IOF

IOF COMPENDIUM
OF OSTEOPOROSIS

Our vision is a world without fragility fractures, in which

healthy mobility is a reality for all.
IOF Compendium of Osteoporosis

First Edition, October 2017

Authors: C Cooper (IOF President); S Ferrari (Chair of the Committee of Scientific Advisors)

on behalf of the IOF Board and Executive Committee (JY Reginster, Chair of Committee of National
Societies; B Dawson Hughes, General Secretary; R Rizzoli, Treasurer; J Kanis, Honorary President; P Halbout,
CEO)

Writer and Editors: P Mitchell, N Harvey, E Dennison

About IOF
The International Osteoporosis Foundation (IOF) is the world’s largest nongovernmental organization
dedicated to the prevention, diagnosis and treatment of osteoporosis and related musculoskeletal diseases.
IOF members, including committees of scientific researchers as well as 240 patient, medical and research
societies in 99 locations, work together to make fracture prevention and healthy mobility a worldwide
heath care priority. www.iofbonehealth.org www.facebook.com/iofbonehealth @iofbonehealth

LOVE YOUR
BONES

® 2017 International Osteoporosis Foundation

Early diagnosis, a bone-healthy
lifestyle, and medication have
helped Jane remain fracture free
ever since her diagnosis of severe
osteoporosis at age 50.
 4

FOREWORD
The 21st Century will bear witness to the most There is still much to be done. Access and
profound change in the age structure of the human reimbursement for diagnosis and treatment
population in history. In 2015, of the 7.3 billion remains highly variable across the world. Public
individuals living in our global society, about 12 awareness of osteoporosis is persistently low.
per cent were aged 60 years or over. By 2050, the Some of the world’s most populous countries
United Nations projects that there will be more lack robust epidemiological data to inform
than 9.7 billion of us, which will include 2.1 billion policy development.
people who have enjoyed their 60th birthday.
The IOF Compendium of Osteoporosis marks
While this longevity miracle should be celebrated, a new era in IOF’s commitment to improve
we are obligated to undertake due diligence with the bone health of humankind. The IOF
respect to the impact that a demographic shift Compendium will be updated on a regular basis
on this unprecedented scale will have upon our to serve as the definitive reference point for all
civilisation. The prevalence of chronic conditions organisations who share IOF’s vision of a world
which afflict older people is poised to rise without fragility fractures, in which healthy
considerably, and this will include osteoporosis mobility is a reality for all.
and the fragility fractures it causes.

Osteoporosis is a very common condition.

Among the population aged over 50 years,
one in three women and one in five men will
suffer a fragility fracture. At the turn of the
century, 9 million fragility fractures occurred
annually. This included 1.6 million hip fractures
which impose a devastating burden on sufferers
and their families, and all too often result in
premature death. The 1.4 million individuals
who sustained vertebral fractures endure back
pain, loss of height and many other adverse
effects on the quality of their lives. And the cost
that osteoporosis imposes on healthcare budgets
is staggering. In 2010, European Union countries
spent Euro 37 billion (US$40 billion), while in
2015 the United States spent US$20 billion.

However, there is reason for optimism.

Osteoporosis can be readily diagnosed and
fracture risk is easily accessed. A broad range of
effective treatments are available throughout
the world that have been shown to reduce the
risk of hip, vertebral and other fragility fractures.
Effective models of care have been developed in
many countries to ensure that the right patient
receives the right treatment at the right time. In
recent years, national alliances – comprised of
national osteoporosis societies and other relevant
non-governmental organisations, policymakers
and healthcare professional organisations (and
some include private sector companies) - have
been formed in a growing number of countries
to combine expertise, resources and the desire to
improve outcomes for those who have sustained
fragility fractures.

IOF Compendium of Osteoporosis - First Edition

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 6

Fifty-eight year-old Maria Filomena, has

suffered many fractures due to osteoporosis.
She is very fearful of falling as this could
result in more fractures which could be
devastating to her independence.

IOF Compendium of Osteoporosis - First Edition

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CONTENTS
Executive Summary 08 Access and reimbursement 44
Introduction 11 Central Asia 45
Epidemiology 45
About osteoporosis 12 Mortality 45
Bone biology 14 Health expenditure 45
A multifactorial disease 16 Access and reimbursement 45
Risk factors for osteoporosis and fracture 16 Europe 46
Osteoporosis induced by medicines 19 Epidemiology 46
Other related comorbidities 19 Mortality 47
The role of nutrition in bone health 21 Health expenditure 48
Supplementation with calcium and 23 Access and reimbursement 48
vitamin D Latin America 51
Dietary sources of calcium 23 Epidemiology 51
Prevention of osteoporosis 24 Mortality 51
Childhood to adolescence 24 Health expenditure 51
Adulthood 24 Access and reimbursement 52
Clinical assessment and treatment 25 Middle East and Africa 54
of osteoporosis Epidemiology 54
Clinical assessment 25 Mortality 54
Treatment of osteoporosis 26 Health expenditure 55
Models of care 27 Access and reimbursement 55
Secondary fracture prevention 27 North America 56
Primary fracture prevention 28 Epidemiology 56
Public awareness of the importance 29 Mortality 57
fracture prevention
Health expenditure 57
Access and reimbursement 57
The Global Burden 30
Global incidence, prevalence and 32
future projections
Blueprint for action 58
The IOF Global Patient Charter 61
Regional disparity 32
The IOF Global Framework for Improvement 63
Human costs 34
Priority Actions 64
Socio-economic burden 36
Secondary fracture prevention 64
United States of America 36
Osteoporosis induced by medicines 64
European Union 36
Primary fracture prevention 65
China 36
Nutrition and exercise 66
Japan 36
Healthcare professional education 67
The impact of fracture in the workplace 36
Public awareness and education 68
Improving access and reimbursement 68
Osteoporosis by region 38 for diagnosis and treatment
Asia-Pacific 43 Formation of national falls and 69
Epidemiology 43 fracture prevention alliances
Mortality 43
Health expenditure 43 References 70

Contents
 8

EXECUTIVE SUMMARY
• The IOF Compendium of Osteoporosis serves estimated at 158 million and is set to
as a reference point for all key stakeholders double by 2040.
in the field of musculoskeletal health globally.
• A broad range of osteoporosis treatments,
• To be updated periodically, the IOF available in an array of dosing regiments,
Compendium provides: have been shown to significantly reduce the
risk of hip fractures, vertebral fractures and
– A summary of current knowledge of other clinically apparent fractures.
bone biology and risk factors which
pre-dispose individuals to suffer fragility • All individuals who are at high fracture
fractures, the clinically significant risk according to national osteoporosis
consequence of osteoporosis. clinical guidelines should be prioritised
for osteoporosis assessment and receive
– Updates on: guidelines-based treatment.

• Costs and burden of osteoporosis and • The Orthogeriatric Service and Fracture
fragility fractures worldwide. Liaison Service models of care have been
• Prevention of osteoporosis and the shown to deliver secondary preventive care
role of nutrition in maintaining for fracture patients in a highly cost-effective
bone health. manner.
• Osteoporosis treatments and public
• The incidence of fragility fractures is currently
awareness of the benefits versus risks
very high and set to increase dramatically as
of treatment.
the world’s population ages:
• Models of care which efficiently
target treatments to individuals at – Asia-Pacific: By 2050, 1.3 billion people
high fracture risk. in Asia will be aged 60 years or older and
more than a quarter of a billion will be
– Clear recommendations for achieving aged 80 years or older. Consequently, the
optimal bone health for all. annual incidence of hip fracture in China
is set to rise from 411,000 cases in 2015 to
• Overarching objectives for good bone health 1 million cases in 2050.
at the various stages of life are:
– Europe: In 2010, the 3.5 million fragility
– Children and adolescents: Achieve fractures which occurred in the European
genetic potential for peak bone mass. Union contributed to the total cost of
osteoporosis reaching Euro 37 billion
– Adults: Avoid premature bone loss and
(US$40 billion).
maintain a healthy skeleton.
– Latin America: The most rapidly ageing
– Seniors: Prevent and treat osteoporosis.
region of the world between 2015
and 2030. In Brazil, the number of hip
• Osteoporosis is the most common bone
fractures will more than double, from
disease. One in three women aged 50 years
80,640 cases in 2015 to 198,000 cases by
and over will sustain a fragility fracture, as
2040.
will one in five men.
– North America: By 2025, the annual
• Fragility fractures impose a tremendous
incidence of fragility fractures in the
burden on our older people, their families
United States is projected to exceed 3
and carers, and national economies:
million cases, at a cost of US$25 billion.
– In 2010, the number of individuals
aged 50 years and over at high risk of
osteoporotic fracture worldwide was

IOF Compendium of Osteoporosis - First Edition

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The IOF Compendium proposes 8 key priorities for the period 2017-20:

