Osteoporosis: what your DEXA result means and how to protect your bones

What is osteoporosis and why does it go unnoticed for so long?

Osteoporosis (from the Greek for porous bone) is a condition in which the internal structure of bone becomes progressively less dense and more porous, like a sponge with widening holes. The bone looks normal from the outside but can no longer absorb impact well. Because this process is entirely painless until a fracture happens, most people are diagnosed only after a minor fall breaks a wrist, a vertebra collapses under ordinary load, or a hip fracture happens from a standing height.

Bone is a living tissue that constantly renews itself. Specialised cells called osteoclasts break down old bone and osteoblasts build new bone in its place. Until around age 30, the building outpaces the breakdown and bones reach their peak density. After that the balance tips slowly towards loss, and in women after menopause the loss accelerates sharply because oestrogen, which normally restrains osteoclast activity, drops away.

The fractures most commonly linked to osteoporosis are the wrist, the vertebrae of the spine, and the hip. A hip fracture is particularly serious because it almost always requires surgery and can permanently affect a person's ability to walk independently. In settings where surgical care is limited, this represents a significant threat to quality of life.

How to read your DEXA result: what is a T-score?

A DEXA (Dual-energy X-ray Absorptiometry) scan is the standard test for measuring bone mineral density. It is painless, takes about 15 minutes, and uses a very small amount of radiation, far less than a chest X-ray. The scan is usually done at two sites: the lumbar spine and the femoral neck (top of the thighbone). The result is expressed as a T-score, which compares your bone density to that of a healthy young adult at their peak bone mass.

A T-score between 0 and -1.0 is normal. Between -1.0 and -2.5 is osteopenia, which means lower than average density but not yet at the fracture threshold. This is a warning stage: with lifestyle changes and sometimes medication, it is possible to prevent progression to osteoporosis. A T-score of -2.5 or lower is the World Health Organization's diagnostic threshold for osteoporosis.

Your doctor may also calculate a FRAX score alongside the T-score. FRAX estimates your probability of a major fracture over the next ten years using age, weight, family history, and other factors as well as bone density. This helps decide whether medication is warranted, because two people with the same T-score can have very different fracture risk depending on their other characteristics.

Why is bone loss so common across the sunny Middle East?

It seems paradoxical that a region with so much sunlight should have such high rates of vitamin D deficiency, yet multiple studies confirm this is the case. A 2012 study published in Archives of Osteoporosis found very high rates of vitamin D inadequacy among women in the UAE, with clothing style being a significant predictor. A 2018 review in Bone Reports covering the entire Middle East and North Africa region confirmed that deficiency was widespread across all age groups and both sexes.

Several factors explain this. Full-body covering limits sun exposure of the skin, which is where the body makes vitamin D through ultraviolet light. Prolonged hours in air-conditioned indoor spaces, high SPF sunscreen use, and low levels of outdoor physical activity all compound the problem. Darker skin tones, which are common in the region, also require longer sun exposure to produce the same amount of vitamin D as lighter skin.

Women entering menopause are hit by a double burden: oestrogen loss accelerates bone breakdown at exactly the time that vitamin D stores may already be low from years of indoor life and limited sun exposure. This combination makes the first decade after menopause the highest-risk period for bone loss in regional women.

Calcium and vitamin D: how much and where to get it

Calcium is the main mineral in bone, and vitamin D is what allows your intestine to absorb calcium from food. Without adequate vitamin D, even a calcium-rich diet does little good. Adult women need around 1,000 to 1,200 milligrams of calcium per day, and the upper end of that range applies after menopause and in older adults of both sexes.

Good dietary sources that fit easily into regional eating patterns include: dairy products such as milk, yoghurt and white cheese; tinned sardines and salmon eaten with their soft bones; sesame seeds and almonds; and dark leafy vegetables such as broccoli and kale. A quarter cup of sesame seeds provides around 350 milligrams of calcium, making tahini and sesame-sprinkled bread surprisingly valuable.

For vitamin D, direct skin exposure to sunlight for 15 to 30 minutes daily on the arms and legs during midday hours outside the peak summer heat is the most reliable source. Those who wear full covering, spend most of the day indoors, or live at high altitude during winter may need a supplement. The appropriate dose should be guided by a blood test (25-hydroxyvitamin D), not guesswork, because high-dose supplementation without monitoring carries its own risks.

Which exercises actually build bone?

Not all exercise is equal for bone health. The exercises that matter most are those that place mechanical load on the skeleton: walking briskly, jogging, dancing, stair climbing, and resistance training with weights. This mechanical stress signals bone-building cells to increase their activity. The Endocrine Society clinical practice guideline, updated in 2019, specifically recommends weight-bearing and muscle-strengthening exercise as a core component of osteoporosis management.

Swimming and cycling are excellent for cardiovascular fitness and muscle strength but have limited impact on bone density because they support the body's weight rather than challenging it. They are still valuable in the overall picture, particularly for people who find high-impact exercise difficult due to joint problems.

