Osteoporosis Facts and Statistics

Exercise

  • Higher levels of leisure time, sport activity, and household chores and fewer hours of sitting daily were associated with a significantly reduced relative risk for hip fracture [97,98].
  • Physical activity and fitness reduce risk of osteoporosis and fracture [99,100,101] and fall-related injuries [102,103,104].
  • Epidemiologic evidence suggests that physical activity is associated with reductions in hip fracture in women and men [105,106,107].
  • Strengthening back muscles can reduce the risk of vertebral fractures and kyphosis [108,109,110,111].
  • Studies have shown that bone mineral density in postmenopausal women can be maintained or increased with therapeutic exercise [112,113,114].
  • In the frail elderly, activity to improve balance and confidence may be valuable in fall prevention. Studies have shown that individuals who practice tai chi have a 47% decrease in falls and 25% the hip fracture rate of those who do not [102] and that tai chi can be beneficial for retarding bone loss in weight-bearing bones in early postmenopausal women [115].
  • Intensive exercise training can lead to improvements in strength and function in elderly patients who have had hip replacement surgery due to hip fracture [116].
  • Childhood and adolescence are particularly valuable times to improve bone mass through exercise [92,93,94,95,96,541,542].

Hip Fracture

  • Nearly 75% of all hip fractures occur in women [25] and about 25% of hip fractures in people over 50 occurs in men [26].
  • Hip fractures are invariably associated with chronic pain, reduced mobility, disability, and an increasing degree of dependence [27]. After sustaining a hip fracture 10-20% of formerly community dwelling patients require long term nursing care [28,29,30], with the rate of nursing home admission rising with age [29,31].
  • A 50 year old woman has a 2.8% risk of death related to hip fracture during her remaining lifetime, equivalent to her risk of death from breast cancer and 4 times higher than that from endometrial cancer [32].
  • Approximately 1.6 million hip fractures occur worldwide each year, by 2050 this number could reach between 4.5 million [9] and 6.3 million [26].
  • 5-10% of patients experience a recurrent hip fracture [532,533], with the mean interval between the first and second fracture being 3.3 years [533].
  • Hip fractures cause the most morbidity with reported mortality rates up to 20-24% in the first year after a hip fracture [33,34], and greater risk of dying may persist for at least 5 years afterwards [35]. Loss of function and independence among survivors is profound, with 40% unable to walk independently, 60% requiring assistance a year later [36]. Because of these losses, 33% are totally dependent or in a nursing home in the year following a hip fracture [34,37,38].
  • The highest risk of hip fractures are seen in Norway, Sweden, Iceland, Denmark and the USA [39].
  • Hip fractures account for a larger proportion of all fracture expenditures in men than women (73% vs. 61%). Overall, 23% of hip fracture expenditure occurs in men [16].

