Osteoporosis is a systemic skeletal disorder characterized by reduced bone mass and deterioration of bone microarchitecture, leading to increased bone fragility and susceptibility to fractures. The World Health Organization (WHO) classifies bone health based on bone mineral density (BMD) using T-scores, defining osteoporosis as a T-score ≤ −2.5 standard deviations (SD) and osteopenia as a T-score between −1.0 and −2.5 SD below the mean of a young healthy reference population.¹ Bone loss is often referred to as a “silent disease” because it progresses without obvious clinical symptoms until a fragility fracture occurs. Osteoporosis-related fractures are associated with substantial morbidity, mortality, loss of independence, and increased healthcare costs, particularly among the elderly population.² Globally, nearly 200 million individuals are estimated to be affected by osteoporosis, making it a major public health concern.³ Despite this growing burden, the WHO has highlighted a relative lack of reliable epidemiological data on osteoporosis from developing countries, including India.⁴ In India, studies assessing the prevalence of osteoporosis among adults—especially women—have reported wide variability, ranging from 8% to 62%, depending on the study population, geographic region, diagnostic method, and age group studied.⁵ This wide variation suggests significant regional, demographic, and lifestyle-related differences in bone health across the country. Several Indian studies have consistently shown that women are at a higher risk of osteoporosis and osteopenia compared to men, largely due to hormonal changes following menopause. In addition, advancing age is a well-established risk factor for progressive bone loss in both sexes.⁶ Beyond age and sex, multiple factors influence bone health, including nutritional status, physical activity, educational level, occupational activity, body weight, reproductive history, and dietary intake of calcium, protein, and micronutrients.⁷˒⁸ Dietary components such as vitamin C, vitamin B12, carotenoids, vitamin K, omega-3 fatty acids, and adequate protein intake have been shown to positively influence bone metabolism and reduce fracture risk.⁹ Given India’s vast cultural diversity and heterogeneity in dietary patterns, lifestyle habits, and socioeconomic conditions, regional differences in the prevalence of osteopenia and osteoporosis are expected. India is undergoing a demographic transition with a rapidly increasing elderly population. According to the 2011 Census, more than 104 million individuals aged 60 years and above reside in India, accounting for approximately 8.6% of the total population. Women constitute a slightly higher proportion of this elderly population compared to men. Furthermore, life expectancy at the age of 60 years is approximately 18 additional years, increasing the duration of exposure to age-related bone loss and fracture risk.¹⁰ This demographic shift underscores the urgent need for early identification and preventive strategies for bone loss. Despite the rising burden of osteoporosis and osteopenia, large-scale data on bone health across different regions of India remain limited. Screening strategies that are simple, non-invasive, radiation-free, and cost-effective are particularly valuable in resource-limited settings. Calcaneal quantitative ultrasound (QUS) has emerged as a practical tool for community-based screening of bone health and has been shown to correlate reasonably well with central BMD measurements and fracture risk. In this context, the present study was undertaken to estimate the prevalence of osteopenia and osteoporosis among apparently healthy adults in India using calcaneal quantitative ultrasound, and to assess variations across age groups, gender, and geographic regions.

