50 years old, bone breakdown begins to outpace bone formation, making bones progressively thinner, and more fragile.

• Female – women are at greater risk due to lower overall bone mass compared to men and menopause, where a sharp drop in oestrogen accelerates bone loss. This increases risk of osteoporosis, and fractures.

• Family history – genetics play a significant role much like everything else in medicine. If an individual’s parents or siblings have osteoporosis or experienced hip or spine fractures, then they may inherit a tendency for low bone density.

• Lifestyle – physical activity, especially weight-bearing exercises like walking or resistance training, stimulates bone growth. Conversely lack of movement/ sedentary lifestyle leads to reduced bone strength, and faster bone loss.

• Medication – long-term use of steroids, anti-seizure drugs or certain cancer treatments can reduce bone density by disrupting calcium balance or affecting hormone levels.

• Nutrition deficiencies – calcium is the key building block for bone, and vitamin D helps the body absorb calcium effectively. Inadequate intake or poor absorption weakens bone structure over time.

• Previous fractures – a history of fragility fractures, even from minor accidents, suggests underlying bone weakness, and a higher risk of future breaks. Dr Dinesh notes that this is the most important risk factor for future fracture. Everyone with a fragility fracture needs treatment regardless of their bone mineral density on a DEXA scan.

• Smoking and alcohol consumption – smoking interferes with bone-forming cells, and reduces oestrogen levels. Additionally, excessive alcohol disrupts calcium balance, and impairs vitamin D production, weakening the bones.

• Weight – low body weight means less bone mass. In addition, people with low body mass index (BMI) may have nutritional deficiencies, and less cushioning to protect bones during falls. Dr Dinesh notes this is one of the most common causes of osteoporosis in our elderly in Singapore. 

Can Osteoporosis be prevented?

Fortunately, osteoporosis is largely preventable through lifestyle changes, and early intervention. The key step is building strong bones during youth, and maintaining bone health throughout your life.

As such, some of the preventive strategies include:

• Adequate calcium and vitamin D intake – this can be achieved through diet, and, if necessary, supplements. Dr. Dinesh states that the rate of Vitamin D insufficiency in the Singapore population is very high due to our indoor jobs and sedentary lifestyle (Vit D is produced naturally from sunlight in your skin).

• Avoiding smoking and limiting alcohol intake – this will help to maintain bone metabolism.

• Bone health screening – routine screening ensures you regain autonomy over your bone health, especially for individuals with risk factors. Dr Dinesh recommends his patients who are peri-menopausal have a screening DEXA scan. 

• Maintaining a healthy weight – as weight loss results in sarcopenia (muscle loss) that is a cause of frailty in addition to bone loss. Dr. Dinesh often recommends patients with a low BMI gain weight in osteoporosis treatment through an increase in portion sizes of healthy foods and protein.

• Regular weight-bearing exercises – such as brisk walking, dancing or resistance training to help strengthen the bone.

How is Osteoporosis diagnosed?

Osteoporosis is diagnosed using a bone mineral density (BMD) scan, typically performed with a dual-energy X-ray absorptiometry (DEXA) scan. This test measures the density of bones, usually at the hip, and spine. The scan then generates a T-score, which compares your bone density to that of a healthy young adult of the same gender. It helps determine whether your bones are normal, weakened or osteoporotic Dr Dinesh stated that this is the most ideal test we have to predict your future risk of fracture. Treatment success is also demonstrated by improvement in bone mineral density. Conversely worsening bone mineral density with treatment is a marker of treatment failure.

Generally, the results are as follows:

T-SCORE	WHAT IT MEANS	EXPLANATION
≥ -1.0	Normal bone density.	Your bones are within the healthy range, with low risk of fracture.
Between -1.0 to -2.5	Low bone mass (osteopenia).	Bone density is below normal, and may lead to osteoporosis if not managed.
≤ -2.5	Osteoporosis.	Bone density is significantly reduced, increasing the risk of fractures.

Beyond the bone mineral density (BMD) scan, our doctors may recommend further investigations to gain a more comprehensive understanding of your bone health, and the underlying cause of osteoporosis. These tests help rule out other medical conditions, identify risk factors, and guide treatment decisions.

Some of the additional tests may include:

TEST	PURPOSE	DESCRIPTION
Blood Test	To rule our secondary osteoporosis causes.	Certain health conditions, and deficiencies can lead to secondary osteoporosis, where bone loss is the result of another underlying disorder. Blood tests may be performed to check levels of:CalciumKidney and Liver functionMarkers of bone turnoverParathyroid Hormone (PTH)PhosphateThyroid FunctionTestosterone in malesUrinary calcium excretionVitamin D These tests help identify treatable causes, such as hormonal imbalances, nutritional deficiencies or chronic illnesses.
FRAX Tool	To assess fracture risk.	The FRAX tool is a widely used online calculator developed by the World Health Organization (WHO). It estimates an individual’s 10-year risk of developing a major osteoporotic fracture, based on the following factors:AgeBMIGenderFamily history of fracturesHistory of previous fracturesSmoking and alcohol consumptionUse of corticosteroidsThe existence of a secondary cause
X-Rays	To detect spinal fractures.	X-rays of the spine may be taken if you have symptoms like persistent back pain, height loss or stooped pressure. These images help identify vertebral compression fractures, which are common in osteoporosis but may go undiagnosed due to their subtle symptoms.