Priority 1: Secondary fracture prevention Seniors, national nutrition foundations/councils,

national dietician/nutritionist organisations, non-
Policymakers, healthcare professional organisations governmental organisations concerned with seniors’
and national osteoporosis societies must collaborate welfare and government Ministries of Sport and
to provide Orthogeriatric Services and Fracture Recreation, national sports councils and relevant
Liaison Services to all older people who suffer private sector corporations and providers to inform
fragility fractures in their jurisdictions. adults on their nutritional and exercise needs to
maintain a healthy skeleton, avoid premature bone
Priority 2: Osteoporosis induced by medicines loss and avoid malnutrition in the elderly.
Where treatments are licensed to prevent
Priority 5: Healthcare professional education
osteoporosis induced by medicines, and guidelines
have been published to inform best clinical practice, National osteoporosis societies and healthcare
osteoporosis management must become a standard professional organisations to collaborate to
consideration for clinicians when prescribing develop and encourage widespread participation
medicines with bone-wasting side effects. in national professional education programmes
designed for 3 distinct audiences: Lead Clinicians
Priority 3: Primary fracture prevention in Osteoporosis, orthopaedic surgeons and
National osteoporosis societies to incorporate primary care providers.
messaging regarding self-assessment of fracture
Priority 6: Public awareness and education
risk with FRAX® into public awareness and
education initiatives, as advocated in Priority 6. National osteoporosis societies, healthcare
National osteoporosis societies to collaborate professional organisations, policymakers and
with healthcare professional organisations for regulators to collaborate to develop impactful
primary care providers (PCPs) to jointly advocate public awareness campaigns which empower
for PCPs to routinely undertake fracture risk consumers to take ownership of their bone health.
assessment when interacting with patients aged
50 years and over. Priority 7: Improving access and reimbursement
for diagnosis and treatment
Priority 4: Nutrition and exercise
Osteoporosis must be designated a national
Specific initiatives encompassing nutrition and health priority in all countries, with
exercise are required for particular age groups: commensurate human and financial resources
to ensure that best practice is delivered for all
Expectant mothers: National osteoporosis societies individuals living with this condition. In countries
to collaborate with national obstetrics organisations where the current disease burden is not known,
to advise government on optimising bone health of epidemiological studies must be commissioned as
mothers and infants. a matter of urgency.
Children and adolescents: National osteoporosis Priority 8: Formation of national falls and fracture
societies to collaborate with government Ministries prevention alliances
of Education, national teachers’ organisations,
national nutrition foundations/councils, national In countries without an existing national alliance,
dietician/nutritionist organisations, government national osteoporosis societies to initiate
Ministries of Sport and Recreation, national sports dialogue with other relevant non-governmental
councils and relevant private sector corporations and organisations, policymakers, healthcare professional
providers to educate children and adolescents on organisations and private sector companies to
achieving their genetic potential for peak bone mass. propose formation of a national falls and fracture
prevention alliance modelled on successful examples
Adults and seniors: National osteoporosis societies from elsewhere. Formation of a national alliance has
to collaborate with government Ministries for the potential to facilitate delivery of Priorities 1-7.

Executive Summary
 10

For years, Peter suffered severe, unexplained

back pain without being investigated for
osteoporosis. He was finally referred for bone
mineral density testing after receiving advice
from the Irish Osteoporosis Society.

IOF Compendium of Osteoporosis - First Edition

 11

INTRODUCTION
The IOF Compendium of Osteoporosis provides a We hope that you enjoy reading this first
summary of current knowledge of bone biology edition of the IOF Compendium, act upon the
and risk factors which pre-dispose individuals to recommendations made and share this inaugural
suffer fragility fractures, the clinically significant publication with your colleagues so that they can
consequence of osteoporosis. The burden imposed do similar. As the population of the world continues
by osteoporosis – from epidemiological, quality to age, left unchecked, the burden imposed by
of life and socio-economic perspectives – are osteoporosis will be enormous, both in terms of
documented at the global and regional level. human suffering and financial costs to our societies.
Preventive strategies, including the role of The IOF Compendium of Osteoporosis provides you
nutrition and exercise in maintaining bone health with the knowledge required to prevent this from
throughout life is considered. Evidence for the happening in your community. We would welcome
effectiveness of treatments is reviewed and will be any feedback you may have for consideration in
expanded as new research is published and new subsequent editions of the Compendium.
therapies become available. Public awareness of
benefits versus risks of treatment are analysed.
Considerable activity is ongoing worldwide to
establish models of care which ensure that the
right patient receives the right treatment at the
right time. The Compendium describes how these
services are organised and the outcomes that they
achieve. Finally, and perhaps most importantly, a
Blueprint for Action provides all stakeholders with
clear recommendations for achieving optimal bone
health for all. The Blueprint will lead to widespread
implementation of proven models of care, better
education for healthcare professionals, greater
public awareness, improved access to diagnosis and
treatment and formation of new national alliances.

The IOF Compendium is intended to serve as a

reference point for all key stakeholders within the
field of musculoskeletal health, including:

– National level policymakers

– Government representatives

– Healthcare professionals and their

organizations

– National osteoporosis societies

– The healthcare industry

– The media

Introduction
 12

ABOUT
OSTEOPOROSIS
13
 14

ABOUT OSTEOPOROSIS

“Our skeleton is formed before we are born, supports us throughout our

lives, and can remain long after we die. Regardless of age, gender, race,
nationality, or belief set, we all have one. Yet this essential organ is so often
taken for granted.”
World Osteoporosis Day Report 2015 [1]

Bone biology
Our skeleton is a remarkably active living tissue a plateau followed by an accelerated period of
comprised of a myriad of cells, blood vessels, bone loss for several years after the menopause
proteins and minerals. At birth, we have 300 soft occurs in women. Overarching objectives for good
bones which are transformed during childhood bone health at the various stages of life are [1]:
and adolescence into hard bones. As some bones
fuse during the developmental process, the adult – Children and adolescents: Achieve genetic
skeleton has 206 bones. The size of our skeleton, potential for peak bone mass.
and the amount of bone contained in it, changes
significantly throughout life. As illustrated in – Adults: Avoid premature bone loss and
figure 1, peak bone mass is achieved for both maintain a healthy skeleton.
males and females by the mid-twenties. Thereafter,
a gradual decline into old age occurs in men, while – Seniors: Prevent and treat osteoporosis.

Figure 1. Bone mass throughout the life cycle

Peak bone mass Male

Menopause Female
Puberty
Bone mass

10 20 30 40 50 60 70

Years

IOF Compendium of Osteoporosis - First Edition

 15

Our bones are comprised of two types of tissue: bone matrix maintain contact with newly
incorporated osteocytes in osteoid, and
– Cortical bone: Also known as compact with osteoblasts and bone lining cells on
bone, this hard outer layer is strong and the bone surfaces, through an extensive
dense. network of cell processes (canaliculi).
They are thought to be ideally situated to
– Cancellous bone: Also known as respond to changes in physical forces upon
trabecular bone, this spongy inner bone and to transduce messages to cells
network of trabeculae is lighter and more on the bone surface, directing them to
flexible than cortical bone. initiate resorption or formation responses.

In addition to osteoid (the unmineralized, organic – Osteoclasts: These cells are large
portion of the bone matrix which forms prior multinucleated cells, like macrophages,
to the maturation of bone tissue) and inorganic derived from the hematopoietic lineage.
mineral salts deposited within the matrix, cells are Osteoclasts function in the resorption of
present which are responsible for bone formation mineralized tissue and are found attached
(osteoblasts and osteocytes) and resorption to the bone surface at sites of active bone
(osteoclasts) [2]: resorption. Their characteristic feature is
a ruffled edge where active resorption
– Osteoblasts: These cells are derived takes place with the secretion of bone-
from mesenchymal stem cells and are resorbing enzymes, which digest bone
responsible for bone matrix synthesis and matrix.
its subsequent mineralization. In the adult
skeleton, the majority of bone surfaces Once peak bone mass has been achieved, the
that are not undergoing formation or structural integrity of bone is maintained by a
resorption (i.e. not being remodelled) are process called remodelling, illustrated in figure
lined by bone lining cells. 3 on the following page. Remodelling continues
throughout life so that most of the adult skeleton
– Osteocytes: These cells are osteoblasts that is replaced about every 10 years.
become incorporated within the newly
formed osteoid, which eventually becomes
calcified bone. Osteocytes situated deep in

Figure 2. The structure of bone

Osteon
Cortical Bone
Endosteum

Periosteum

Trabecular Bone

Blood Vessels & Nerve

(adapted from the Servier Medical Art Slide Kit)

About osteoporosis
 16

Figure 3. Bone renewal through the bone remodelling cycle

Bone
Remodeling
Resorption
Cycle Formation

Osteoclasts Osteoblasts

Bone Resorption Bone Formation

Reversal
Bone resorption begins when Osteoblasts lay down collagen
osteoclasts remove a portion of the and mineral deposits over the
bone to be replaced later by the area previously remodeled by
action of osteoblasts. This is a vital osteoclasts. Osteoblast activity is
step for signalling bone formation. vital for maintaining bone mineral
density and bone strength.

A multifactorial disease
Many factors influence an individual’s propensity
to develop osteoporosis and suffer the fragility
fractures it causes. Some of these factors are
“A 10% increase in peak BMD was predicted
non-modifiable, such as family history, while
others can be avoided or ameliorated. From the to delay the development of osteoporosis
perspective of the patient or their physician, as in by 13 years, while a 10% change in the
all things, knowledge is power. age at menopause or the rate of non-
menopausal bone loss was predicted to
Risk factors for osteoporosis and fracture delay osteoporosis by approximately 2
years, suggesting that peak BMD may be
Osteoporosis has been characterized as a paediatric
the single most important factor in the
disease with geriatric consequences [3]. Achieving
peak bone mass during youth is paramount, as development of osteoporosis.”
was clearly demonstrated by an analysis of relative
influences on peak bone mineral density (BMD),
age-related bone loss and menopause on the
development of osteoporosis [4]:

IOF Compendium of Osteoporosis - First Edition

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In 1994, the World Health Organization (WHO) –– Severe osteoporosis (established

established four general operational categories osteoporosis): A value for BMD more than
relating to BMD in postmenopausal women, 2.5 SD below the young adult mean in the
principally for epidemiological classification, presence of one or more fragility fractures.
but which have become regarded as clinical
diagnostic categories for osteoporosis [5]: In 2014, investigators in the United States
determined the prevalence of osteoporosis
and low bone mass at the femoral neck and
–– Normal: A value for BMD within 1 the lumbar spine in adults aged 50 years and
standard deviation (SD) of the young older in the 2010 US Census population [6].
adult reference mean, subsequently The key findings from this study shown in table
referred to as a T-score < -1. 1 highlight two risk factors for osteoporosis:
gender and age. Among the 10.2 million adults
–– Low bone mass (osteopenia): A value for estimated to have osteoporosis in the United
BMD more than 1 SD below the young States, more than 80% were women. Further, a
adult mean but less than 2.5 SD below clear correlation exists between the prevalence of
this value, subsequently referred to as a osteoporosis and increasing age.
T-score in the range -1 to -2.5.