This was a retrospective, hospital-based cross-sectional study conducted using data collected from routine in-clinic bone health screening camps. The screening camps were organized at a tertiary care hospital and research institute in Cuttack, Odisha, India, between January 2018 and August 2019. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Participant confidentiality and data anonymity were strictly maintained throughout the study. A total of 1200 apparently healthy adult participants aged 18 years and above, of either gender, were included in the analysis. Participants attending the screening camps voluntarily were evaluated for bone mineral density. Inclusion Criteria • Adults aged ≥18 years • Both males and females • Apparently healthy individuals not previously diagnosed with osteoporosis Exclusion Criteria • Individuals with known disorders affecting bone metabolism (e.g., chronic kidney disease, malignancy, endocrine disorders) • Participants receiving medications known to influence bone health (e.g., long-term corticosteroids, anticonvulsants, hormone replacement therapy) • Pregnant and lactating women Bone mineral density was assessed using calcaneal quantitative ultrasound (QUS) of the left heel in all participants. After application of a sterile coupling solution over the foot and lower leg, participants were instructed to place their left foot in the designated position on the ultrasound device. A trained technician assisted with proper positioning and conducted all assessments to ensure uniformity. The QUS measurement was completed automatically within approximately 20 seconds, and the BMD T-score generated by the machine was recorded for each participant. Calcaneal QUS has been shown to be a reliable screening tool for osteoporosis, correlates with central BMD measurements, and predicts fracture risk, particularly in postmenopausal women and the elderly.¹¹–¹⁵ Based on WHO criteria, participants were classified as: • Normal bone density: T-score > −1.0 SD • Osteopenia: T-score between −1.0 and −2.5 SD • Osteoporosis: T-score ≤ −2.5 SD For each participant, the following variables were recorded: Age, Gender, Geographic region of residence, Bone mineral density T-score. Participants were categorized into: Adults: 18–59 years and Elderly: ≥60 years. All females aged 50 years and above were considered postmenopausal for analysis purposes. Data were entered and analyzed using Microsoft Excel 2016. Categorical variables were expressed as frequencies and percentages; continuous variables were summarized using mean and standard deviation. The Chi-square test was used to assess associations between categorical variables such as age group, gender, and region with bone health status. A p-value < 0.05 was considered statistically significant.

A total of 1200 participants were included in the final analysis. The mean age of the study population was 48.1 ± 13.9 years, with 286 (23.8%) participants aged ≥60 years. Males constituted 628 (52.3%), while 572 (47.7%) were females. Among females, 222 (38.8%) were postmenopausal. Participants were recruited from all four geographic regions of India, with the highest representation from South India (35.0%). The overall prevalence of osteoporosis in the study population was 18.4%, while osteopenia was observed in 50.0% of participants. Normal bone mineral density was seen in 31.6% of participants. Table 1: Demographic characteristics of study participants (N = 1200) Characteristics N (%) Age (years) ≤40 412 (34.3) 41–59 502 (41.8) ≥60 286 (23.8) Mean ± SD 48.1 ± 13.9 Gender Male 628 (52.3) Female 572 (47.7) Postmenopausal females (>50 years) 222 (38.8) Region East 246 (20.5) West 278 (23.2) North 256 (21.3) South 420 (35.0) Of the 1200 participants, 600 (50.0%) had osteopenia and 221 (18.4%) had osteoporosis. The remaining 379 (31.6%) participants had normal BMD. Table 2: Overall and zone-wise distribution of bone mineral density BMD Total (N=1200) East (n=246) West (n=278) North (n=256) South (n=420) Normal 379 (31.6) 75 (30.5) 100 (36.0) 72 (28.1) 132 (31.4) Osteopenia 600 (50.0) 126 (51.2) 133 (47.8) 142 (55.5) 199 (47.4) Osteoporosis 221 (18.4) 45 (18.3) 45 (16.2) 42 (16.4) 89 (21.2) Among males, osteoporosis was present in 17.2%, while among females it was 19.6%. Osteopenia was nearly equally distributed between males (50.1%) and females (49.8%). The gender-wise difference in BMD distribution was statistically significant (p < 0.001). Postmenopausal women showed a markedly higher burden of bone loss, with 33.3% having osteoporosis and 47.7% having osteopenia. Table 3: Gender-wise comparison of BMD in adults and elderly BMD Adult males (n=472) Elderly males (n=156) p-value Adult females (n=442) Elderly females (n=130) p-value Normal 172 (36.4) 32 (20.5) 157 (35.5) 21 (16.2) Osteopenia 244 (51.7) 72 (46.2) <0.001 227 (51.4) 56 (43.1) <0.001 Osteoporosis 56 (11.9) 52 (33.3) 58 (13.1) 53 (40.7) Osteoporosis was significantly more common in elderly participants compared to adults in both males (33.3% vs 11.9%) and females (40.7% vs 13.1%). Table 4: Zone-wise distribution of BMD among adults and elderly Region Adults – Osteoporosis % Elderly – Osteoporosis % p-value East 13.4 37.9 <0.001 West 9.9 35.8 <0.001 North 11.7 32.5 <0.001 South 14.2 39.6 <0.001 Across all regions, elderly participants consistently demonstrated a significantly higher prevalence of osteoporosis compared to adults. Table 5: Zone-wise distribution of bone mineral density by gender Region Male – Osteoporosis % Female – Osteoporosis % p-value East 17.1 19.9 0.001 West 15.6 17.0 0.041 North 15.0 18.0 0.005 South 19.6 21.9 0.028 In all regions, females had a higher prevalence of osteoporosis than males, with the highest burden observed in South India.