Key statistics for Asia

  • Hong Kong, China: The prevalence of vertebral fractures is estimated at 30% in women and 17% in men between the ages of 70-79 years of age. These rates are comparable to those in American Caucasians [159,160,167].
  • Taiwan, China: The prevalence of osteoporosis in 1996-2001 among those ages 50 years and older was 1.6% in men and 11.4% in women [605]. A study showed a high incidence rate of hip fractures, close to those of Western countries, and substantially higher than the rates in Beijing (3-5 times) and Hong Kong (1-2 times), except after age 85 [602]. During 1996-2002, the incidence of hip fractures in the 65 years and older population increased by 30%, with rates greater in males (36%) than females (22%) [606].
  • China: The average direct cost of a hip fracture in 2007 was 3603 USD and statistics from different cities indicate that the cost of hip fracture has been increasing at a rate of 6% per year. In 2006 China spent ca. 1.5 billion USD treating hip fracture. It is estimated that this will rise to 12.5 billion USD in 2020 and by 2050 to more than 264.7 billion USD [596,597,598,599,600,601].
  • India: Expert groups peg the number of osteoporosis patients at approximately 26 million (2003 figures) with the numbers projected to increase to 36 million by 2013 [168].
  • India: In a study among Indian women aged 30-60 years from low income groups, BMD at all the skeletal sites were much lower than values reported from developed countries, with a high prevalence of osteopenia (52%) and osteoporosis (29%) thought to be due to inadequate nutrition [560].
  • It is projected that more than about 50% of all osteoporotic hip fractures will occur in Asia by the year 2050 [9,26]
  • Japan: The prevalence of osteporosis in the Japanese female population aged 50-79 years has been estimated to be about 35% at the spine and 9.5% at the hip [161].
  • Osteoporosis is greatly underdiagnosed and undertreated in Asia, even in the most high risk patients who have already fractured. The problem is particularly acute in rural areas. In the most populous countries like China and India, the majority of the population lives in rural areas (60% in China), where hip fractures are often treated conservatively at home instead of by surgical treatment in hospitals [593].
  • Japan: New hip fractures increased 1.7-fold during 1987-1997 [169].
  • DXA technology is relatively expensive and is not widely available in most developing Asian countries, especially in rural areas. For example, in 2008 Indonesia had a total of only 34 DXA machines, half of them in Jakarta, for a population of ca. 237 million (0.001 per 10,000 population). Like in many Asian countries, this falls far below the recommended number for Europe, of 0.11 per 10,000 [593].
  • Japan: The total number of hip fractures is forecast to be 153,000 per year in 2010 and 238,000 in 2030 [569].
  • Nearly all Asian countries fall far below the FAO/WHO recommendations for calcium intake of between 1000 and 1300 mg/day. The median dietary calcium intake for the adult Asian population is approximately 450 mg/day, with a potential detrimental impact on bone health in the region [593].
  • Korea: The occurrence of hip fractures increased about 4-fold over 10 years (1991-2001) [170].
  • Studies carried out across different countries in South and South East Asia showed, with few exceptions, widespread prevalence of vitaminosis D (vitamin D deficiency/insufficiency), in both sexes and all age groups of the population [594].
  • Korea: The number of hip fractures after 75 years of age was 4.3 per 1000 in women and 2.97 per thousand in men [171].
  • China: Osteoporosis affects almost 70 million Chinese over the age of 50 and causes some 687,000 hip fractures in China each year [595]. From 1988 to 1992, the incidence of hip fractures in Beijing increased by 34% in women and 33% in men [162]. There is a higher incidence of hip fractures in men than in women in China [162,163,164].
  • Singapore: The incidences of hip fracture in 1998 have gone up 5 times in women and 1.5 times in men compared to those observed in the 1960s [172]. During 1991-1998, the incidence of hip fracture increased by 0.7% annually in men and by 1.2% annually in women [607].
  • China: The overall prevalence of osteoporosis in mainland China might be approximately 7% among adults, 10-20% in urban areas, 22.5% among men aged 50 years or more, and 50.1% among women aged 50 years or more [604].
  • China: The average direct cost of a hip fracture in 2007 was 3603 USD and statistics from different cities indicate that the cost of hip fracture has been increasing at a rate of 6% per year. In 2006 China spent ca. 1.5 billion USD treating hip fracture. It is estimated that this will rise to 12.5 billion USD in 2020 and by 2050 to more than 264.7 billion USD [596,597,598,599,600,601].
  • China: Osteoporosis prevention and awareness is largely restricted to urban areas of China and DXA machines are only available in the urban centers. In 2008 there were only 450 DXA machines in China for a population of ca. 1.3 billion [595].
  • China: The average length of hospital stay (19-24 nights) for a hip fracture exceeds that for treating breast cancer, ovarian cancer, prostate cancer or heart disease [595].
  • Hong Kong, China: Epidemiological studies showed that hip fracture incidence had increased by 300% from the 1960s to 1990s, and has stabilized from 2001-2006. The reasons are not clear, but may possibly be due to a number of factors including improved availability of medical intervention, increases in BMI, use of HRT, and improved falls prevention strategies [166,593].
  • Hong Kong, China: Despite the stabilization of hip fracture rates, fractures remain a major burden on health services and society. The acute hospital care cost of hip fractures amounted to 1% of the total annual hospital budget, or 17 million USD for a population of 6 million [165].

