Osteoporosis: A Global Health Crisis
- By 2050 the globally there will be up to 21.3 million hip fractures each year.
- Globally, 80-90% of patients with osteporotic fractures go untreated.
- Family members and medical professionals bear the burden of short-term and long-term care, impacting communities and possibly lowering GDP in some countries.
by Dr. John Neustadt
Osteoporosis is a global health epidemic. Globally more than 200 million people struggle with bone loss and 44 million of these are in the United States. According to the World Health Organization (WHO), osteoporosis is second only to cardiovascular disease as a global healthcare problem and medical studies show a 50-year-old woman has a similar lifetime risk of dying from hip fracture as from breast cancer. Fractures among the elderly are so common that 50% of women and up to 25% of men 50 years old and older will break a bone due to osteoporosis.
The burden to the healthcare system is staggering. Each year the U.S. spends nearly $17 billion treating more than 2 million osteoporosis fractures. When you add in the money spent in US, Canada and EU, annually $48 billion is spent treating osteoporosis fractures. And this doesn’t take into count the indirect costs such as disability and loss of productivity.
Since life expectancy is increasing worldwide and the risk for osteoporosis increases with age, it’s not surprising that osteoporosis and its dangerous effects are increasing around the world. It’s estimated that the number of individuals aged 65 years and older will increase from the current figure of 323 million to 1.55 billion by the year 2050.
Osteoporosis affects all countries; however, not all people are at the same risk for fractures. The highest fracture risks are in the Scandinavian countries (Denmark, Norway, Sweden Finland, Iceland). In fact, every 30 seconds, someone in the European Union has an osteoporotic fracture. By 2050 the globally there will be up to 21.3 million hip fractures each year. The largest increase in hip fractures is expected to occur in Latin America and Asia. The largest increase in hip fractures is expected to occur in Latin America and Asia.
While much emphasis is placed on treating a person’s bone mineral density, bone density predicts less than 50% of people who will break a bone. In fact, a bone density scan only predicts 44% of women and just 21% of men who will fracture a bone. A global analysis of fracture risk shows that this is the case around the world as well. While bone density tends to be lower among East Asians in comparison to Caucasians, Chinese, Japanese, and Koreans suffer less hip fracture. Learn more about bone density scans in Dr. Neustadt’d blog, The Most Important Osteoporosis Question You’re Not Asking.
Globally, osteoporosis fractures are a significant cause of disability and death. Its impact is so large that the disease burden created by osteoporosis outranks other chronic diseases, including many common cancers, rheumatoid arthritis and high blood pressure. This certainly highlights the incongruity inherent in the health care agendas of many countries, which place osteoporosis low on the list of priorities.
International studies show that doctors are failing to recognize Osteoporosis as a cause of fractures and are not consistently offering appropriate treatment or referrals, despite the psychosocial and economic consequences of further fractures. It is estimated that 80 – 90% of patients with osteoporosis fractures of the spine, forearm or hip remain uninvestigated and untreated.
Osteoporosis in the United States
According to US data obtained by the National Health and Nutrition Examination Survey (NHANES III, 1988-1994), up to 88% of women over 50 years old (up to 33 million women) and 53% of men (15 million men) had osteoporosis or pre-osteoporosis (osteopenia). As the population in the US ages, those numbers are climbing. By 2004 the number of people diagnosed with osteoporosis nearly doubled. In the U.S., approximately 30% of postmenopausal women have osteoporosis, and by 2020 the number of people with osteoporosis is projected to increase by approximately 50%.
Debilitating acute and chronic pain in the elderly is often attributed to fractures from osteoporosis and can lead to further disability and early death. In Caucasian women and men aged 50 years or older, the remaining lifetime risk of a hip, spine, or forearm fracture is estimated at 40% and 13%, respectively. A 2005 report estimated that of the nearly 2 million osteoporosis fractures in the United States that year, 27% were vertebral fractures, 19% were wrist fractures, 14% were hip fractures, 7% were pelvic fractures, and 33% were “other” fractures. Nonvertebral fractures represented 73% of total fractures, with 71% of all fractures occurring in women. It is startling to note that up to 40% of patients with osteoporosis who suffer hip fractures die within 6 months.
