Osteoporosis in the Pakistan Population A comprehensive review of prevalence, determinants, clinical consequences, and public-health responses

Osteoporosis in the Pakistan Population

A comprehensive review of prevalence, determinants, clinical consequences, and public-health responses

Abstract (≈220 words)

Osteoporosis—characterised by low bone mass and microarchitectural deterioration—is an emerging public-health problem in Pakistan as the population ages and risk factors (vitamin D deficiency, low calcium intake, sedentary behaviour, and obesity) become more common. This review synthesises published evidence on the prevalence and distribution of low bone mineral density (BMD) and osteoporosis in Pakistan, examines key determinants, summarises clinical and economic consequences (including fracture burden), and evaluates current opportunities for prevention and management at individual and population levels. Data from community and hospital studies indicate large proportions of adults—especially postmenopausal women—have osteopenia or osteoporosis; population-level modelling using country-calibrated FRAX estimates suggests tens of thousands of hip fractures annually with projections of rapid increases as the elderly population grows. Major determinants in Pakistan include older age, female sex and postmenopausal status, vitamin D deficiency, low dietary calcium, multiparity, low body mass index (BMI), low literacy/socioeconomic status, limited physical activity, and high prevalence of smoking in some subgroups. Despite substantial burden, awareness, diagnosis and treatment rates are low. Evidence supports a multi-pronged response: (1) primary prevention through vitamin D and calcium sufficiency, weight-bearing physical activity and smoking cessation; (2) case finding using risk assessment tools (FRAX with Pakistan calibration) and targeted DXA scanning; (3) ensuring access to affordable pharmacologic therapies for high-risk individuals; and (4) health-system strategies—fortification, antenatal/postmenopausal counselling, and fracture liaison services—to reduce fractures. Priorities include nationally representative surveillance, health-economics analyses, and implementation research on scalable interventions. PMC+2PMC+2

Keywords

Osteoporosis, Pakistan, bone mineral density, fractures, FRAX, prevention, vitamin D, public health

Introduction

Osteoporosis is defined by the World Health Organization (WHO) as a BMD that is 2.5 standard deviations or more below the young adult mean (T-score ≤ −2.5). Clinically, osteoporosis becomes most significant because of fragility fractures—particularly hip, spine and wrist fractures—that increase morbidity, mortality and health-care costs. Although much of the global burden has historically been described in Western populations, low- and middle-income countries (LMICs) including Pakistan face growing burdens due to population ageing, nutrition transitions, and pervasive risk factors such as vitamin D deficiency and physical inactivity. Understanding the magnitude and drivers of osteoporosis in Pakistan is essential to design cost-effective, culturally appropriate prevention and management strategies. Recent systematic reviews and Pakistan-specific analyses have highlighted high prevalence of low BMD and projected large numbers of osteoporotic fractures if current trends continue. PMC+1

This article reviews the epidemiology of osteoporosis in Pakistan, summarises major risk factors, presents the burden of fractures and projections, discusses diagnostic and management challenges, and proposes evidence-based public-health and clinical strategies tailored to the Pakistani context.

Methods (literature selection and scope)

We synthesised peer-reviewed articles, systematic reviews, national/regional surveys and modelling studies reporting BMD, osteoporosis prevalence, fracture incidence or risk factors in Pakistan up to 2025. Key sources included narrative reviews of osteoporosis in Pakistan, community and hospital cross-sectional BMD studies (DXA and surrogate measures), FRAX calibration and modelling papers for Pakistan, and policy/epidemiologic summaries (JPMA, PJMS). Where national representative data were unavailable, we drew on multi-centre clinical studies and modelling efforts to infer burden and trends. For load-bearing and policy statements we prioritised the most recent, largest and nationally relevant sources. PMC+1

Epidemiology — prevalence and distribution

Community and hospital studies

Multiple hospital-based and community BMD studies in Pakistan show high frequencies of low BMD, osteopenia and osteoporosis across adult age groups—particularly among postmenopausal women:

• A cross-sectional study in a suburban Pakistani population using DXA reported osteopenia prevalence of ~29.8% and osteoporosis prevalence of ~27.2%, with only ~43% of subjects having normal BMD. These data indicate that more than half of adults in the sampled population had low bone mass. PMC
• Earlier and subsequent hospital and community studies report variable but consistently elevated prevalence; for example, surveys focused on peri- and postmenopausal women commonly identify osteoporosis/osteopenia in 30–70% depending on age group and threshold definitions. PubMed+1

National estimates and projected fracture burden

Although nationally representative BMD surveys are limited, modelling efforts using Pakistan-calibrated FRAX or surrogate FRAX models estimate substantial fracture burden. A surrogate FRAX model estimated about 36,524 hip fractures in 2015 among individuals aged ≥50 in Pakistan, with projections of a ~214% increase to over 114,000 hip fractures by 2050 if demographic trends continue—illustrating the potential exponential increase in fracture burden with ageing. These projections underscore the urgency of population-level prevention. PMC+1

Gender and age patterns

As globally, women—particularly postmenopausal women—bear the greatest burden. Reported prevalence of osteoporosis is substantially higher in women than men (studies report female osteoporosis prevalence ranging from ~20–40% in adult samples and lower prevalence in men but significant at older ages), and prevalence rises with advancing age and menopause duration. jpma.org.pk+1

Table 1 — Selected prevalence estimates and projections (Pakistan)

Key determinants and risk factors in Pakistan

Multiple interacting determinants explain the high prevalence of low BMD and osteoporosis:

1. Advancing age and postmenopausal status. Rapid bone loss occurs in the years after menopause due to reduced estrogen; Pakistan’s demographic transition is increasing the proportion of older adults. Several studies list age and menopause duration as dominant risk factors. old.jsp.org.pk+1
2. Vitamin D deficiency. Pakistan has a high prevalence of vitamin D deficiency across age groups—a critical determinant of bone health that impairs calcium absorption and may exacerbate bone loss. Vitamin D deficiency is widespread and interacts with low dietary calcium to increase skeletal risk. PMC+1
3. Low dietary calcium intake. Dietary patterns with low dairy consumption and limited consumption of calcium-rich foods reduce lifelong calcium intake, contributing to lower peak bone mass and increased osteoporosis risk. PMC
4. Low BMI and nutritional status. Several Pakistani studies identify low BMI and poor general nutrition as risk factors in some populations, though increasing overweight/obesity in other subgroups complicates patterns. Low body weight reduces mechanical loading on bone and is a well-known osteoporosis risk. old.jsp.org.pk+1
5. Reproductive factors and multiparity. High parity and extended periods of lactation—common in some subpopulations—may influence maternal bone density, particularly in contexts of inadequate nutritional replenishment. Some local studies list multiparity as an associated factor. old.jsp.org.pk
6. Physical inactivity and sedentary lifestyle. Urbanisation and decreasing physical activity reduce weight-bearing exercise that maintains bone strength. SMJ
7. Socioeconomic and educational status. Lower education and socioeconomic status are associated with lower BMD in Pakistan, likely mediated through diet, limited health literacy, and reduced access to preventive care. Pakistan Journal of Medical Sciences
8. Smoking and alcohol use. Tobacco use—more common among men—negatively affects bone; alcohol also contributes where used. Local data show smoking is a risk factor in community studies. SMJ

Clinical consequences and burden

Fractures and outcomes

Fragility fractures—particularly hip fractures—carry high morbidity and mortality. The FRAX-based modelling indicates large absolute numbers of hip fractures and a projected sharp rise by mid-century given population ageing. Hip fractures are associated with loss of independence, reduced mobility, increased institutionalisation, and high short-term mortality; vertebral fractures contribute chronic pain and disability. The health-system and economic consequences in Pakistan—where rehabilitation and long-term care capacity are limited—are substantial. PMC+1

Low awareness and under-diagnosis

Many Pakistani studies point to low public and clinician awareness, under-diagnosis and under-treatment. For instance, a national review estimated that only a minority of those with osteoporosis were aware of their diagnosis or receiving treatment, signalling a large care gap and missed opportunities for secondary prevention. jpma.org.pk