Key statistics for Europe

  • Germany: A lifetime prevalence of any fracture was found to be 45% for men and 31% for women within the age range of 25-74 years; and 42% for men and 40% for women within the age range of 65-74 years [544].
  • Germany: The report of the European Commission (1998) estimates an increase in the incidence of hip fractures in Germany from 117,000 in the year 2000 to 240,000 in the year 2040 [562].
  • Greece: During 1977-1992 there was an average annual increase of 7.6% for hip fractures. In 1992, 70% of the patients were women and approximately 50% of the patients were aged 80 and over [550].
  • Spain: Approximately 2 million women have osteoporosis and is prevalent in 26.1% of women who are 50 years of age and older [563].
  • Spain: 25,000 fractures occur each year, resulting in direct costs of more than €126 million and indirect costs of €420 million [564].
  • Spain: There was a 54% increase in new cases of hip fracture within a 14-year period (1998-2002). This increase occurred mainly in women (64%) compared to men (19%) [549].
  • Spain: 13% of patients who have suffered a fracture die after 3 months and this figure rises to 38% after 24 months. Furthermore, after experiencing a vertebral fracture, 45% of patients suffer from functional damage and 50% are afflicted by partial or total disability [564].
  • Sweden: The probability of sustaining an osteoporotic hip fracture at the age of 50 years is 23% in women and 11% in men. The risk of sustaining a clinical vertebral fracture is 15% in women and 8% in men. For any common osteoporotic fracture, the remaining lifetime risk is 46% in women and 22% in men [4].
  • Bone mineral density measurement is underutilized in majority of European countries. Reasons include limited availability of densitometers, restrictions in personnel permitted to perform scans, low awareness of usefulness of BMD testing, limited or nonexistent reimbursement [136].
  • In 2000, there were an estimated 4 million new fractures, with 8 fractures each minute or one every 8 seconds [581]. The number of osteoporotic fractures was estimated at 3.79 million of which 0.89 million were hip fractures. The total direct costs were estimated at €31.7 billion (£21 billion) which were expected to increase to €76.7 billion (£51 billion) in 2050 based on the expected changes in the demography of Europe [137].
  • Sweden: The annual cost of osteoporosis is estimated at SEK 8.5 billion. The total annual fracture cost is about 3.2% of the total healthcare costs in Sweden. Hip, vertebral and wrist fractures accounted for 78%, 17% and 5%, respectively, of the total costs. Community care accounted for 66% of the total annual cost, followed by medical care (31%), informal care (2%) and indirect costs (1%) [545].
  • It is estimated that in Europe, 179,000 men and 611,000 women will suffer a hip fracture each year and that the cost of all osteoporotic fractures in Europe is provisionally €25 billion [138].
  • Sweden: Hip fractures account for nearly as many hospital days as acute myocardial infarction and for more than prostate and breast cancers combined [140].
  • Belgium: The annual costs of osteoporotic fracture are estimated at about €150 million [28].
  • Switzerland: Between 2000-2020, osteoporotic hip, vertebral and wrist fracture are predicted to rise by 33%, 27% and 19%, respectively, if current prevention and treatment patterns are maintained [543].
  • Denmark: The estimated prevalence of osteoporosis in persons aged 50 years or more is about 41% among women and 18% among men [141].
  • Switzerland: The annual costs of hospitalizations (in terms of duration of stay) for osteoporotic fractures were greater than those for myocardial infarction, stroke and breast cancer, and only slightly lower than for chronic obstructive pulmonary disease. For women, the costs associated with osteoporosis were higher than for all these diseases [139].
  • Denmark: The first hip fracture incidence rate increased by 56% during the period 1987-1997, with an increase of 41% among women and 104% among men aged 50 years and older [547].
  • Switzerland: In 2000, 62,535 hospitalizations for fractures (57% women and 43% men) were registered. 51% of all fractures in women and 24% in men were considered as osteoporotic. The direct medical cost of hospitalization of patients with osteoporosis and/or related fractures was 357 million CHF. Hip fractures accounted for approximately half of these costs. Among other common diseases in women and men, osteoporosis ranked number 1 in women and number 2 (behind COPD) in men [565].
  • Finland: The total number of hip fractures increased by 70% within a 10-year period (1992-2002) [546].
  • UK: 1 in 2 women and 1 in 5 men will suffer a fracture after the age of 50 [566].
  • France: Of the 118,839 fractures registered in 2001, 61% were at the hip, 28% at the distal radius and 11% at the proximal humerus [561].
  • UK: Based on current trends, hip fracture rates may increase from 46,000 in 1985 to 117,000 in 2016 [567].
  • Germany: In 2003, 7.8 million Germans (6.5 million women) were affected by osteoporosis. Of them, 4.3% experienced at least one clinical fracture and only 21.7% were treated with an antiosteoporotic drug. The total direct costs attributable to osteoporosis amounted to €5.4 billion [562].
  • UK: The cost of treating all osteoporotic fractures in postmenopausal women has been predicted to increase to more than £2 billion by 2020 [568].