Balance and coordination training, such as yoga or tai chi, matters for a different reason: it reduces the risk of falls, which are the proximate cause of most osteoporotic fractures. Even a modest improvement in balance can have a significant effect on fracture risk in older adults. Aim for at least 30 minutes of weight-bearing activity on most days of the week.

When does osteoporosis need medication?

Not everyone with a low T-score needs drug treatment immediately. Your doctor weighs the T-score against the FRAX fracture probability and any additional risk factors. If the 10-year risk of a major fracture exceeds a country-specific threshold, or if the T-score is -2.5 or below with other risk factors, medication is likely to do more good than harm.

The most widely used drugs are the bisphosphonates, which include alendronate (Fosamax), risedronate and zoledronic acid. Oral bisphosphonates are usually taken once weekly on an empty stomach with a full glass of water, staying upright for at least 30 minutes afterwards to prevent oesophageal irritation. A 2022 review in Osteoporosis International confirmed that bisphosphonates significantly reduce the risk of vertebral and hip fractures when taken correctly and consistently.

Newer injectable options include denosumab (Prolia), given every six months by a healthcare provider, and bone-forming agents such as teriparatide for very high-risk cases. Do not stop any of these medications without consulting your doctor: stopping bisphosphonates abruptly after several years may be safe, but stopping denosumab without a bridging strategy can cause rapid bone loss and rebound fractures.

Preventing falls at home: where most fractures actually happen

The majority of osteoporotic fractures follow a fall that would have caused no injury in someone with normal bone density. The bathroom is consistently the most dangerous room: wet floors, no grab rails, and the sudden movement of stepping in or out of the bath or shower are all risk factors. Fitting grab rails beside the toilet and shower, using a non-slip mat, and ensuring adequate lighting in the bathroom overnight are among the most effective single changes you can make.

Poor vision doubles fall risk, so regular eye checks matter. Some medications, particularly sedatives, strong blood pressure drugs, and some antidepressants, can cause dizziness or orthostatic hypotension (a blood pressure drop on standing). If you are on these medications and feel unsteady, mention it to your doctor rather than accepting it as normal.

Footwear matters more than most people realise. Sandals and socks without grip are responsible for a disproportionate number of indoor falls. Shoes with a low, wide heel and a non-slip sole, or slippers with a firm sole, are safer choices inside the home.

Osteoporosis in men: a diagnosis that is frequently missed

Osteoporosis is strongly associated with women in most people's minds, and this association leads to underdiagnosis in men. Approximately one in five men over the age of 50 will experience an osteoporosis-related fracture, and hip fractures in men carry a higher mortality risk in the first year than in women, partly because they occur later in life alongside other illnesses.

Risk factors specific to men include low testosterone, which declines gradually with age and more sharply with certain medications such as androgen deprivation therapy used in prostate cancer treatment. Prolonged alcohol use, low body weight, and long-term corticosteroid therapy are shared risk factors with women. Men over 70 should have a discussion with their doctor about whether a DEXA scan is warranted, and younger men with any of these risk factors should not wait.

The treatment principles are the same regardless of sex: adequate calcium and vitamin D, weight-bearing exercise, fall prevention, and medication where fracture risk is high enough to justify it. The misconception that this is a women's disease should not delay a man from seeking assessment.

Monitoring over time: how often should you repeat the scan?

A DEXA scan does not need to be repeated every year unless your circumstances change significantly. For most people with normal or mildly reduced density, a repeat every two to three years is sufficient. If you have started drug treatment, your doctor will usually suggest a repeat scan after two years to assess the response.

Your 25-hydroxyvitamin D blood test is the measure of your vitamin D stores. It should be checked before starting any supplement to know what dose is needed, and then rechecked after two to three months to confirm you have reached an adequate level, generally between 30 and 50 nanograms per millilitre. Over-supplementing without testing can lead to vitamin D toxicity, which causes its own problems.

Keeping a record of your DEXA results alongside your vitamin D and calcium intake over time gives you and your doctor a clearer picture of whether your bone health is stable, improving or declining. The Sihtak app lets you log results from each visit so the trend is visible at a glance.

Sources

• Chakhtoura M, Rahme M, Chamoun N et al: Vitamin D in the Middle East and North Africa, Bone reports, 2018
• Al Attia HM, Ibrahim MA: The high prevalence of vitamin D inadequacy and dress style of women in the sunny UAE, Archives of osteoporosis, 2012
• LeBoff MS, Greenspan SL, Insogna KL et al: The clinician's guide to prevention and treatment of osteoporosis, Osteoporosis international, 2022
• Eastell R, Rosen CJ, Black DM et al: Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline, Journal of clinical endocrinology and metabolism, 2019
• World Health Organization: WHO Scientific Group on the Assessment of Osteoporosis at Primary Health Care Level, Geneva, 2004
• Al-Musharaf S, Fouda MA, Turkestani IZ et al: Vitamin D Deficiency Prevalence and Predictors in Early Pregnancy among Arab Women, Nutrients, 2018