How is Osteoporosis treated?

Treatment for osteoporosis focuses on reducing fracture risk, slowing bone loss, and strengthening existing bone. 

Lifestyle and Nutritional Support

• Diet rich in calcium and vitamin D – supports strong bones, and helps prevent further bone loss. Calcium is essential for bone structure, while vitamin D helps the body absorb calcium effectively. Sunlight is essential for Vitamin D. Our frailer patients may require supplementation. 
• Safe, regular physical activity – weight-bearing, and resistance exercises help maintain bone density, and improve muscle strength, balance, and coordination, thereby reducing the risk of falls, and fractures. This also preserves the co-existent condition of sarcopenia (muscle loss) which leads to frailty and falls risk. 
• Smoking cessation and alcohol moderation – smoking, and excessive alcohol weaken bones, and interferes with calcium absorption. Stopping smoking, and limiting alcohol can help slow bone loss.

Medications

• Bisphosphonates – these medications slow down bone breakdown, helping to maintain or increase bone density, and reduce fracture risk.
• Denosumab – a monoclonal antibody given by injection every 6 months. It helps slow down bone loss, and is useful for people who cannot take oral bisphosphonates or did not respond to weaker agents
• Selective oestrogen receptor modulators (SERMs) – these drugs mimic oestrogen’s bone-protective effects, helping to reduce bone loss in postmenopausal women.
• Parathyroid hormone analogues – these stimulate the body to build new bone, and are often used in severe cases or when other treatments have not worked.This is termed anabolic therapy. 
• Sclerostin inhibitor – This agent both blocks bone loss and increases bone formation and is now the first-line treatment for osteoporosis.
• Hormone replacement therapy (HRT) – for selected postmenopausal women, HRT can help maintain bone density by replacing declining oestrogen levels.

Monitoring and Follow-up

• Regular BMD scans – BMD scans are usually done every 1 to 2 years to track changes in bone density, and assess treatment effectiveness.
• Blood tests – blood tests are done to monitor calcium, vitamin D levels, and bone turnover markers to guide, and adjust treatment.
• Ongoing assessment – regular review of fall risk, lifestyle factors, and potential medication side effects helps optimise long-term bone health.

Summary

Osteoporosis is a serious but manageable condition. With early detection, and tailored treatment, it is possible to reduce fracture risk, and maintain an active, independent lifestyle. At The Metabolic Clinic, we offer specialised endocrine care for osteoporosis, using evidence-based strategies to protect and strengthen your bones.Dr Dinesh was the lead for bone health at Khoo Teck Puat hospital and is highly experienced in this sub-speciality. 

If you are concerned about your bone health or have experienced fractures, schedule a consultation today for a detailed assessment and personalised care plan.

Frequently Asked Questions

Is osteoporosis a painful condition?
Osteoporosis itself is not painful, but it can lead to fractures that cause significant pain, particularly in the spine, hips, and wrists. Chronic pain may persist if spinal compression fractures occur.

Is osteoporosis life-threatening?
While not directly fatal, osteoporosis increases the risk of serious fractures, especially hip fractures, which can lead to long-term disability, hospitalisation, and even increased mortality in older adults.

What happens if I delay treatment for osteoporosis?
Delaying treatment increases the risk of further bone loss, and fractures, some of which may lead to permanent disability or a decline in quality of life.

How often should I undergo a bone density test?
If you have risk factors or are undergoing treatment, your doctor may recommend a DEXA scan every 1 to 2 years to monitor bone health, and treatment response.

How does osteoporosis affect my daily life?
Osteoporosis can limit mobility, and independence, especially after a fracture. You may experience difficulty with walking, bending or lifting, and require lifestyle adjustments to reduce fall risk.

Is osteoporosis reversible?
In most patients osteoporosis is reversible. Bone density can be improved with appropriate treatment, and lifestyle changes but it takes time.

At what age should I start screening for osteoporosis?
Peri-menopausal women, and men over 70 should be screened or earlier if you have risk factors such as a previous fracture, family history or long-term corticosteroid use.

Can men get osteoporosis?
Yes. Although more common in women, men account for up to 20% of osteoporosis cases in Singapore. Men with low testosterone, poor diet or chronic illness are particularly at risk.

Can exercise help improve bone density?
Yes. Weight-bearing, and resistance exercises stimulate bone formation, and improve balance, which reduces the risk of falls and fractures.
Do calcium supplements alone prevent osteoporosis?
Calcium is essential but not sufficient on its own. A holistic approach, including vitamin D, exercise, and in most medication, is necessary to reduce fracture risk