Key statistics for Latin America

  • Chile: In 1985, a large clinical trial of women older than 50 indicated that 46% had osteopenia and 22% had osteoporosis [156].
  • Mexico: 1 out of every 4 people has osteopenia or osteoporosis [157] and the lifetime probability of having a hip fracture at 50 years of age is 8.5% for women and about 4% for men [555]. For 2006, the estimated cost of healthcare for hip fracture was $97 million [556].
  • Venezuela: The lifetime probability of having a hip fracture at 50 years of age is 5.5% for women and 1.5% for men, and for any osteoporotic fracture is 13.6% for women and 3.5% for men [609].
  • Venezuela: In 1995 there were 9.6 hip fractures per day. In 2030 it is estimated that there will be 67 hip fractures per day. Of the people that suffer a hip fracture, 17% die in the first 4 months after the fracture. Clinical trials indicated that only the 10% of the population older than 70 years have normal peak bone mass [158].
  • From 1990 to projections in 2050 the number of hip fractures for women and men aged 50-64 in Latin America will increase by 400%. For age groups older than 65 the increase will be a staggering 700% [26].
  • Latin Americans will suffer an estimated 655,648 hip fractures in 2050, at an estimated direct cost of $13 billion [154]. The mortality rates in the year following a hip fracture are 23-30% and are higher in men compared to women [608,609].
  • The prevalence of vertebral osteopenia in women 50 years and older has been reported at 45.5-49.7% and vertebral osteoporosis at at 12.1-17.6%; while the prevalence of femoral neck osteopenia has been reported at 46-57.2% and femoral neck osteoporosis at 7.9-22% [608].
  • In a study of five Latin American countries (Argentina, Brazil, Colombia, Mexico and Puerto Rico), the prevalence of vertebral fractures in women over 50 years of age was about 15%, with 7% occuring within the 50-60 years old age group and increasing to 28% for those greater than 80 years old [553].
  • Argentina: The prevalence in women over 50 years old is 50% for osteopenia and 25% for osteoporosis [610]. It is projected that by 2050, 5.24 million and 2.62 million women will have osteopenia and osteoporosis, respectively [611].
  • Argentina: 34,000 hip fractures occur every year in the population aged 50 years and older, with an average of 90 fractures/day. By 2050, there will be >63,000 hip fractures in women and >13,000 in men [612]. The prevalence of vertebral fractures in these women is 16.2% [553]. Hospitalization costs of hip and vertebral fractures exceed 190 million USD per year [612].
  • Brazil: 10 million people, approximately one person in every 17, has osteoporosis [155]. The lifetime prevalence of fractures has been found to be 37.5% among men and 21% among women with proportions among white, mixed and black subjects at about 29%, 31% and 22%, respectively [554].
  • Brazil: It is estimated that just 1 in 3 patients with hip fractures are diagnosed as having osteoporosis and of those, only 1 in 5 receive any kind of treatment [559].
  • Brazil: The economic burden of osteoporosis hip fractures to private health plan companies in Brazil is estimated in the region of $6 million [558].

Key statistics for Middle East/North Africa

  • In Saudi Arabia with a population of 1,461,401 persons aged 50 years or more, 8,768 would suffer femoral fractures yearly at a cost of $1.14 billion [587].
  • Iran accounted for 0.85% of the global burden of hip fracture and 12.4% of the burden of hip fracture in the Middle East [583].