–– Osteoporosis: A value for BMD 2.5 SD

or more below the young adult mean,
subsequently referred to as a T-score < -2.5.

Table 1. Prevalence of osteoporosis and low bone mass in the United States in 2010 [6]

Total population Osteoporosis Low bone mass

(millions) prevalence (%) prevalence (%)
Women 53.2 15.4 51.4
50-59 years 21.5 6.8 49.3
60-69 years 15.3 12.3 53.4
70-79 years 9.2 25.7 51.8
80+ 7.2 34.9 52.7

Men 45.9 4.3 35.2

50-59 years 20.5 3.4 30.7
60-69 years 13.9 3.3 32.9
70-79 years 7.4 5.0 41.8
80+ 4.1 10.9 53.1

(Adapted with permission of the authors, P. Sambrook and C. Cooper)

Just as the prevalence of osteoporosis increases with the obverse perspective, approximately half of
age, the incidence of fragility fractures increases patients who present to hospital with a hip fracture
dramatically among older people, as illustrated have sustained prior fractures in the months or
in figure 4. Furthermore, individuals who have years before breaking their hip [9]. As such, fragility
sustained a fragility fracture are at approximately fracture patients are an obvious group to target
twice the risk of suffering future fractures, as for secondary preventive care. This theme will be
compared to their fracture-free peers [7, 8]. From explored in more detail later in the Compendium.

About osteoporosis
 18

Figure 4. Age- and gender-specific incidence of hip, vertebral and distal forearm fractures [10]

400 Women Men

Rate per 10 000 per year

Radiographic
300 Vertebral
Hip
200 Wrist

100

0
4

5
-5

-5

-6

-6

-7

-7

-8

>8

-5

-5

-6

-6

-7

-7

-8

>8
50

55

60

65

70

75

80

50

55

60

65

70

75

80
Age (years) Age (years)

(Adapted with permission of the authors, P. Sambrook and C. Cooper)

In addition to age, gender and a history of older age [14]. This effect is not altered
fragility fracture, the following risk factors identify for women treated with osteoporosis
individuals likely to be at increased fracture risk: therapies, suggesting that early age
of menopause is an independent
–– Underweight: In 2005, a meta-analysis contributor to postmenopausal fracture
evaluated body mass index (BMI) as a risk. Investigators have also evaluated
predictor of fracture risk [11]. When the impact of hysterectomy on long-term
compared with a BMI of 25 kg/m2, a BMI of fracture risk [15]. About a 20% increase
20 kg/m2 was associated with almost a two- in overall fracture risk is observed, but
fold increase in the risk ratio for hip fracture. no significant effect on the typical
osteoporotic fractures, defined as hip,
–– Parental history of fracture: Meta-analysis wrist or spine fractures, collectively.
has also shown parental history of
fracture to be associated with increased –– Lifestyle considerations:
risk of any fracture, osteoporotic fracture
and hip fracture in men and women • Alcohol: The relationship between
combined [12]. The increases in the risk alcohol intake and fracture risk is non-
ratios were 17%, 18% and 49% for any linear [16]. No significant increase in
fracture, any osteoporotic fracture and risk is observed for intakes of 2 units
hip fracture, respectively. or less daily (e.g. 2 glasses of 120 ml of
wine). Above this threshold, alcohol
–– Frequent falls: Falls are very common intake is associated with an increased
among older people, with one third of risk of 23%, 38% and 68% for any
people aged 65 years and over falling fracture, any osteoporotic fracture,
each year and half of those aged 85 years and hip fracture, respectively.
and over [13]. Notably, half of those who
fall do so repeatedly and approximately • Smoking: The impact of smoking on
5% of falls result in a fracture. fracture risk has been evaluated in a
meta-analysis [17]. Current smoking
–– Early menopause: Women who was associated with an increased risk
experience menopause before age 40 of 25% for any fracture compared
years have a higher risk of any fracture to non-smokers and 60% for hip
than women reporting menopause at an fracture, after adjustment for BMD.

IOF Compendium of Osteoporosis - First Edition

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Osteoporosis induced by medicines

Adverse effects on BMD and/or fracture risk have bone loss and/or fragility fracture incidence are
been reported for many classes of drugs [18-29]. summarised in table 2.
Associations for commonly used drug classes and

Table 2. Commonly used drug classes associated with bone loss and/or fragility fractures [18]

Drug class Loss of BMD [19] Increased fracture risk [19] Literature review
Androgen deprivation Gonadotropin-releasing The risk of hip and vertebral Bienz and Saad [20]
therapy hormone agonists (GnRHs) are fractures increases to 20-50%
the most commonly used ADT. after 5 years of ADT. Fracture
BMD declines by 2-5% during risk correlates with age, rate of
the first year of ADT. BMD loss and ADT exposure.
Aromatase inhibitors The annual rate of bone loss Women treated with AIs have Rizzoli et al [23]
in women taking AIs is approx. a 30% higher fracture risk
2.5% as compared to 1-2% than age-matched healthy
for healthy postmenopausal women. AI users sustain more
women [23]. peripheral fractures than hip or
vertebral fractures [23].
Glucocorticoids While all recipients of GCs are 30-50% of patients receiving Whittier and Saag [25]
at increased risk of bone loss, GCs develop fractures. GC-
older men and postmenopausal induced osteocyte apoptosis
women are at highest risk with leads to early increase in fracture
GC doses of >20 mg daily. risk prior to loss of BMD.
Selective serotonin Small studies have found an Two meta-analyses have re- Rizzoli et al [28]
reuptake inhibitors association between SSRI use ported the adjusted odds ratio
and bone loss. However, meta- for fracture among SSRI users
analysis has reported SSRI- to be approx. 1.7. Fracture
related fractures in the absence risk is dependent on dose and
of bone loss. duration of SSRI treatment.
Thiazolidinediones TZDs reduce bone formation Two meta-analyses have Napoli et al [29]
through impairing differentiation reported that TZDs significantly
of osteoblast precursors, and increase fracture incidence in
increase resorption through women with Type 2 diabetes,
several mechanisms, resulting in but not in men. Notably, frac-
bone loss. ture risk is increased in young
women without risk factors.

(Adapted from Osteoporos Int. 2017 May;28(5):1507-1529 with kind permission of Springer)

Other related comorbidities

Individuals who are living with a broad array Common examples are illustrated in figure 5,
of diseases are pre-disposed to develop several of which were described in more detail in
osteoporosis or sustain fragility fractures. a recent review article [18].

About osteoporosis
 20

Figure 5. Common diseases associated with bone loss and/or fragility fractures [18]

Chronic kidney Diabetes: Dementia:

disease (CKD):
Both Type 1 and Type 2 The incidence of hip
Patients with dialysis- diabetics are at increased fracture among people
dependent end-stage risk of sustaining hip living with dementia in the
renal disease (ESRD) fractures. A systematic UK is three times higher
sustain fractures at a review estimated the than among cognitively
rate approximately relative risks to be 6.3-6.9 well peers [34].
4-fold higher than the and 1.4-1.7 for Type 1 and
general population [31]. Type 2, respectively [35].
Among patients with less
severe renal dysfunction,
decreasing estimated
glomerular filtration
rate (eGFR) has been
shown to be associated
with increased risk of hip
fracture [32].

Chronic disease
in childhood:

Many chronic/serious
conditions occurring
in childhood (e.g.
inflammatory bowel
disease, juvenile idiopathic
arthritis, malignancy),
may impair skeletal health
directly, or as a consequence
of treatment (e.g.
corticosteroids). Low peak
bone mass and increased
risk of osteoporosis in older
age may result.
 21

The role of nutrition in bone health

In 2015, the World Osteoporosis Day Report and
an associated comprehensive review described
Chronic obstructive pulmonary disease how nutritional factors affect musculoskeletal
(COPD): health throughout life [1, 39]. The evidence was
appraised from a life-course perspective:
In Taiwan, a nationwide population-
based cohort study reported that COPD –– Maternal nutrition.
sufferers were 24% more likely to sustain
an osteoporotic fracture compared to a –– Building bone in childhood and adolescence.
matched comparator group [33].
–– Maintaining bone mass in adulthood.

–– The special nutritional needs of seniors.

