A minor fall. A broken wrist. A vertebra that collapses. Often, this is how osteoporosis first comes to light — after years of silent bone loss.

That is one of the disease’s great paradoxes: Osteoporosis can progress without obvious symptoms until a fracture occurs.

As the world marked World Osteoporosis Day on Oct. 20, the latest figures highlighted the scale of a health problem that remains too often overlooked. According to Italy’s Ministry of Health, about 5 million people in the country live with osteoporosis, 80% of them postmenopausal women. But the disease is not exclusive to women, nor is it an inevitable consequence of aging.

Bone loss also affects men, particularly as they grow older, and can be exacerbated by chronic illnesses, hormonal changes, a sedentary lifestyle, malnutrition and certain medications.

More Than 1,500 Fractures a Day: The Cost of Osteoporosis

The International Osteoporosis Foundation’s SCOPE 2021 report estimated that Italy recorded about 568,000 new fragility fractures in 2019 — more than 1,500 a day, or roughly one every minute.

The consequences extend well beyond the initial injury. A hip fracture, for example, may require surgery, hospitalization, rehabilitation and long-term care. For older patients, it can also lead to a permanent loss of independence. Vertebral fractures, which often go undiagnosed, can cause chronic pain, loss of height and significant functional limitations, sometimes requiring long-term pain management.

The economic burden is equally substantial. Estimates for 2019 put direct health care and assistance costs associated with osteoporosis at €9.45 billion. The figure reflects the scale of a structural problem likely to worsen as the population ages unless prevention and patient care improve.

A First Fracture Is a Warning Sign, Not an Inevitable Fate

Osteoporosis weakens the skeleton through a loss of bone mass and deterioration of the bone’s internal structure. The first sign may be a wrist or forearm fracture after a fall from standing height. In other cases, vertebral fractures may occur, sometimes accompanied by loss of height, back pain or changes in posture.

Not every fracture after a fall indicates osteoporosis. But a fracture resulting from minimal trauma in someone over 50 warrants an appropriate assessment of bone health.

Major risk factors include age, a previous fracture, a family history of hip fractures, early menopause, low body weight and prolonged use of corticosteroids. Men’s risk should also be recognized, rather than waiting for a fracture to occur before taking action.

Nutrition Protects Bone Health from an Early Age

Prevention begins long before symptoms appear. Luisella Cianferotti, an Associate Professor of Endocrinology at the University of Florence and a Physician in the Bone Metabolism Unit at Careggi University Hospital in Florence, emphasizes the importance of nutrition.

“Fragility fractures are increasing dramatically around the world in both men and women,” she says. “Nutrition is important in primary prevention, before a fragility fracture has occurred, and it also supports every therapeutic strategy for secondary prevention, after fractures have already happened.”

Peak bone mass is generally reached between the ages of 20 and 30. Building strong bones during childhood and adolescence, then preserving bone health throughout adulthood, is an investment in quality of life later on.

Don’t Drink Milk? Calcium-Rich Mineral Water Can Help

When people think of calcium, they tend to think of milk, yogurt and cheese. But another often-overlooked source can help meet daily needs: water.

“Dairy products are certainly essential, but so are other calcium-containing foods and calcium-rich mineral waters,” Cianferotti says.

Calcium is vital for bone mineralization, but it also plays a role in muscle contraction and the transmission of nerve impulses.

Under European regulations, natural mineral water can be classified as calcium-rich if it contains more than 150 milligrams of calcium per liter. Consider a simple example: Drinking 1.5 liters of water containing 300 milligrams of calcium per liter provides 450 milligrams of calcium — a substantial contribution to daily dietary needs.

The benefits are not limited to the amount of calcium. Research indicates that calcium in calcium-rich mineral water is efficiently absorbed by the body, with bioavailability generally comparable to that of calcium in dairy products. Check the label for calcium content, listed in milligrams per liter. Tap water can also contribute to calcium intake, depending on the composition of the local water supply.

The role of water and nutrition in bone health was also a focus of a congress organized by SISA, the Italian Society of Nutritional Sciences, in Rome in September. Its President, Silvia Migliaccio, Professor of Food Science at Sapienza University in Rome, highlighted the importance of calcium in an interview with SAE Salute.

“Calcium is a mineral that is fundamental to bone health,” Migliaccio said. The good news, she added, is that “water provides zero calories but can contain significant amounts of calcium and other minerals.”

Vitamin D Is Essential for Bone Health, but Avoid Self-Prescribing Supplements

Vitamin D plays a crucial role in calcium and phosphorus metabolism. It helps the body absorb these minerals and supports proper bone mineralization and muscle health.

The main source of vitamin D is production in the skin triggered by ultraviolet B (UVB) rays. Vitamin D3 produced in the skin is processed by the liver into 25-hydroxyvitamin D [25(OH)D] and then converted, primarily in the kidneys, into its biologically active form, calcitriol [1,25(OH)₂D]. This hormone helps regulate calcium and phosphorus levels in the body.

Vitamin D production in the skin varies according to the season, time of day, skin type, age and amount of skin exposed to sunlight. There is no single dose that is right for everyone, and taking more does not necessarily provide greater protection. When supplementation is appropriate, it should be tailored to the individual’s clinical condition, dietary calcium intake, risk factors and current medications. Unnecessary high doses should be avoided.

The message is clear: Vitamin D is essential for bone health, but supplements should address a clinical need — not the assumption that more is always better.

When Diet and Exercise Aren’t Enough, Effective Medications Are Available

Osteoporosis can be prevented and, when diagnosed, treated. Calcium and vitamin D are important foundations of bone health, but several effective classes of medication are available when additional treatment is needed. These include antiresorptive drugs, which slow bone loss, and anabolic agents, which stimulate new bone formation.

Treatment depends on the severity of the disease, whether fractures have occurred, the patient’s age and risk profile, and other individual health considerations. In Italy, access to medications reimbursed by the National Health Service is governed, for eligible patients, by Italian Medicines Agency (AIFA) Note 79.

Osteoporosis is a chronic disease, and treatment requires consistency and regular reassessment. Therapy may need to be adjusted over time and, in some cases, different medications must be given in a planned sequence. Patients should not stop treatment on their own, particularly when taking certain drugs whose discontinuation can paradoxically increase the risk of fractures.

References

Italian Ministry of Health, Osteoporosis: Prevention, Risk Factors and Impact on Health, official website.

International Osteoporosis Foundation, SCOPE 2021: Epidemiology, Burden, and Treatment of Osteoporosis in Italy.

Nuti R, Brandi ML, Checchia G, et al., “Guidelines for the Management of Osteoporosis and Fragility Fractures,” Internal and Emergency Medicine, 2019.

Thomasius F, Kurth A, Baum E, et al., “Clinical Practice Guideline: The Diagnosis and Treatment of Osteoporosis,” Deutsches Ärzteblatt International, 2025.

Hawarden A, Paskins Z, Mughal F, “What’s New in Osteoporosis Management? Leading the Fight in Primary Care,” British Journal of General Practice, 2024.

Vannucci L, Fossi C, Quattrini S, et al., “Calcium Intake in Bone Health: A Focus on Calcium-Rich Mineral Waters,” Nutrients.

Italian Medicines Agency (AIFA), Note 79: Medications for the Treatment of Osteoporosis.

International Osteoporosis Foundation, World Osteoporosis Day 2026: “Build, Protect, Strengthen Your Bones for Life.”