Key statistics for North America

  • Canada: Osteoporosis affects approximately 1.4 million Canadians, mainly postmenopausal women and the elderly [152]. Osteoporosis affects 1 in 4 women and more than 1 in 8 men over the age of 50 years, with 1 in 4 men and women having evidence of a vertebral fracture [152,179].
  • Canada: Almost 30,000 hip fractures occur each year [152]. 70-90% of these hip fractures are caused by osteoporosis [176]. By the year 2030, the number of hip fractures is expected to quadruple [177,178].
  • USA: It is estimated that around 40% of US white women and 13% of US white men aged 50 years will experience at least one clinically apparent fragility fracture in their lifetime. At age 50, a white woman has a 17% chance of sustaining a hip fracture, 15% chance of vertebral fracture and 16% chance for forearm fracture, with comparable figures of 6%, 5% and 2.5%, respectively, for fractures in white males [11].
  • USA: It has been estimated that 54% postmenopausal white women are osteopenic and 30% are osteoporotic, and by the age of 80, 27% of women are osteopenic and 70% are osteoporotic [143].
  • USA: Fracture incidence is usually higher for whites and lower for other ethnic groups [144,145]. The average rate of hip BMD loss is twice as great in white compared to African-American women and increases in age in both groups [557].
  • USA: The National Osteoporosis Foundation reported that by 2010, about 12 million people over the age of 50 are expected to have osteoporosis and another 40 million to have low bone mass. By 2020, it is expected to increase to 14 million cases of osteoporosis and over 47 million cases of low bone mass [147]. This increase in cases could cause the number of hip fractures to double or triple by 2040 [148].
  • USA: In 2005, there were predicted over 2 million fractures costing $17 billion. Nonvertebral fractures represented 73% of total fractures and accounted for 94% of total costs. The majority of costs are incurred by inpatient care (57%) and long-term care (30%) vs. 13% by outpatient care. Men accounted for 29% of fractures and 25% of the total cost burden. 70% of fractures and 87% of costs are incurred by those over 65 years of age. By 2025, annual fractures and costs are projected to increase by 50% and $25 billion, respectively [588].

Key statistics for Oceania

  • New Zealand: It is estimated that both the number of osteoporotic fractures and the cost of healthcare associated with osteoporosis will increase by over 30% between 2007-2020 [589].
  • Australia: 2.2 million Australians are affected by osteoporosis [174]. About 11% of men and 27% of women aged 60 years or more are osteoporotic, and 42% of men and 51% of women are osteopenic [173].
  • Australia: The lifetime risk of osteoporotic fracture after 50 years of age: 42% in women, 27% in men [174].
  • Australia: There are 20,000 hip fractures per year in Australia (increasing by 40% each decade) [174].
  • Australia: Total costs relating to osteoporosis are $7.4 billion per year of which $1.9 billion are direct costs [174].
  • New Zealand: There were an estimated 84,000 osteoporotic fractures in 2007, with 60% of these occurring in women. Hip fractures were estimated to account for 5% of all fractures [589].
  • New Zealand: The total cost of osteoporosis is estimated to be over $1.15 billion per year [589].

Nutrition

  • Adequate levels of calcium intake can maximize the positive effect of physical activity on bone health during the growth period of children [120].
  • Calcium supplementation has been shown to have a positive effect on bone mineral density in postmenopausal women [121].
  • Calcium and vitamin D supplementation reduces rates of bone loss and also fracture rates in older male and female adults, and the elderly [122,123,124]. In institutionalized elderly women, this combined supplementation reduced hip fracture rates [122].
  • Fruit and vegetable intake was positively associated with bone density in a study in men and women. The exact components of fruits and vegetables which may confer a benefit to bone are still to be clarified [125,126].
  • In a study in elderly men and women, higher dietary protein intake was associated with a lower rate of age-related bone loss [128].
  • Good nutrition is an important part of a successful rehabilitation program in patients who have had an osteoporotic fracture. In frail, elderly, hip fracture patients this is crucially important, as poor nutritional status can slow recovery, and increase susceptibility to further fractures [129,130,131,132].
  • Lactose intolerance has been shown to be associated with low bone mass and increased risk of fracture due to low milk (calcium) intake [134].
  • Moderate alcohol intake is not thought to be harmful to bone. However, chronic alcohol abuse is detrimental to bone health, with one of the mechanisms being a direct toxic effect on bone forming cells [135].
  • Studies in children and adolescents have shown that supplementation with calcium, dairy calcium-enriched foods or milk enhances the rate of bone mineral acquisition [117,118,119].
  • The onset of anorexia nervosa frequently occurs during puberty, the time of life when maximal bone mass accrual occurs, thereby putting adolescent girls and boys with anorexia nervosa at high risk for reduced peak bone mass [133,571,591].