Hypogonadism:
Expectant mothers should be well nourished to
The Massachusetts Male Aging support an infant’s development in utero. In this
Study estimated the prevalence of regard, it is of concern that surveys conducted
testosterone deficiency in men to throughout the world report both low levels of
be 12.3% among US men aged 40 calcium intake and vitamin D insufficiency to
to 69 years, representing a common be common in pregnancy. In 2016, results were
contributor to osteoporosis in men [36]. published from the UK Maternal Vitamin D
Osteoporosis Study (MAVIDOS) [40]. This large-
scale randomised-controlled trial was designed to
test whether offspring of mothers supplemented
Inflammatory bowel disease (IBD):
with vitamin D during pregnancy have higher
A large study from Canada reported bone mass at birth than those of mothers who
that the incidence of fracture among were not supplemented. Although there was
individuals with IBD was 40% greater no difference in whole body bone mineral
than that of the general population [37]. content (BMC) between offspring of mothers
supplemented with 1,000 International Units (IU)
per day of cholecalciferol (vitamin D3) compared
with offspring of mothers randomised to placebo,
Coeliac disease (CD): in a pre-specified secondary analysis, there was a
large (0.5 SD) increase in neonatal BMC amongst
Analysis of data from the US National offspring of supplemented mothers versus
Health and Nutrition Examination Survey offspring of placebo mothers, for births occurring
(NHANES) demonstrated that CD is during winter months. The supplement appeared
associated with reduced BMD in children safe, and these findings suggest potential season-
and adults aged 18 years and over, and is dependent benefits for antenatal vitamin D
a risk factor of osteoporotic fractures in supplementation. Further results will follow from
men aged 40 years and over [30]. the ongoing MAVIDOS childhood follow-up study.

An individual’s peak bone mass is determined

to a great extent during the first two decades
Rheumatoid arthritis (RA):
of life. While genetics plays a significant role,
A large study from the UK found decisions regarding nutrition and exercise impact
RA patients’ risk of hip fracture and on a child’s likelihood, or not, of achieving their
vertebral fracture to be increased 2-fold genetic potential for peak bone mass. In this
and 2.4-fold as compared to a control regard, osteoporosis has been characterised as a
group [38]. paediatric disease with geriatric consequences,
and for good reason. In 2003, Hernandez and
 22

colleagues undertook a theoretical analysis to Further studies are required to determine

determine the relative influences of peak BMD, the impact of several other vitamins on bone
age-related bone loss and age at menopause on health (A, B and K). With regards to minerals,
the development of osteoporosis in women [4]. magnesium and zinc play a role in bone
Osteoporosis would occur 13 years later if peak metabolism. Accordingly, ensuring adequate
BMD was increased by 10%. By comparison, a dietary intake of these minerals is important.
10% change in the age at menopause or the rate
of postmenopausal bone loss would delay the Malnutrition is highly prevalent in the elderly,
onset of osteoporosis by just 2 years. Findings and as such, ensuring adequate dietary intake of
from the MAVIDOS study and similar work calcium, vitamin D and protein in this age group
suggest that environmental contributions to bone is paramount. A summary of recommendations
mass begin even as early as in the womb. on this subject by expert groups was provided
in the 2015 World Osteoporosis Day Report [1].
In adulthood, the combination of a well-balanced The key recommendations made in a consensus
diet and regular weight-bearing exercise play statement published in 2014 by the European
an important part in ensuring good adult bone Society for Clinical and Economic Aspects of
health. The key components of a “bone healthy” Osteoporosis and Osteoarthritis (ESCEO) are
diet include: illustrative of themes common to all such
recommendations [47]:
–– Calcium: Consensus is evident among
leading organisations regarding –– Optimal dietary protein intake of 1.0–1.2
recommended dietary intake of calcium for g/kg body weight/day with at least 20-
adults. The National Health and Medical 25g of high-quality protein at each main
Research Council in Australia [41], the meal.
Institute of Medicine in the United States
(now known as the National Academy –– Vitamin D intake of 800 IU per day to
of Medicine) [42] and the World Health maintain serum 25(OH)D levels greater
Organization/Agriculture Organization than 50 nmol/L (20 ng/mL).
of the United Nations [43] all recommend
intake of 1,000 mg per day of calcium. –– Calcium intake of 1,000 mg per day.

–– Vitamin D: While sun exposure provides the –– Regular physical activity/exercise 3–5
primary source of vitamin D by triggering times per week combined with protein
synthesis in the skin, increasingly indoor intake in close proximity to exercise.
lifestyles are contributing to vitamin D
insufficiency becoming a global problem.
In 2009, an IOF Working Group published
a review of global vitamin D status and
determinants of insufficiency [44]. Low
levels of vitamin D were highly prevalent
among adults, as subsequently illustrated
on the IOF vitamin D status map [45].

–– Protein: Protein provides a source of amino

acids which are needed to maintain bone
structure, and stimulates release of IGF-I
which may increase osteoblast activity
resulting in increased production of bone
matrix. In 2009, a systematic review and
meta-analysis reported a small positive
association between protein intake and
BMD and BMC, and a reduction in markers
of bone resorption [46].

IOF Compendium of Osteoporosis - First Edition

 23

Supplementation with calcium and 7. On the basis of the current evidence, we

vitamin D recommend that calcium and vitamin D
supplements are generally appropriate
The role of calcium supplementation, for those with a high risk of calcium and
with or without concomitant vitamin D vitamin D insufficiency and in those who
supplementation, has been the subject of are receiving treatment for osteoporosis.
considerable scientific debate in the literature
in recent years. Many clinical trials, and meta-
analyses of these trials have explored the Dietary sources of calcium
benefits of supplementation, in terms of
fracture reduction, and adverse events. In 2017, Calcium is contained in several food groups and
an expert consensus meeting of ESCEO and is most readily accessible in dairy foods such
IOF was convened to review the evidence for as milk, yoghurt and cheeses. Common non-
the value of calcium supplementation, with or dairy foods containing calcium include certain
without vitamin D supplementation, for healthy vegetables (e.g. kale); whole canned fish with
musculoskeletal ageing. The report which soft edible bones such as sardines; some nuts;
documented the meeting reached the following calcium-set soy products (tofu, soy milk); and
conclusions [48]: some mineral waters, among others.

1. Calcium and vitamin D supplementation Recent publications from France and Belgium
leads to a modest reduction in fractures, have demonstrated the efficacy and cost-
but use of calcium supplementation alone effectiveness of dairy products as a source of
is not robustly supported. calcium, proteins and, where supplemented,
vitamin D to relieve the burden of osteoporosis
2. The evidence for calcium and vitamin D [48-52]. Public beliefs regarding benefits versus
supplementation for fracture reduction perceived detrimental effects of dairy products
is most robust in those who are likely need to be considered by clinicians to enable
to be at greatest risk of calcium and/ their patients to make informed decisions. In
or vitamin D insufficiency; population- 2016, a commentary from the Belgian Bone
based interventions have not convincingly Club and ESCEO sought to bring some clarity to
demonstrated benefit. this issue [53]. Key conclusions included:

3. Although calcium is intimately involved –– Lactose intolerant individuals may not

in muscle physiology, the best clinical need to completely eliminate dairy
evidence suggests that vitamin D products from their diet, as both yogurt
optimisation, rather than supplementation and hard cheese are well tolerated.
with calcium, leads to reduced risk of falls.
–– Dairy products do not increase the risk
4. Calcium supplements are associated with of cardiovascular disease, particularly if
gastrointestinal side effects and a small low fat.
increased risk of renal stones.
–– Intake of up to three servings of dairy
5. The assertion that calcium with vitamin D products per day appears to be safe and
supplementation increases cardiovascular may confer a favourable benefit with
risk is based on inadequate evidence; regard to bone health.
several studies demonstrate the converse
or no cardiovascular effect.

6. A large randomised control trial of

calcium supplementation powered
to detect validated fractures and
cardiovascular events is required to
ultimately clarify this issue.

About osteoporosis
 24

Prevention of osteoporosis rate of bone resorption is greater than the rate

of bone formation and results in net bone loss –a
Childhood to adolescence thinning of your bones. Any factor which causes
a higher rate of bone remodelling will ultimately
Building strong bones starts in the womb, and lead to a more rapid loss of bone mass and more
thus a healthy diet and lifestyle during pregnancy fragile bones. The nutritional and lifestyle advice
can help the next generation. Bones are living for building strong bones in youth is just as
tissue, and after birth, the skeleton continues to applicable to adults to.
grow to the end of the teenage years, reaching
a maximum strength and size (peak bone mass) Adults should:
in early adulthood, around the mid-20s. It’s
therefore never too early to invest in bone –– Ensure a nutritious diet and adequate
health. The prevention of osteoporosis begins calcium intake.
with optimal bone growth and development in
youth. –– Avoid under-nutrition, particularly the
effects of severe weight-loss diets and
Children and adolescents should: eating disorders.

–– Ensure a nutritious diet with adequate –– Maintain an adequate supply of vitamin

calcium intake. D.

–– Avoid protein malnutrition and under- –– Participate in regular weight-bearing

nutrition. activity.

–– Maintain an adequate supply of vitamin –– Avoid smoking and second-hand smoking.

D.
–– Avoid heavy drinking.
–– Participate in regular physical activity.

–– Avoid the effects of second-hand

smoking.

It has been estimated that a 10% increase of

peak bone mass in children reduces the risk of an
osteoporotic fracture during adult life by 50%
[54].

Adulthood

Bone mass acquired during youth is an important

determinant of the risk of osteoporotic fracture
during later life. The higher the peak bone mass,
the lower the risk of osteoporosis. Once peak
bone mass has been reached, it is maintained by
a process called remodelling. This is a continuous
process in which old bone is removed (resorption)
and new bone is created (formation). The
renewal of bone is responsible for bone strength
throughout life.