In addition to its impacts on health, the economic effect of osteoporosis is significant and growing. In 2005 the cost for treating the more than 2 million osteoporotic fractures in this country was almost $16.9 billion. Of that, the largest cost ($12.8 billion) was spent on treating fractures in women, largely because they suffer a greater number of hip fractures than men (73% vs 69%, respectively). Although in 2005 only 14% of all osteoporotic fractures were of the hip, they accounted for 72% of the total costs of treating osteoporotic fractures. By 2025 the estimated cost of treating more than 3 million expected fractures is pro- jected to increase more than 48% to $25.3 billion.
Osteoporosis in Australia
Osteoporosis is a major health concern in Australia, where it’s estimated 1 in 3 women over 45 will develop osteoporosis. However, a report prepared by the Department of Medicine, University of Melbourne, Western Hospital, Footscray, Victoria, concluded that osteoporosis still remains the great undetected and untreated National Health Priority Disease.
Someone in Australia is admitted to a hospital with an osteoporotic fracture every 5-6 minutes in 2007 (up from every 8.1 minutes in 2001) – averaging 262 hospitalizations per day. Of those who sustain a hip fracture, 25% die within 12 months, and of those who do not die following their hip fracture 50% require long-term help with routine activities and cannot walk unaided and 25% require full-time nursing-home care. For the elderly who survive a hip fracture, only one in three returns to their previous level of independence.
Almost half of the people with a hip fracture will be permanently disabled and not regain their independence. About 40% of people are unable to walk independently one year after hip fracture, about 60% have difficulty with at least one essential activity of daily living, and about 80% are limited in activities such as driving and shopping. In 2001 alone in Australia, 25,000 years of healthy life were lost due to osteoporosis, with over half of these years lost due to premature death, and the remainder due to disability and burden of disease.
In contrast to Europe and North America where numbers of hip fractures are expected to double by 2026 and then stabilize, in Australia hip fractures will continue to place a growing demand on health care resources for many years to come. The number of adults sustaining a hip fracture is likely to more than double in Australia from 15,000 in 1996 to 34,000 in 2026, then almost double again by 2051. Fractures at other sites are expected to increase by 70% from 1996 to 2026, then by a further 26% to 2051. These rates of increase are far above the expected growth in total healthcare costs due to the aging of the Australian population, which is estimated to be 4% every five years for the next 30 to 40 years.
Despite these shocking numbers, osteoporosis remains an under-recognized and under-treated disease. A study of women aged 55 years or more with wrist fractures in a managed-care setting reported that 23% had been started on some form of Osteoporosis-specific therapy, and less than 3% had had a BMD scan. The situation for hip fracture is more disturbing. In a study of 502 hospitalized hip-fracture patients, only 14% had BMD scans, 13% received calcium and/or vitamin D, and only 18% received HRT, calcitonin, or bisphosphonates. Other studies have reported that only 5% of patients with recent hip fractures left the hospital with a new medication prescribed for reducing the risk of subsequent fractures.
Osteoporosis in Asia
With socio-economic development in many Asian countries and rapid aging of the Asian population, osteoporosis has become one of the most prevalent and costly health problems in the region. Unsurprisingly, Asia is the region expecting the most dramatic increase in hip fractures during coming decades; by 2050 half of all hip fractures worldwide will occur in Asia.
The belief that osteoporosis is prevalent in the West and rare in the East is a myth. There is consistent evidence that epidemics of hip fracture occur with urbanization throughout Asia. The incidence of hip fracture has risen already 2- to 3-fold in most Asian countries during the past 30 years.