India is the second most populous country in the world, and with a steady rise in life expectancy, the proportion of the ageing population is increasing rapidly. Projections indicate that by 2050, nearly 20% of the Indian population will be aged ≥60 years, with a corresponding sharp rise in osteoporotic fractures, particularly hip fractures, where the male-to-female ratio is estimated to be 1:3. Loss of bone mass leads to reduced compressive and torsional strength of bone, substantially increasing the risk of fragility fractures, especially among the elderly. Early identification of osteopenia and osteoporosis is therefore critical to reduce fracture burden and associated morbidity and mortality. In the present hospital-based cross-sectional study involving 1200 apparently healthy adults, the overall prevalence of osteoporosis and osteopenia was 18.4% and 50.0%, respectively. These findings are consistent with global estimates suggesting that osteoporosis affects more than 200 million individuals worldwide. Indian studies have reported wide variation in osteoporosis prevalence, ranging from 8% to 62%, with osteopenia often affecting more than half of the studied population. However, many of these studies were conducted exclusively among women. In contrast, our study included both genders and demonstrated osteoporosis in 17.2% of males and 19.6% of females, emphasizing that bone loss is also a significant concern among men and should not be overlooked in clinical practice. Age and menopausal status are well-established determinants of bone loss. In the present study, osteoporosis prevalence among elderly participants (≥60 years) was 37.0%, significantly higher than in adults aged 18–59 years (12.5%). This trend was consistent across genders, with 33.3% of elderly males and 40.7% of elderly females affected by osteoporosis. These findings are comparable with previous Indian studies reporting a marked rise in osteoporosis prevalence with advancing age. Accelerated bone loss during the early postmenopausal period—estimated at 2–5% annually—followed by a slower decline thereafter likely explains the higher burden observed among elderly women. Nutritional deficiencies, early menopause, and low peak bone mass further compound this risk in Indian women. Interestingly, osteopenia was more prevalent among adults than the elderly and was also observed more commonly in males than females. This suggests that bone loss begins at an earlier age in the Indian population, possibly due to genetic susceptibility, sedentary lifestyle, inadequate calcium intake, and widespread vitamin D deficiency. The high prevalence of osteopenia is clinically important, as this group represents a population at imminent risk of progression to osteoporosis if preventive measures are not initiated. Regional analysis revealed notable geographic variations. The South Indian region demonstrated the highest prevalence of osteoporosis (21.2%), while osteopenia was most prevalent in North India (55.5%). Similar regional patterns have been reported previously, though with varying prevalence estimates due to differences in study design, sample size, age groups, and diagnostic methods. Our findings suggest that despite cultural and dietary diversity, bone loss is a widespread public health concern across all regions of India. Among postmenopausal women, 47.7% were osteopenic and 33.3% were osteoporotic, indicating that nearly one in two postmenopausal women has osteopenia and one in three has osteoporosis. Although some regional studies have reported higher prevalence rates, these were often based on smaller samples and may overestimate the true burden. Nonetheless, the consistently high prevalence highlights the urgent need for targeted screening and intervention in this vulnerable group. The major strength of this study lies in its large sample size and inclusion of both genders across multiple geographic regions, providing a comprehensive overview of bone health in an Indian hospital-based population. Bone mineral density assessment was performed using calcaneal quantitative ultrasound (QUS), a simple, non-invasive, and radiation-free method suitable for large-scale screening. While axial DEXA remains the gold standard, peripheral QUS has been shown to correlate well with central BMD and predict fracture risk, making it a pragmatic tool in resource-limited settings. However, the study has certain limitations. Detailed information on lifestyle factors, dietary calcium intake, vitamin D status, physical activity, and history of fragility fractures was not available, which could have provided deeper insight into regional and demographic differences. Additionally, the hospital-based design may limit generalizability to the wider community.