Diagnosis, risk assessment and tools

DXA and resource constraints

Dual-energy X-ray absorptiometry (DXA) is the gold standard to diagnose osteoporosis. However, DXA access in Pakistan is limited and concentrated in urban tertiary centres; cost and geographic access make universal screening impractical. Many community studies rely on opportunistic DXA or surrogate measures. Given resource constraints, a pragmatic approach is targeted DXA for those identified as high risk using clinical tools. PAFMJ

FRAX and Pakistan calibration

FRAX—an internationally used fracture risk calculator—has been calibrated for Pakistan using surrogate incidence data. The Pakistan FRAX model enables clinicians to estimate 10-year probabilities of hip and major osteoporotic fractures, guiding treatment thresholds when combined with local cost-effectiveness and guideline considerations. Recent publications describe FRAX-based intervention thresholds adapted to Pakistan. FRAX without BMD may be useful in primary care to prioritise who should receive DXA or treatment. PubMed+1

Prevention and management: evidence-based approaches for Pakistan

1. Primary prevention (population level)

• Vitamin D and calcium sufficiency. Given high vitamin D deficiency and low calcium intake, population strategies—fortification of staple foods, public education on safe sun exposure, supplementation for high-risk groups—are priorities. Routine counselling on dietary calcium (dairy, fortified foods, green leafy vegetables) and vitamin D supplementation where indicated can prevent bone loss. PMC+1
• Physical activity promotion. Encourage weight-bearing and resistance exercises (walking, stair-climbing, resistance bands) across the life course; public health messaging and community exercise programmes can be integrated into primary health services. SMJ
• Tobacco and alcohol control. Strengthening tobacco cessation programmes reduces long-term skeletal harm, alongside multiple other health benefits. SMJ

2. Case finding and secondary prevention (clinical level)

• Risk stratification using FRAX. Implement FRAX in primary care to identify individuals at high 10-year fracture risk who should receive DXA and/or pharmacologic therapy. FRAX without BMD can be used where DXA is unavailable to prioritise scanning and interventions. White Rose Research Online+1
• DXA for confirmation and monitoring. Targeted DXA for postmenopausal women ≥65 years, patients with fragility fractures, long-term glucocorticoid use, or other high-risk features. Use baseline BMD for treatment decisions and follow-up to monitor response where feasible. PAFMJ

3. Pharmacologic treatment

• First-line options. Bisphosphonates (oral or IV), denosumab, selective estrogen receptor modulators, and parathyroid hormone analogues are effective for fracture risk reduction in appropriate patients. Cost and access restrict availability; national formularies and procurement strategies should prioritise essential, evidence-based agents for high-risk individuals. PMC
• Adherence and safety. Ensure patient counselling on dosing (e.g., bisphosphonate administration), monitor for adverse effects (renal function, hypocalcaemia), and address barriers to adherence (cost, access). PMC

4. Post-fracture care and fracture liaison services (FLS)

• FLS model. Establishing FLS—coordinated programmes that identify patients with fragility fractures and ensure secondary prevention (treatment, rehabilitation, fall prevention)—has been effective globally in reducing subsequent fractures. Adapting FLS to Pakistan’s hospital settings can improve outcomes and reduce recurrent fractures. Pilot programmes and implementation research are needed. PMC

Table 2 — Interventions: benefits, barriers and Pakistan feasibility

(References supporting intervention effectiveness and feasibility are discussed in text.) PMC+1

Health economics and policy considerations

The projected rise in hip fractures implies growing direct (hospital, surgery, rehabilitation) and indirect (loss of productivity, long-term care) costs. There is an urgent need for country-specific health-economics analyses to compare the cost-effectiveness of prevention strategies (fortification, supplementation, FRAX-guided treatment, FLS). In many LMIC settings, prevention and targeted treatment have favourable cost-effectiveness compared with the high costs of hip fracture care and long-term disability. Policymakers should consider integrating osteoporosis prevention into existing noncommunicable disease (NCD) and maternal-child health programmes to leverage resources. PMC+1