Osteoporosis - General

  • In women over 45 years of age, osteoporosis accounts for more days spent in hospital than many other diseases, including diabetes, myocardial infarction and breast cancer [13].
  • Worldwide, an osteoporotic fracture is estimated to occur every 3 seconds, a vertebral fracture every 22 seconds [581].
  • Evidence suggests that many women who sustain a fragility fracture are not appropriately diagnosed and treated for probable osteoporosis [88,89].
  • Osteoporosis is estimated to affect 200 million women worldwide - approximately one-tenth of women aged 60, one-fifth of women aged 70, two-fifths of women aged 80 and two-thirds of women aged 90 [613].
  • The great majority of individuals at high risk (possibly 80%), who have already had at least one osteoporotic fracture, are neither identified nor treated [90].
  • Osteoporosis affects an estimated 75 million people in Europe, USA and Japan [1].
  • An IOF survey, conducted in 11 countries, showed denial of personal risk by postmenopausal women, lack of dialogue about osteoporosis with their doctor, and restricted access to diagnosis and treatment before the first fracture result in underdiagnosis and undertreatment of the disease [14].
  • For the year 2000, there were an estimated 9 million new osteoporotic fractures, of which 1.6 million were at the hip, 1.7 million were at the forearm and 1.4 million were clinical vertebral fractures. Europe and the Americas accounted for 51% of all these fractures, while most of the remainder occurred in the Western Pacific region and Southeast Asia [581].
  • 1 in 3 women over 50 will experience osteoporotic fractures, as will 1 in 5 men [2,3,4].
  • 80%, 75%, 70% and 58% of forearm, humerus, hip and spine fractures, respectively, occur in women. Overall, 61% of osteoporotic fractures occur in women, with a female-to-male ratio of 1.6 [581].
  • Nearly 75% of hip, spine and distal forearm fractures occur among patients 65 years old or over [7].
  • Between 1990 and 2000, there was nearly a 25% increase in hip fractures worldwide. The peak number of hip fractures occurred at 75-79 years of age for both sexes; for all other fractures, the peak number occurred at 50-59 years and decreased with age [581].
  • A 10% loss of bone mass in the vertebrae can double the risk of vertebral fractures, and similarly, a 10% loss of bone mass in the hip can result in a 2.5 times greater risk of hip fracture [8].
  • By 2050, the worldwide incidence of hip fracture in men is projected to increase by 310% and 240% in women [9].
  • The combined lifetime risk for hip, forearm and vertebral fractures coming to clinical attention is around 40%, equivalent to the risk for cardiovascular disease [10].
  • In white women, the lifetime risk of hip fracture is 1 in 6, compared with a 1 in 9 risk of a diagnosis of breast cancer [11].
  • Osteoporosis takes a huge personal and economic toll. In Europe, the disability due to osteoporosis is greater than that caused by cancers (with the exception of lung cancer) and is comparable or greater than that lost to a variety of chronic noncommunicable diseases, such as rheumatoid arthritis, asthma and high blood pressure related heart disease [581].
  • A prior fracture is associated with an 86% increased risk of any fracture [12].
  • Although low BMD confers increased risk for fracture, most fractures occur in postmenopausal women [58,529,530] and elderly men [531] at moderate risk.

Osteoporosis in Men

  • About 20-25% of hip fractures occur in men. The overall mortality is about 20% in the first 12 months after hip fracture and is higher in men than women [15,16].
  • It is estimated that the lifetime risk of experiencing an osteoporotic fracture in men over the age of 50 is 30% [3], similar to the lifetime risk of developing prostate cancer [17].
  • Vertebral fractures may cause equal morbidity in men and women. Hip fractures in men cause significant morbidity and loss of normal functioning [18].
  • Although the overall prevalence of fragility fractures is higher in women, men generally have higher rates of fracture related mortality [16,19].
  • As in women, the mortality rate in men after hip fracture increases with age and is highest in the year after a fracture [20,21]. Over the first 6 months, the mortality rate in men approximately doubled that in similarly aged women [20].
  • Forearm fracture is an early and sensitive marker of male skeletal fragility. In aging men, wrist fractures carry a higher absolute risk for hip fracture than spinal fractures in comparison to women [22].
  • In Sweden, osteoporotic fractures in men account for more hospital bed days than those due to prostate cancer [23].
  • 30% of hip fractures and 20% of vertebral fractures occur in men [24].