This study demonstrates that osteoporosis affects nearly one in five adults, while osteopenia is present in one in two adults in India. Although osteoporosis is more common among women—particularly postmenopausal women—and the elderly, osteopenia is widely prevalent among men and younger adults, indicating early onset of bone loss. Regional variations exist, with South India showing a slightly higher burden of osteoporosis, but bone loss remains a pan-India public health issue. The high prevalence of osteopenia underscores a critical window for preventive intervention to halt progression to osteoporosis and reduce future fracture risk. There is an urgent need for increased awareness, early screening, lifestyle modification, and appropriate management strategies to address bone health in the Indian population. Large-scale, regionally representative studies incorporating risk factor assessment and fracture outcomes are essential to inform policy decisions and strengthen osteoporosis prevention programs nationwide.

1. National Institute for Health and Care Excellence (NICE). Bone Health Programme: A proactive population approach to bone health. October 2017. Available from: https://www.nice.org.uk/sharedlearning/bone-health-programme-proactive-population-approach-to-bone-health. Accessed June 12, 2020. 2. World Health Organization. WHO scientific group on the assessment of osteoporosis at primary health care level. Geneva: WHO; 2007. Available from: https://www.who.int/chp/topics/Osteoporosis.pdf. Accessed June 12, 2020. 3. International Osteoporosis Foundation. Facts and statistics. Available from: https://www.iofbonehealth.org/facts-statistics#category-26. Accessed June 12, 2020. 4. World Health Organization. Nutrition: Recommendations for preventing osteoporosis. Available from: https://www.who.int/nutrition/topics/5_population_nutrient/en/index25.html. Accessed June 12, 2020. 5. Khadilkar AV, Mandlik RM. Epidemiology and treatment of osteoporosis in women: an Indian perspective. Int J Womens Health. 2015;7:841–850. 6. Kaushal N, Vohora D, Jalali RK, Jha S. Prevalence of osteoporosis and osteopenia in an apparently healthy Indian population: a cross-sectional retrospective study. Osteoporos Sarcopenia. 2018;4(2):53–60. 7. Alonge TO, Adebusoye LA, Ogunbode AM. Factors associated with osteoporosis among older patients at a geriatric centre in Nigeria: a cross-sectional study. S Afr Fam Pract. 2017;59:87–93. 8. Thomas-John M, Codd MB, Manne S, Watts NB, Mongey AB. Risk factors for the development of osteoporosis and osteoporotic fractures among older men. J Rheumatol. 2009;36:1947–1952. 9. Sahni S, Mangano KM, McLean RR, Hannan MT, Kiel DP. Dietary approaches for bone health: lessons from the Framingham Osteoporosis Study. Curr Osteoporos Rep. 2015;13:245–255. 10. Ministry of Statistics and Programme Implementation. Elderly in India: Profile and programmes 2016. Available from: http://mospi.nic.in/sites/default/files/publication_reports/ElderlyinIndia_2016.pdf. Accessed June 12, 2020. 11. Hashmi FR, Elfandi KO. Heel ultrasound scan in detecting osteoporosis in low-trauma fracture patients. Orthop Rev (Pavia). 2016;8:6357. 12. Gnudi S, Ripamonti C, Malavolta N. Quantitative ultrasound and bone densitometry to evaluate the risk of non-spine fractures: a prospective study. Osteoporos Int. 2000;11:518–523. 