Osteoporosis is known to currently affect more than 69.4 million Chinese over age 50 and causes some 687,000 hip fractures in China each year. Total prevalence rate of osteoporosis in the middle-aged and elderly in China was 16. 1% in 2002.
According to the International Osteoporosis Foundation, “Though osteoporosis prevention and treatment began in China more than 20 years ago, public awareness of this disease still needs to be raised. At present, all treatments, prevention and education efforts are limited to cities; people in rural areas have little knowledge about this disease.”
With the advances in quality of life and health conditions in China, the population has been experiencing aging, and osteoporosis has, therefore, become an important public health problem.
With the aging of the Hong Kong population, osteoporosis has become one of the most prevalent conditions that is associated with a great medical and socioeconomic burden.
The incidence of hip fracture has increased by 200% in Hong Kong over the past 20 years: about 10 elders fracture their hip every day. The mortality rate for hip fracture patients is 20% while 70% remain permanently disabled.
50% of men and women aged 60 years and over could be diagnosed as “osteoporotic.”
Osteoporosis is currently among the top five conditions causing disability and prolonged hospital stay for elders in Hong Kong.
For women aged 65 and over: 45% is osteoporosis, 42% is osteopenia (low bone mass). For men aged 65 and over: 13% is osteoporosis, 47% is osteopenia.
The number of hip fractures per year in Singapore are projected to increase from 1300 in 1998 to 9000 in 2050 because of the aging of the population.
According to the Singapore Health Promotion Board, over the past thirty years, hip fractures have increased 5 fold, which is expected to continue to increase in the coming decades.
About 20% of people with osteoporotic hip fracture die within the year, and 33% become wheelchair-bound or bedridden.
The number of hip fracture cases for men and women in Malaysia is 88 and 218 per 100,000 populations.
In Japan, more than 15 million people have osteoporosis, and many more are at risk. More than 130,000 osteoporosis fractures occur every year in Japan.
Results of a 2001 national census reported almost 163 million Indians over age 50 with osteoporosis – a number expected to increase to 230 million by 2015. It’s been estimated that up to 51% of Indian women have osteoporosis, with many more having osteopenia. In most Western countries, while the peak incidence of osteoporosis occurs at about 70-80 years of age, in India it may afflict those 10-20 years younger, at age 50-60.
The number of hip osteoporosis fractures in India are estimated to climb to 600,000 per year by 2020 and to more than 1 million by 2050.
The prevalence of osteoporosis in Indonesia is relatively unknown. However, one study conducted in 2002 showed that 65% of participants had either osteoporosis or osteopenia.
The prevalence of osteoporosis in Sri Lanka is unknown due to lack of investigation facilities. However, a large epidemiological studies done in Sri Lanka, Galle Prospective Osteoporosis Survey, found 42.4% of women in the entire sample of 350 women and 61.5% in women over 50 years to have osteoporosis. The estimated total number of hip fractures per year in Sri Lanka in 2006 was 2730. This number is expected to rise substantially, to about 7000 by 2040, as the population over 50 increases.
Osteoporosis in Europe
Europe’s osteoporosis crisis is a growing burden to the citizens of the EU and its economy. The healthcare costs in Europe for treating osteoporosis are expected to reach 38.5 billion Euros by 2025, and already cost the EU 30.7 billion Euros in 2010 alone.
The incidence of osteoporosis in postmenopausal women continues to increase with progressively aging populations. Based on current trends, hip fracture rates might increase in the United Kingdom from 46,000 in 1985 to 117,000 in 2016.
The reduction in bone strength associated with this disease markedly increases the risk of skeletal and non-skeletal fractures, and the consequent pain and loss of function impinge adversely on the quality of life. In the United States and the European Union, about 30% of all postmenopausal women have osteoporosis, and it has been predicted that more than 40% of them will suffer one or more fragility fractures during their remaining lifetime.