Risk Factors

  • Physical inactivity and a sedentary lifestyle as well as impaired neuromuscular function (e.g., reduced muscle strength, impaired gait and balance) are risk factors for developing fragility fractures [81,82,538,539].
  • Smoking can lead to lower bone density and higher risk of fracture [66,67,68,69] and this risk increases with age [69].
  • A high intake of alcohol confers a significant risk of future fracture (e.g., over 4 units of alcohol/day can double the risk of hip fracture) [70]. The risk of vertebral and hip fractures in men increases greatly with heavy alcohol intake, particularly with long term intake [71].
  • Prolonged use of corticosteroids is the most common cause of secondary osteoporosis. It is estimated that 30-50% of patients on long term corticosteroid therapy will experience fractures [72,73], with an increased in risk of hip fracture by 2-fold in women and 2.6-fold in men [573].
  • Proton pump inhibiting drugs can reduce the absorption of calcium from the stomach and long term use of these drugs can significantly increase the risk of an osteoporosis-related fracture [574,592].
  • Low body weight and weight loss is associated with greater bone loss and increased risk of fracture [74,75,76,77,570].
  • Some young females, particularly those training for elite athletic competition, exercise too much, eat too little, and consequently experience amenorrhea which makes them at risk for low bone mass and fractures [78].
  • After an initial low trauma fracture from a simple fall, both older men and women have an increased equivalent risk of all types of subsequent fractures, especially in the next 5-10 years [537].
  • Middle-aged and older men and women with annual height loss >0.5 cm are at increased risk of hip and any fracture [585].
  • Falls contribute to fractures - 90% of hip fractures result from falls [79]. A third of people over age 65 fall annually, with approximately 10-15% of falls in the elderly resulting in fracture, and almost 60% of those who fell the previous year will fall again [79,80].
  • Since the clinical outcome of osteoporosis is bone fracture, attention is now increasingly focused on the identification of patients at high risk of fracture rather than the identification of people with osteoporosis as defined by BMD alone [575,576,577,578,579,580].
  • Although osteoporosis is defined in terms of BMD and microarchitectural deterioration of bone tissue, BMD is just one component of fracture risk. Accurate assessment of fracture risk should ideally take into account other proven risk factors that add information to that provided by BMD [575,576,577,578,579,580].
  • Osteoporosis has been shown in studies to have a large genetic component [60,61,572]. A parental history of fracture (particularly hip fracture) confers an increased risk of fracture that is independent of BMD [62].
  • Studies have provided evidence that weight in infancy is a determinant of bone mass in adulthood [63,64,65] .

Treatment

  • There is a range of drug treatment available for postmenopausal osteoporosis. Different studies have consistently shown that, depending on the drug and the patient population, treatment reduces the risk of vertebral fracture by between 30-65% and of nonvertebral fractures by between 16-70% [84,590].
  • Treatment of established osteoporosis is cost-effective irrespective of age [85] and therapies with proven rapid efficacy may offer important value to healthcare payers, providers and patients [86].
  • Identifying and treating patients at risk of fracture, but who have not yet sustained a fracture, will substantially reduce the long term burden of osteoporosis. Reducing the risk of first fracture from 8% to 2% can reduce the 5-year fracture incidence from approximately 34% to 10% [87].
  • Sunlight exposure can increase the BMD of vitamin D deficient bone and lead to the prevention of nonvertebral fractures [540].
  • Poor compliance by patients with drug therapies for osteoporosis over a year leaves them at risk for fractures and higher healthcare costs [91,584].

Vertebral Fracture

  • Vertebral fractures can lead to back pain, loss of height, deformity, immobility, increased number of bed days, and even reduced pulmonary function [44,45,46]. Their impact on quality of life can be profound as a result of loss of self-esteem, distorted body image and depression [47,48,49,50]. Vertebral fractures also significantly impact on activities of daily living [51,52].
  • After hospitalization for a vertebral fracture, there is a greatly increased risk of requiring hospitalization for a further fracture in the years following initial hospitalization [53].
  • The incidence of vertebral factures increases with age in both sexes. Most studies indicate that the prevalence of vertebral facture in men is similar to, or even greater than, that seen in women to age 50 or 60 years [56,57].
  • Vertebral fractures are associated with an increased risk of both further vertebral and nonvertebral fractures [8,19,40,41,42,586]. Women who develop a vertebral fracture are at substantial risk for additional fracture within the next 1-2 years [40,586].
  • It is estimated that only one-third of vertebral fractures come to clinical attention [54] and underdiagnosis of vertebral fracture is a worldwide problem. The proportion of vertebral fractures that go unrecognized is as high as 46% in Latin America, 45% in North America, and 29% in Europe/South Africa/Australia [55].
  • A 50 year old white woman has a 16% lifetime risk of experiencing a vertebral fracture and 5% in white men [3].
  • A woman 65 years of age with one vertebral fracture has a one in four chance of another fracture over 5 years, which can be reduced to one in eight by treatment [43].