Research gaps and priorities

1. Nationally representative BMD and fracture incidence data. Robust surveillance to establish baseline burden and track trends. PMC
2. Implementation research on fortification and supplementation programmes. Which vehicles (wheat flour, milk, edible oil) are most acceptable and effective? PMC
3. Economic evaluations. Cost-effectiveness of screening thresholds, pharmacologic strategies, and FLS in Pakistan. ACU Research Bank
4. Pilot FLS and FRaX implementation studies. To demonstrate feasibility and impact on secondary fracture prevention. White Rose Research Online
5. Behavioural interventions. Culturally adapted programmes to increase weight-bearing exercise, dietary calcium, and vitamin D sufficiency. SMJ

Limitations of the evidence base

• Most prevalence data are from hospital or regional studies and may not be nationally representative; assay and methodological heterogeneity complicate comparisons.
• FRAX modelling uses surrogate estimates where national fracture incidence data are sparse; while informative for planning, these projections carry uncertainty.
• Data on treatment coverage, adherence and long-term outcomes in Pakistan are limited, constraining health-systems planning.

Conclusion and recommendations

Osteoporosis and low bone mass are common in Pakistani adults—especially postmenopausal women—and projected fracture burden suggests large future health and economic consequences if preventive action is not scaled. Key recommendations:

1. Prioritise vitamin D and calcium sufficiency through targeted supplementation (pregnant and postmenopausal women, elderly), public education and selective food fortification pilot programmes. PMC
2. Implement FRAX risk assessment in primary care to prioritise DXA and pharmacologic therapy for those at highest 10-year fracture risk. White Rose Research Online
3. Expand access to cost-effective pharmacologic treatment (e.g., bisphosphonates) for high-risk individuals, with monitoring and adherence support. PMC
4. Develop pilot fracture liaison services in tertiary hospitals to close the secondary prevention gap. PMC
5. Invest in national surveillance and research (BMD surveys, fracture registries, implementation trials and cost-effectiveness studies) to inform policy and scale-up.

Concerted action combining public-health prevention and targeted clinical interventions can substantially reduce the personal and societal burden of osteoporosis in Pakistan over coming decades.

Tables & Figures (for publication)

• Table 1: Selected prevalence estimates and projections (above).
• Table 2: Intervention matrix (above).
• Figure 1 (suggested): Projected hip fractures in Pakistan (2015 ≈ 36,524 → 2050 ≈ 114,820) based on FRAX surrogate modelling (Naureen et al., 2021). This bar-chart visually emphasises the projected rise if prevention is not scaled. ACU Research Bank

Selected references

1. Khan AH. Osteoporosis and its perspective in Pakistan: A review. (2018). Provides an overview of prevalence, risk factors and management challenges in Pakistan. PMC
2. Naureen G, et al. A surrogate FRAX model for Pakistan. (2021). Estimated hip fracture numbers and projections for Pakistan using surrogate incidence data. PMC+1
3. Tariq S, et al. Status of bone health and association of socio-demographic factors with bone mineral density in Pakistan. PJMS (2019). Reported osteopenia 29.8% and osteoporosis 27.2% in a suburban sample. PMC
4. Farooq M. Low Bone Mineral Density and its age and gender related distribution in a suburban population of Pakistan. PAFMJ (recent). High frequency of low BMD with increase by age. PAFMJ
5. JPMA editorial / review. Osteoporosis’s undertreatment in Pakistan. (2023). National estimates of current burden (~9.9 million people) and calls for action. jpma.org.pk
6. Mamji MF. Risk factors for osteoporosis in post-menopausal women — Pakistani study. JSP (2010). Identified advancing age, longer menopause duration, multiparity, low BMI, low socioeconomic status as significant factors. old.jsp.org.pk
7. Fatima M. Determining the risk factors and prevalence of osteoporosis among women in Pakistan. (2009). Early community BMD work showing substantial osteopenia/osteoporosis prevalence. PubMed
8. Johansson H, et al. FRAX-based intervention thresholds for Pakistan. (2022). Guidance on applying FRAX in clinical practice for Pakistan. PubMed