In the European Union, in the year 2000, the number of osteoporotic fractures was estimated at 3.79 million, of which 0.89 million were hip fractures. Of all fractures due to osteoporosis, hip fractures are the ones that are most disabling. In 1990, about 1.7 million new hip fractures occurred worldwide, and this figure is expected to rise to 2.6 million by 2025.
The need to find solutions to this epidemic is a global health imperative.
Osteoporosis in the Middle East
The International Osteoporosis Foundation (IOF) considers osteoporosis a “neglected” disease in the Middle East. Demographic and socioeconomic changes in the region have contributed to the rise of this disease and its burden on the populations and healthcare systems. In Egypt alone, more than 80% of women have osteoporosis or osteopenia (pre-osteoporosis). Osteoporosis in Turkey is extremely common. Nearly 65% of men and women 65 years old or older have osteoporosis.
Unfortunately, according to an IOF report published in 2012, the level of awareness among health care professionals is poor in many countries, and they are “in general ill-equipped to take care of patients with osteoporosis in many countries.” In fact, osteoporosis is not even integrated in the medical school curricula in most countries with the exception of Lebanon and Morocco.
One of the greatest predictors of osteoporosis and factures is age, and the population in these countries is getting older. By 2020 up to nearly 25% of the population in some countries will be over 50 years old, which will grow to up to 40% by 2050.
Countries with the highest rate of hip fractures include the United Arab Emirates (UAE), Jordan, Lebanon, Tunisia, Morocco, Syria, Saudi Arabia, Turkey and Iran.
Vertebral fractures are the most common osteoporosis fracture. In Morocco, it’s estimated that there are more than 1.5 million vertebral fractures. Nearly 50% of all postmenopausal women have vertebral fractures, and 60% of women with fractures have at least two fractures.
In 2010 alone in Turkey, there were more than 24,000 hip fractures, with 77% of those fractures treated with surgery. If you’re unfortunate enough to have an osteoporosis hip fracture in Turkey, you will likely undergo surgery and spend an average of 11 days in the hospital. Most of these (73%) occurred in women.
Mortality incurred post-hip fracture is projected at 1.4 to 2 million deaths per year in 2050, yet this rising tide is still largely unrecognized.
Vitamin D Deficiency
The prevalence of low vitamin D has been estimated to range between 50-90% in most countries and across age groups, depending on the threshold chosen. Consistent predictors of low levels of 25(OH)-vitamin D are older age, female gender, having had multiple children, the season, conservative clothing style, low socioeconomic status and urban living.
Even in populations that expose more skin to direct sunlight, Vitamin D levels are lowest in the summer in some gulf countries due to the scorching heat during that season which keeps people indoors. In Saudi Arabia up to 80% of girls have low vitamin D. Between 50-80% of people in Tunisia, Iran, Lebanon and Jordan may have low vitamin D.
Death from Hip Fractures
Mortality rates post-hip fracture may be higher in this region than those reported from western populations. While such rates vary between 25-35 % in western populations, they are 2-3 fold higher in populations from this region, as discussed in a recent review.
Indeed, in a retrospective chart review of 274 patients admitted with an osteoporotic hip fracture to a tertiary referral center, between 1992 and 2002, in Beirut, Lebanon, the mortality rate in a subset of the original cohort was 47% overall, 73% in males and 28% in females; 70% of those who died did so within the first year.
Mortality was documented in two other case-series. One from Turkey included 92 hip fracture patients (56 females, 36 males) who were operated on with a 36 month follow-up, and reported a 3-year mortality rate of 61% in females and 50% in males. Another retrospective study from Saudi Arabia reported an average 2-year mortality rate of 27%.
Several countries reported loss of productivity post-hip fractures ranging from 3-6 months. One study from Lebanon reported that 20% of patients with a hip fracture never regain normal walking.
Information on social costs and quality of life is practically non-existent for this region of the world; however, since family members and medical professionals end up bearing the burden of short-term and long-term care, the impact on communities is likely quite severe. This could impact on productivity and a country’s gross domestic product (GDP).
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