During childhood and the beginning of

adulthood, bone formation is more important
than bone resorption. Later in life, however, the

IOF Compendium of Osteoporosis - First Edition

 25

Clinical assessment and treatment The information obtained, in combination with

of osteoporosis clinical risk factors ascertained from the patient’s
medical history, will inform the inputs to the
The previous section of the Compendium has FRAX® fracture risk calculation. FRAX® estimates
identified a substantial number of risk factors the patient’s probability of sustaining a hip
for osteoporosis and fragility fractures. In the fracture or a major osteoporotic fracture over a
broadest sense, the population can be sub- 10-year period.
divided into two distinct groups with respect to
future fracture risk: Bone density testing by DXA is a non-invasive,
comparatively inexpensive, convenient
–– Individuals with a history of fragility diagnostic procedure which enables clinicians
fracture: the secondary prevention to stratify fracture risk of individuals. However,
population. the advent of DXA technology has resulted in
some unintended consequences. Importantly,
–– Individuals without a history of fragility the majority of individuals who sustain fragility
fracture: the primary prevention fractures do not have a BMD T-score below -2.5
population. standard deviations, the WHO category for
osteoporosis [5]. The majority of fracture patients
The secondary prevention population is by have osteopenia rather than osteoporosis as
definition a high fracture risk group. Individuals defined by BMD [56], which has resulted in
with a fragility fracture history should undergo confusion among patients and generalists in the
clinical assessment and be offered osteoporosis healthcare profession. In 2017, a perspective
treatment, where warranted. Disease models paper from leading clinicians in the field
developed for several European countries have highlighted this issue:
estimated the proportion of women aged 50
years and over who have sustained at least one
fragility fracture [18]. This ranges from 10% in
France to almost 23% in Sweden. This highlights
the fact that at any point in time, the majority
of older people lack a fracture history. As such,
tools to stratify fracture risk across the highly “Particularly harmful may be the term
heterogeneous primary prevention population “osteoporotic fracture”, which has been
are required. In this regard, the advent of
interpreted by some as requiring both an
absolute fracture risk calculators such as FRAX®
provide a platform to readily identify individuals osteoporotic bone mineral density (BMD)
who should undergo further clinical assessment value, i.e., a T-score ≤ -2.5, and fracture [57].”
[55]. FRAX® can be accessed online at
https://www.sheffield.ac.uk/FRAX/.

Clinical assessment

Clinicians use the following techniques to make a

diagnosis of osteoporosis: The authors proposed that all fractures
in older people should trigger secondary
–– BMD testing by dual-energy X-ray preventive assessment, including lifestyle,
absorptiometry (DXA). non-pharmacological and pharmacological
interventions to reduce future fracture risk.
–– X-Rays or Vertebral Fracture Assessment Indeed, the limitations of DXA for identifying
(VFA) to identify vertebral fractures. individuals who will experience a fragility fracture
led to the development of the FRAX® calculator,
–– Measurement of Bone Turnover Markers which integrates BMD with other, at least partly
(BTM) in the serum or urine. BMD-independent risk factors.

About osteoporosis
 26

Bone density testing has an additional limitation uniquely flexible array of dosing regimens, which
in that it provides a measure of the quantity includes daily, weekly or monthly oral tablets,
of bone, but does not provide information on daily, three-monthly and six-monthly injections, or
the quality of bone [58]. Moving forwards, new annual infusions. The anti-fracture efficacy of the
diagnostic modalities are required which can most commonly used agents for postmenopausal
readily provide clinically meaningful information osteoporosis is summarised in table 3 [59].
relating to the determinants of bone quality,
which is likely to include measures of bone Numerous national clinical guidelines are
microarchitecture, turnover, mineralisation and available to inform best practice. While the
accrual of damage. detail of these recommendations varies between
countries, practically all guidelines advocate pro-
Treatment of osteoporosis active case-finding of fragility fracture patients
and individuals at high risk of sustaining a first
During the last 25 years, a broad range of major fragility fracture. A recent systematic
therapeutic options have become available to review noted that FRAX® has been incorporated
reduce an individual’s risk of sustaining a fragility into a substantial number of guidelines
fracture. These medicines are available in a worldwide [60].

Table 3. Anti-fracture efficacy of the most commonly used treatments for postmenopausal osteoporosis
[59, 61-63]

Effect on vertebral fracture risk Effect on non-vertebral fracture risk

established established
osteoporosis osteoporosisa osteoporosis osteoporosisa

Alendronate + + n/a + (including hip)

Risedronate + + n/a + (including hip)

Ibandronate n/a + n/a +b

Zoledronic acid + + n/a +c

HRT + + + + (including hip)

Raloxifene + + n/a n/a

Abaloparatide + + n/a +c

Teriparatide and PTH n/a + n/a +

Denosumab + +c + (including hip) +b

n/a no evidence available

+ effective drug
a
women with a prior vertebral fracture
b
in subsets of patients only (post hoc analysis)
c
mixed group of patients with or without prevalent vertebral fracture

IOF Compendium of Osteoporosis - First Edition

 27

As illustrated previously in figure 4 of this Models of care

Compendium, the incidence of fragility fractures
increases dramatically with increasing age [10]. In Secondary fracture prevention
2014, an ESCEO expert working group evaluated
management of osteoporosis in the “oldest old” Case finding individuals who have sustained
segment of the population (i.e. individuals over fragility fractures represents the obvious first
80 years of age) [64]. The authors noted that step in implementation of a systematic approach
undertreatment of osteoporosis in this age group to fragility fracture prevention [9]. However,
was potentially attributable to the perception numerous audits conducted throughout the
that osteoporosis treatments must be used in the world have identified a persistent and pervasive
long-term to demonstrate a fracture reduction secondary prevention care gap [18]. In 2017, an
benefit. Given that studies of many of the agents ESCEO expert consensus meeting highlighted
described above reported statistically significant that approximately one-fifth of eligible fracture
benefits by 12 months of treatment, this concern patients receive osteoporosis treatment after
is without foundation. Further, the authors a fracture, and that considerable variation is
highlighted several precautionary measures evident between countries [66]. Despite effective
that can be taken to ensure patient safety in treatments having been available since the
this population. mid-1990s and publication of many national
clinical guidelines which advocate assessment
Recently, ESCEO and IOF working groups and treatment of fracture patients, osteoporosis
have considered currently unmet needs in the is neither assessed nor treated in the majority of
management of individuals who are at high cases.
risk of sustaining fragility fractures [65, 66].
These groups concluded that the future research In response to this missed opportunity for
agenda should focus on the following areas: intervention, models of care have been developed
to ensure that fracture patients reliably receive
–– Identification of risk factors for imminent osteoporosis management and interventions to
fractures. prevent future falls. Two complementary models
of care have been established in a growing
–– Periods in the life-cycle of high fracture risk. number of countries [18, 67-69]:

–– The most appropriate treatments for –– Orthogeriatric Services (OGS): Also

individuals at high fracture risk. known as Orthopaedic-Geriatric Co-Care
Services or Geriatric Fracture Centres, OGS
–– The role of preventive surgical intervention focus on delivering best practice for hip
for individuals at imminent and/or very fracture patients. This includes expedited
high risk of hip fracture. surgery, optimal management of the
acute phase through adherence to clinical
–– Optimal implementation strategies in standards overseen by senior orthopaedic
primary, secondary and tertiary care. and geriatrician/internal medicine
clinicians, and delivery of secondary
fracture prevention addressing both bone
health and falls risk.

–– Fracture Liaison Services (FLS): A FLS is a

coordinated model of care for secondary
fracture prevention. A FLS ensures that
all patients aged 50 years or over, who
present to urgent care services with
a fragility fracture, undergo fracture
risk assessment and receive treatment
in accordance with prevailing national
clinical guidelines for osteoporosis. The

About osteoporosis
 28

FLS also ensures that falls risk is addressed Primary fracture prevention
among older patients through referral to
appropriate local falls prevention services.

Detailed analysis of the clinical effectiveness

and cost-effectiveness of OGS and FLS was the
subject of a recent review article [67]. In summary,
OGS in combination with national hip fracture
registries have been demonstrated to transform
care of hip fracture patients. The UK National “Secondary prevention is the single most
Hip Fracture Database (NHFD) is currently the important, immediate mechanism to
largest continuous audit of hip fracture care in directly improve patient care and reduce
the world, with more than 500,000 cases entered spiraling fracture related healthcare costs.
since launch in 2007. The NHFD, in combination The ultimate goal in the longer term would
with national clinical standards [70] and a major
be the prevention of the first fracture,
workforce development program has resulted
in widespread implementation of OGS in UK and advances in fracture risk assessment
hospitals during the last decade. In 2015, 97% during the last decade provide a platform
of patients underwent bone health and falls for development of clinically effective and,
prevention assessments [71]. crucially, cost-effective approaches.”

In hospitals without an OGS, the FLS provides World Osteoporosis Day Report 2016 [73]
secondary preventive care for all fragility fracture
patients. In hospitals with an OGS, the FLS
provides care specifically for non-hip fragility
fracture patients, which usually represents 80%
of the entire fracture case load. FLS have been
shown to dramatically improve osteoporosis
treatment rates for fragility fracture patients and
reduce secondary fracture incidence [67]. Further,
Once a health system has implemented a
FLS may have potential beneficial effects on
systematic approach to secondary fracture
mortality outcomes. Patients followed up in a FLS
prevention, attention must be focused on primary
in the Netherlands had a significant reduction in
prevention of major fragility fractures. Such a
mortality of 35% over 2 years of follow-up when
strategy will likely be achieved through pursuit of
compared with those who underwent standard
several “tracks”:
non-FLS care [72].
–– Consistent bone health assessment
Widespread implementation of FLS is the and treatment for individuals taking
objective of IOF’s flagship initiative, the Capture medicines which induce osteoporosis.
the Fracture® Programme [68]. The Capture the
Fracture® Programme, hosted on http://www. –– Incorporation of routine bone
capturethefracture.org/, provides resources, best health assessment and treatment for
practice guidance, and global recognition to individuals living with diseases related to
help support the implementation of new FLS or osteoporosis and fragility fractures.
improve existing FLS worldwide.
–– Systematic application of tools such as
FRAX® to risk stratify the older population
served by a medical practice, hospital or
entire health system.