13. Roux C, Laugier P. Quantitative ultrasound evaluation of postmenopausal osteoporosis. J Radiol. 1999;80:279–285. 14. Sung KH, Choi Y, Cho GH. Peripheral DXA measurement around the ankle joint to diagnose osteoporosis as assessed by central DXA measurement. Skeletal Radiol. 2018;47:1111–1117. 15. Huopio J, Kröger H, Honkanen R, Jurvelin J, Saarikoski S, Alhava E. Calcaneal ultrasound predicts early postmenopausal fractures as well as axial BMD: a prospective study of 422 women. Osteoporos Int. 2004;15:190–195. 16. International Osteoporosis Foundation. Asian regional audit – India. Available from: https://www.iofbonehealth.org/sites/default/files/PDFs/Audit%20Asia/Asian_regional_audit_India.pdf. Accessed June 15, 2020. 17. Marwaha RK, Tandon N, Garg MK, Kanwar R. Bone health in healthy Indian population aged 50 years and above. Osteoporos Int. 2011;22:2829–2836. 18. Meeta, Digumarti L, Agarwal N, Vaze N, Shah R, Malik S. Clinical practice guidelines on menopause: executive summary and recommendations. J Midlife Health. 2013;4:77–106. 19. Chitten JJ, James B. Prevalence of osteopenia and osteoporosis in orthopaedic outpatients in Southern India. J Clin Diagn Res. 2018;12:RC14–RC17. 20. Singh K, Kumar R, Shukla A. Status of 25-hydroxyvitamin D deficiency and effect of vitamin D receptor gene polymorphisms on bone mineral density in thalassemia patients of North India. Hematology. 2012;17:291–296. 21. Paul T, Thomas N, Seshadri MS, Oommen R, Jose A, Mahendri NV. Prevalence of osteoporosis in ambulatory postmenopausal women from Southern India: relationship to calcium nutrition and vitamin D status. Endocr Pract. 2008;14:665–671. 22. Shetty S, Kapoor N, Naik D, Asha HS, Prabu S, Thomas N. Osteoporosis in healthy South Indian males and the influence of lifestyle factors and vitamin D status on bone mineral density. J Osteoporos. 2014;2014:723238. 23. Agrawal NK, Sharma B. Prevalence of osteoporosis in otherwise healthy Indian males aged 50 years and above. Arch Osteoporos. 2013;8:116. 24. Acharya S, Srivastava A, Sen IB. Osteoporosis in Indian women aged 40–60 years. Arch Osteoporos. 2010;5:83–89. 25. Silvanus V, Ghosal K, Behera A, Subramanian P. Screening for osteopenia and osteoporosis in an urban community in India. Nepal Med Coll J. 2012;14:247–250. 26. Kadam NS, Chiplonkar SA, Khadilkar AV, Khadilkar VV. Prevalence of osteoporosis in apparently healthy adults above 40 years of age in Pune City, India. Indian J Endocrinol Metab. 2018;22:67–73. 27. Borgohain B, Phukan P, Sarma K. Prevalence of osteoporosis among vulnerable adults in North-Eastern India: a preliminary report. J Orthop Traumatol Rehabil. 2017;9:84–87. 28. Thulkar J, Singh S, Sharma S, Thulkar T. Preventable risk factors for osteoporosis in postmenopausal women: a systematic review and meta-analysis. J Midlife Health. 2016;7:108–113. 29. Kaur M. Prevalence and associated risk factors of osteoporosis in postmenopausal women in North India. Mal J Nutr. 2013;19:285–292. 30. Aggarwal N, Raveendran A, Khandelwal N, Sen RK, Thakur JS, Dhaliwal LK, et al. Prevalence and related risk factors of osteoporosis in peri- and postmenopausal Indian women. J Midlife Health. 2011;2:81–85.