–– Incorporation of fracture risk assessment into

routine practice by primary care providers
when interacting with older individuals.

IOF Compendium of Osteoporosis - First Edition

 29

Two leading health systems in the United States osteoporosis. In this regard, taking into account
have implemented systematic approaches patients’ preferences regarding the attributes
to primary fracture prevention in parallel to of an optimal osteoporosis treatment may play
secondary prevention strategies, the Kaiser an important role in enhancing adherence with
Permanente Health Bones Program [74] and the treatment in the long-term. In 2017, a discrete
Geisinger Health System Hi-ROC Program [75]. choice experiment conducted in seven European
Recently, evidence from the UK SCOOP trial, countries reached the following conclusions [78]:
has demonstrated that actively screening older
women for fracture risk (using FRAX®) in the –– Statistically significant differences existed
primary care setting leads to a reduction in the between patients’ preferences in different
risk of incident hip fracture [76]. countries.

–– In all countries, patients preferred

Public awareness of the importance treatment with higher effectiveness
and less frequent dosing (i.e. 6-monthly
fracture prevention
subcutaneous injection was preferred to
First and foremost, the bone health community weekly oral tablets).
globally must develop public awareness
–– In five countries, patients preferred
campaigns which ensure that individuals who
monthly oral tablets or annual intravenous
sustain fragility fractures understand that
injections over weekly oral tablets.
osteoporosis was the likely underlying cause of
their fracture. Award-winning campaigns such as
–– In three countries, where out-of-pocket
2Million2Many developed by the National Bone
cost was included as an attribute, lower
Health Alliance (NBHA) in the United States
costs significantly influences treatment
provide a successful case study which could
preference.
inform efforts elsewhere [77]. The 3.6 metre by
3.6 metre “Cast Mountain” installation shown
in figure 6 served as a physical representation Figure 6. US National Bone Health Alliance
of the 5,500 fractures which occur daily among 2Million2Many “Cast Mountain” [77]
people aged 50 years and over in the US. The
key messages for 2Million2Many are very simple
and compelling:

–– Every year, there are two million bone

breaks that are no accident (in the USA).

–– They are the signs of osteoporosis in people

as young as 50.

–– But only 2 out of 10 get a simple follow-up

assessment.

–– Together, we can break osteoporosis

before it breaks us. But we must speak up.
Remember:

• Break a bone, request a test.

Supplementary campaigns which put the benefits

of osteoporosis treatment, as compared to the
risks, into context, and highlight the importance
of staying on treatment will contribute (Reproduced with kind permission of the National Bone Health
to improved long-term management of Alliance in the United States)

About osteoporosis
 30

THE GLOBAL
BURDEN
31

Photo: Gilberto D Lontro/IOF

 32

THE GLOBAL BURDEN

This section of the Compendium considers the global epidemiology of fragility
fractures, regional disparities, the human costs and socio-economic burden imposed
by these fractures.

In the year 2000 there were an estimated 9.0 million fragility fractures, of which 1.6
million were at the hip, 1.7 million at the forearm, 1.4 million were clinical vertebral
fractures, 0.7 million at the humerus and 3.6 million fractures at other sites [79]. The
total disability-adjusted life-years lost was 5.8 million, of which half were accounted
for by fractures that occurred in Europe and the Americas. Worldwide, fragility
fractures accounted for 0.83% of the global burden of non-communicable disease.

Global incidence, prevalence and fracture) which was equivalent to that of a

future projections woman with a body mass index (BMI) of 24 kg/m2
and a prior fragility fracture, but with no other
As the population of the world has aged over clinical risk factors for fracture. In 2010, 21 million
the last three decades, the incidence of hip men (3.1%) and 137 million women (18.2%) had
fracture has increased significantly. In 1990, a fracture probability at or above the threshold.
it was estimated that 1.3 million hip fractures By 2040, the number of men and women
occurred worldwide and the prevalence of hip combined who will be above the threshold is
fracture sufferers living with disability was almost expected to almost double, from 158 million in
4.5 million [80]. By 2010, the global incidence of 2010 to 319 million in 2040.
hip fracture was estimated to have increased to
2.7 million cases per year [81]. The most recent
estimate of the prevalence of any fragility Regional disparity
fracture, defined as the number of individuals
suffering disability, was 56 million worldwide in Marked variations in the incidence of hip
year 2000 [79]. fractures, the prevalence of vertebral fractures
and the 10-year probability of major osteoporotic
In 1997, worldwide projections for hip fracture fractures have been reported for different
incidence were made for the period 1990 to regions of the world.
2050 [82]. Assuming no change to the age- and
sex-specific incidence, it was projected that The findings of a systematic literature review of
almost 4.5 million hip fractures would occur in hip fracture incidence studies are shown in figure
2050. However, making modest changes to the 7 for women [84]. Age-standardised rates varied
assumptions concerning secular trends suggested approximately 10-fold for both men and women.
that this estimate could be much higher, in the Why hip fracture risk varies so much between
range 7 million to 21 million cases. Notably, countries is not currently known. The authors
this analysis estimated that almost 1.9 million suggest that environmental factors may play a
hip fractures would occur in 2010, which is greater role than genetic factors. Epidemiological
considerably lower than the more recent estimate studies of immigrant populations lend support
of 2.7 million cases cited above for same year [81]. to this hypothesis. While African Americans
living in the United States have lower fracture
In 2015, Kanis and colleagues sought to quantify probabilities than their Caucasian countrymen
the number of individuals worldwide aged 50 and women, their hip fracture risk is higher than
years or more at high risk of fracture in the years native Africans [85]. Similar patterns are observed
2010 and 2040 [83]. High fracture probability was for the Japanese population of Hawaii [86] and
defined as the age-specific 10-year probability of Chinese living in Hong Kong or Singapore [84].
suffering a major osteoporotic fracture (i.e. hip,
humeral, wrist or clinically apparent vertebral During the next 3 decades, the demographic shift

IOF Compendium of Osteoporosis - First Edition

 33

in Asia, Africa and Latin America will result in projections suggesting 1 million cases annually
these regions bearing the brunt of the increase in 2030 and 2 million annually in 2050, estimates
in hip fracture incidence worldwide. In absolute which assume no increase in age- and sex-specific
terms, Asia faces the most marked increases, with rates which were modelled in 1997 [82].

Figure 7. Age-standardised annual incidence of hip fractures in women (per 100,000) according to
country, colour-coded as high, moderate or low incidence [84]

Denmark
Sweden
Austria
Norway
Switzerland
Ireland
Iran
Slovakia
Taiwan
Argentina
Iceland
Czech
Hungary
Turkey
Belgium
Malta
UK
Slovenia
Germany
Italy
Singapore
Greece
Hong Kong
Lebanon
Oman
FInland
France
Canada
New Zealand
Lithuania
Malaysia
S Korea
Portugal
Japan
Israel
US
Australia
Russia
Nertherlands
Kuwait
Spain
Mexico
Estonia
Poland
Chile
Thailand
Brazil
Romania
Jordan
Colour Category Women
Croatia
Indonesia High >300
China
India
Saudi Arabia
Philippines Moderate 200-300
Colombia
Morocco
Ecuador
Tunisia Low <200
S Africa
Nigeria

0 100 200 300 400 500 600

Incidence (rate/100 000)

(Reproduced from Osteoporos Int 2012 Sep;23(9):2239-56 with kind permission of Springer)

The Global Burden

 34

In 2017, El-Hajj Fuleihan and colleagues either hospitalised or ambulatory indicated that
investigated the prevalence and incidence of the highest age-standardised rates were evident
vertebral fractures worldwide [87]. In terms of in South Korea, the United States and Kong
prevalence, the highest rates were reported Kong, while the lowest rate was in the UK.
for Scandinavia (26%), intermediate rates for
Western Europe, USA and Mexico (20%), and low In terms of the regional disparity of the 10-year
rates for Latin America (15%). Studies concerned probability of major osteoporotic fractures, the
with the incidence of vertebral fractures were majority (55%) of individuals deemed to be at or
comparatively sparse. Studies which combined above the high fracture probability in 2010, as
individuals with vertebral fractures who were described above, lived in Asia [83].

Human costs
Fragility fractures impose a substantial burden 8. A correlation exists between the number of
on individuals who suffer them, their carers and fractures an individual suffers and decline in
family members. When a fracture occurs, a cycle physical function and health-related quality of
of impairment follows, as illustrated in figure life (HRQL) [88, 89].

Figure 8. The cycle of impairment and fracture in osteoporosis [90]

• Comorbid conditions
Impaired • Beliefs about
physical physical activity and
function fracture
Pain &
changes in • Prescribed treatment
spinal and advice from HCPs
alignment
• Treatment
compliance and
persistence
Psychological
and social
• Fear of failing/fracture Reduction in activities
Fracture • Depression requiring physical
(location/number) • Altered body image
function
• Low self-esteem
• Reduced social interaction

Loss of
muscle/bone
strength

(Reproduced from Osteoporos Int. 2017 Mar 6 with kind permission of Springer)

IOF Compendium of Osteoporosis - First Edition

 35

Hip fractures are particularly devastating: specific tools [105]. Six specific tools have been
developed for use in the context of osteoporosis:
–– Less than half of individuals who survive a
hip fracture will walk unaided again [91] –– Quality of life questionnaire of the
and a significant proportion will never European foundation for osteoporosis
regain their former degree of mobility (QUALEFFO) [98].
[92].
–– Quality of life questionnaire in
–– A year after hip fracture, 60% of sufferers osteoporosis (QUALIOST) [106].
require assistance with activities such as
feeding, dressing or toileting, and 80% –– Osteoporosis assessment questionnaire
need help with activities such as shopping (OPAQ) [107].
or driving [93].
–– Osteoporosis quality of life questionnaire
–– Between 10-20% of sufferers will become (OQLQ) [108].
residents of care homes in the year
following a hip fracture [94-96]. –– Osteoporosis functional disability
questionnaire (OFDQ) [109].
Vertebral fractures adversely affect sufferers in
many ways: –– Osteoporosis-targeted quality of life
questionnaire (OPTQoL) [110].
–– Back pain, loss of height, deformity and
immobility [97, 98]. Whilst the direct benefits of anti-osteoporosis
therapies on HRQL remain to be elucidated,
–– Loss of self-esteem, distorted body image recent findings from the UK SCOOP trial suggest
and depression [99-101]. that treatment on the basis of population
screening is likely to improve HRQL compared
–– A significant negative impact on routine with usual care [76]. One recent cohort study
activities of daily living [102]. incorporated HRQL measurement using the
EuroQol- 5 Dimension (EQ-5D) standardised
Survival is also impacted by hip and vertebral instrument into follow-up and demonstrated
fractures. Mortality during the 5 years after a hip modest increases in values with treatment, albeit
or vertebral fracture is approximately 20% higher in a non-intervention design [111].
than would be expected, with most premature
deaths occurring within the first 6 months after
hip fracture [93].

Non-hip, non-vertebral (NHNV) fractures account

for approximately two-thirds of all fragility
fractures. The Global Longitudinal Study of
Osteoporosis in Women (GLOW) has reported
that NHNV fractures have a detrimental effect
on HRQL [103]. Further, analysis of data from
the Canadian Multicentre Osteoporosis Study
(CaMOS) has demonstrated that NHNV fractures
also are associated with increased mortality [104].

Improving the quality of life of individuals who

are living with osteoporosis should be a focus for
interventions to prevent and treat the disease.
Consequently, there has been considerable
research activity to develop effective measures
of HRQL, which can be classified as generic or

The Global Burden

 36

Socio-economic burden
Global health expenditure attributable to China
osteoporosis is currently not known, on account
of a lack of data on fracture rates for many In 2015, Chen and colleagues modelled the
developing countries [18]. The most obvious incidence and economic burden of fragility
example is India, which is set to become the fractures in China for period 2010 to 2050 [114].
world’s most populous country within the next The projected costs to the Chinese healthcare
few decades. However, information is available system for all osteoporosis-related fractures for
for many countries/regions, including the 4 the years 2015, 2035 and 2050 were US$11 billion,
largest economies in the world (USA, European US$20 billion and US$25 billion, respectively.
Union [EU], China and Japan), which provide
an indication of the immense financial burden Japan
osteoporosis imposes on our global society.
In 2016, the Japanese Ministry of Health, Labour
United States of America and Welfare undertook a survey to quantify
the costs related to deficiencies of bone density
In 2007, Burge and colleagues modelled the and bone structure, as well as fracture-related
incidence and economic burden of fragility expenditure in the population aged 65 and over
fractures in the United States for period 2005 to [115]. In 2013, total costs were estimated to be
2025 [112]. Inpatient, outpatient and long-term almost JPY 944 billion (US$8 billion).
care costs were included in the model. In the base
year (2005), hip fractures accounted for 72% of The impact of fracture in the workplace
all costs but just 14% of fractures. The projected
costs for years 2015, 2020 and 2025 were The proportion of older people remaining active in
US$20 billion, US$22 billion and US$25 billion, the workforce is growing as the world’s population
respectively. ages. As such, health conditions associated with
ageing have the potential to adversely affect work
European Union place productivity. In 2014, investigators from
The Netherlands evaluated total costs of clinical
In 2013, IOF in collaboration with the European fractures in osteoporotic patients aged 50 years
Federation of Pharmaceutical Industry and older [116]. Indirect costs accounted for half
Associations (EFPIA) published a comprehensive of total costs and sick leave for employed patients
report on osteoporosis in the EU which included accounted for more than 80% of the mean
the economic burden [113]. For year 2010, the indirect costs for a fracture.
total cost of osteoporosis in the EU, including
pharmaceutical intervention, was estimated to
be Euro 37 billion (US$40 billion). Two-thirds
of this cost was attributed to treating incident
fractures, long-term care accounted for 29% and
pharmacological prevention just 5%. Excluding
the cost of pharmacological prevention, hip
fractures represented 54% of the costs.

IOF Compendium of Osteoporosis - First Edition

37
 38

OSTEOPOROSIS
BY REGION
39
40
 41

OSTEOPOROSIS BY REGION
The world’s population is ageing, and ageing fast. In 2015, the United Nations report
on World Population Ageing described the demographic shift for the various regions
of the world [117]. The relative distribution of the world’s older population in 2015,
as illustrated in figure 9, is set to change dramatically. Consequently, during the first
half of this century, absolute hip fracture incidence will remain high and costly in
the West and will increase enormously in the East. This section of the Compendium
considers the current and future impact of osteoporosis on the regional populations
of the world.

Figure 9. Population aged 60 years or over and aged 80 years or over by country, 2015 [117]

900 000 All other areas 140 000

800 000 All other areas

120 000

700 000
Turkey
Republic of korea
Population aged 60 years or over (thousands)

Population aged 80 years or over (thousands)

Vietnam
Ukraine
Thailand
100 000
Bangladesh
Spain
600 000 Mexico
Pakistan
Thailand
Canada
Ukraine
United Kingdom Bangladesh
Poland
France Indonesia
Italy Vietnam
Mexico
Indonesia
80 000 Spain

500 000 Germany United Kingdom

Brazil Brazil
France
Russian Federation
Italy
Japan
Russian Federation
400 000 United States
60 000 Germany

Japan

India

300 000 India

40 000
United States

200 000 China

China
20 000
100 000

0 0

(Reproduced from World Population Ageing Report 2015 with kind permission of the United Nations Department of Economic and
Social Affairs Population Division)

Osteoporosis by region
 42

Following a vertebral fracture, a bone mineral density test

revealed that Ms. Tang (66) had osteoporosis. She is strict about
taking her medication, eating bone-healthy foods, and taking
regular exercise. She says: “Luckily I never suffered another
fracture, otherwise my life would be very different now.”

IOF Compendium of Osteoporosis - First Edition

 43

Asia-Pacific –– Japan: In 2012, the annual incidence of

hip fracture was estimated to be almost
The Asia-Pacific region is currently home to more 176,000 cases [123].
than 4.4 billion people. In 2016, the United Nations
Economic and Social Commission for Asia and Mortality
the Pacific (ESCAP) Social Development Division
estimated that 12.4% of this population was aged According to the 2013 IOF Audit, in Pakistan,
60 years or older, a figure which is set to rise to Philippines, Sri Lanka and Vietnam only half of
25.1% by 2050 [118]. Further, the proportion of the hip fracture patients receive surgery [119]. While
population classified as the “oldest-old” (i.e. 80 years published studies are currently not available,
or older) will increase from 12.3% in 2016 to 19.9% post-fracture mortality is likely to be very high for
in 2050. Accordingly, by the middle of this century, these individuals.
1.3 billion people in Asia will have celebrated their
60th birthday, and more than a quarter of a billion In China, one year mortality among hip fracture
will have celebrated their 80th birthday. patients in Beijing is 23%, representing an
approximately two-fold excess compared to
In 2013, IOF published the second Asia-Pacific controls [124]. A small-scale study in India reported
Regional Audit which provided an overview that at least a quarter of hip fracture patients died
of the epidemiology, costs and burden of within a year of surgery [125]. In 2007, Tsuboi and
osteoporosis for 16 jurisdictions: Australia, China, colleagues described post-hip fracture mortality for
Chinese Taipei, Hong Kong, India, Indonesia, a cohort from Nagoya in Japan [126]. The overall
Japan, Malaysia, New Zealand, Pakistan, survival rates at one, two, five and ten years
Philippines, Republic of Korea, Singapore, Sri after fracture were 81%, 67%, 49% and 26%,
Lanka, Thailand and Vietnam [119]. Key findings respectively. Mortality rates were approximately
from the IOF Audit, and more recent studies double that of the general population throughout
where available, relating to epidemiology, the entire period of observation.
mortality, health expenditure, and access and
reimbursement follow. Health expenditure

Epidemiology The costs of fragility fractures in this region are

currently enormous, and set to rise substantially
On account of the mass ageing of the population of in the coming decades:
this region, it has been projected that half of all hip
fractures will occur in Asia by 2050 [120]. Estimates –– Australia: Osteoporosis Australia estimates
of the annual incidence of hip fracture in the most the total costs of fragility fractures to be
populous countries in the region are as follows: AU$2.2 billion (US$1.7 billion) in 2017,
increasing to AU$2.6 billion (US$2 billion)
–– China: The incidence of 411,000 cases of by 2022 [127].
hip fracture in 2015 is projected to exceed
1 million cases by 2050 [114]. –– China: The projected costs to the Chinese
healthcare system for all osteoporosis-
–– India: Currently, there is a paucity of hip related fractures for the years 2015 and
fracture epidemiology available for India. 2050 are US$11 billion and US$25 billion,
Application of hip fracture rates reported respectively [114].
for the Rohtak district of North India in
2013 [121] to the most recent United –– Japan: In 2013, total costs related to
Nations Population Projection for India fragility fractures in the population aged 65
[122] suggests that 306,000 hip fractures and over were estimated to be almost JPY
occurred in 2015 [73]. 944 billion (US$8 billion) [115].

–– Indonesia: The IOF Audit reported that –– Republic of Korea: In 2011, the total
43,000 hip fractures occurred in men and societal cost of osteoporotic fractures was
women aged over 40 years in 2010 [119]. estimated to be US$149 million [128].

Osteoporosis by region
 44

Access and reimbursement

The 2013 IOF Audit documented considerable in figure 10, the number of DXA scanners per
variation in access and reimbursement for diagnosis million of population varied from 24 in the Republic
of osteoporosis and treatment [119]. As illustrated of Korea to less than 1 in Sri Lanka and Vietnam.

Figure 10. Number of DXA scanners per million of population in Asia-Pacific [119]

Vietnam

Sri Lanka

Philippines

Pakistan

Indonesia

India

China

Thailand

Malaysia

Chinese Taipei

New Zealand

Singapore

Australia

Hong Kong

Japan

R. of Korea

5 10 15 20 25

DXA scanners/million

Country-specific FRAX® Fracture Risk Assessment Reimbursement of osteoporosis treatment varied

Tools are available for the following countries greatly across the region, ranging from 0 to
in the Asia-Pacific region [55]: Australia, China, 100% reimbursement for the most commonly
India, Indonesia, Japan, New Zealand, Philippines, prescribed medications.
Singapore, Republic of Korea, Sri Lanka, Taiwan
and Thailand.

IOF Compendium of Osteoporosis - First Edition

 45

Central Asia
In 2010, IOF published the Eastern European and
Central Asian Regional Audit which provided an
overview of the epidemiology, costs and burden of
osteoporosis for 21 countries, including 4 countries
in Central Asia: Republic of Kazakhstan, Kyrgyz
Republic, Republic of Tajikistan and Republic of
Uzbekistan [129]. Key findings from the IOF Audit,
and more recent studies where available, relating
to epidemiology, mortality, health expenditure,
and access and reimbursement follow.

Epidemiology

Epidemiological studies in this region are limited.

In 2009, government statistics suggested that 2,238
hip fractures occurred in the Republic of Kazakhstan
[129]. In 2016, Tlemissov and colleagues described
the epidemiology of geriatric trauma in an urban
Kazakhstani setting [130]. More than 80% of injuries
were the result of a fall. The IOF Audit estimated
the incidence of hip fracture in the Kyrgyz Republic
to be 2,300 cases per year, while no data was
available for the Republic of Tajikistan [129]. In 2016,
Ismailov and colleagues determined the prevalence
of osteoporosis among Uzbek women aged over
50 years to be 36% [131]. The Research Institute
of Traumatology and Orthopaedics of the Ministry
of Public Health estimate that 30,000 Uzbeks have
osteoporosis and 150,000 have osteopenia [129].

Mortality

The IOF Audit highlights that a significant

proportion of hip fracture patients in this region
do not undergo surgery. Accordingly, post-hip
fracture mortality is likely to be significantly
higher than in countries where surgical
intervention is standard practice.

Health expenditure

The costs of fragility fractures to health systems in

this region have not been studied.

Access and reimbursement

The IOF Audit documented low levels of access to

DXA scanners and reimbursement of treatment
across this region. Country-specific FRAX® Fracture
Risk Assessment Tools are currently not available
for the countries of the Central Asia region.
46

Europe
In 2015, the combined population of the 28
European Union member states (EU-28) was
508.5 million [132]. Almost a fifth (18.9%) of this
population was aged 65 years and over. By 2050,
Eurostat projections suggest that 28.1% of the
EU-28 population will be aged 65 years and over,
representing 147.7 million people. More than 57
million of these will be aged 80 years and over
(n.b. the departure of the United Kingdom from
the EU is not reflected in these figures).

In 2013, IOF in collaboration with the European

Federation of Pharmaceutical Industry
Associations (EFPIA) undertook a comprehensive
osteoporosis and fragility fracture audit of the
27 EU member states at the time [113, 133,
134]. Key findings from the IOF Audit, and
more recent studies where available, relating to
epidemiology, mortality, health expenditure, and
access and reimbursement follow. Additional
information relating to Switzerland [135], the
Russian Federation [136] and several other
Eastern European/Western Asian countries [129]
is also available.

Epidemiology

In 2010, it was estimated that 22 million women

and 5.5 million men in the EU had osteoporosis
in accordance with the diagnostic criterion of the
WHO [113]. The total number of new fractures
in the same year was estimated to be 3.5 million,
comprised of 620,000 hip fractures, 520,000
vertebral fractures, 560,000 forearm fractures and
1.8 million other fractures. In addition, the number
of individuals with ‘prior’ fracture was estimated.
A prior fracture was defined as a fracture in an
individual who was alive during 2010, which had
occurred after the age of 50 years and before
2010. The unit was the individual so that multiple
fractures at the same site in one individual were
only counted as one prior fracture of that site. The
prevalence of prior hip fracture was 3.3 million
individuals and prior clinical vertebral fracture
was 3.5 million individuals. Studies from France
[137], Germany [138], Italy [139], Sweden [140] and
the UK [141] suggest that prior hip and vertebral
fractures combined account for approximately
30% of all prior fractures. Accordingly, it is likely
that 22.7 million individuals in the EU had a prior
fracture history in 2010.
 47

A total of 74,000 fragility fractures occurred Mortality

in Switzerland in 2010, including 14,000 hip
fractures [135]. In the same year, it was estimated In 2010, the number of deaths causally related to
that 112,000 hip fractures occurred in the Russian fractures in the EU was estimated at 43,000 [113].
Federation, a figure expected to rise to 159,000 Approximately half of fracture-related deaths in
by 2035 [136]. The IOF Eastern European and women were attributable to hip fractures, 28% to
Central Asian Regional Audit published in 2010 clinical vertebral fractures and 22% to other fractures.
[129] included the following Eastern European/ The IOF Eastern European and Central Asian Regional
Western Asian countries which were not included Audit reported high rates of post-hip fracture
in the subsequent EU audit described previously mortality in the Russian Federation and some of the
[113, 133, 134]: Armenia, Azerbaijan, Republic of Eastern European/Western Asian countries [129].
Belarus, Georgia, Republic of Moldova, Russian In the Russian Federation, 33-40% of hip fracture
Federation and Ukraine. With the exception of patients were hospitalised and just 13% received
the Russian Federation, epidemiological studies surgical intervention. Consequently, mortality rates for
are scarce in these countries. hip fracture in some Russian cities reached 50%.

Without proper surgical treatment, hip fracture patients are invariably left bedridden and
unable to walk. This Russian patient suffered a fracture of the femur (hip) several years ago. She
did not receive surgical treatment, or treatment of any kind. Now, even several years later, she is
unable to walk. Twice a day, everyday, her husband pushes her in a wheelbarrow all the way to
town. This way she is at least able to leave the house and maintain some social contact.

Osteoporosis by region
 48

Health expenditure The costs of fragility fractures to the Russian

Federation and health systems in the Eastern
In 2010, the cost of osteoporosis in the EU, European/Western Asian countries have not
including pharmacological intervention, been studied.
was estimated to be Euro 37 billion (US$40
billion) [113]. Two-thirds of this costs was Access and reimbursement
attributable to treatment of new fractures,
long-term care accounted for 29% and The IOF-EFPIA EU audit documented considerable
pharmacological prevention just 5%. Excluding variation in access and reimbursement for
cost of pharmacological prevention, hip fractures diagnosis of osteoporosis and treatment [113,
accounted for 54% of the costs. Assuming a 133, 134]. As illustrated in figure 11a, the number
Quality-Adjusted Life Year (QALY) to be valued of DXA scanners per million of population varied
at twice the GDP per capita, the total cost of from 53 in the Belgium to 1.2 in Bulgaria. Access
osteoporosis in 2010 would be Euro 98 billion to DXA is considerable lower in the Eastern
(US$106 billion). In 2010, the economic burden of European/Western Asian countries, as illustrated
new and prior fragility fractures in Switzerland in figure 11b.
was estimated to be CHF 2 billion (US$2 billion).

Figure 11a. Number of DXA scanners per million of Figure 11b. Number of DXA scanners per million of
population in the European Union [134] population in Eastern Europe/Western Asia [129]

Belgium
Greece Ukraine
France
Austria
Slovenia
Portugal Georgia
Cyprus
Germany
Italy
Finland Moldova
Denmark
Slovakia
Netherlands
Sweden Belarus
Ireland
Malta
Estonia
Spain Azerbaijan
UK
Hungary
Czech Republic May have adequate
Latvia provision Russia
Poland
Lithuania Borderline provision
Romania
Luxembourg Very inadequate provision Armenia *
Bulgaria

0 10 20 30 40 50 0 1 2 3 4 5

DXA units/million DXA units/million

(Reproduced from Arch Osteoporos. 2013;8:144 with kind *2017

permission of Springer)

IOF Compendium of Osteoporosis - First Edition

 49

Country-specific FRAX® Fracture Risk Assessment overall ranking and score for access to medical
Tools are available for the following countries intervention was provided for each country as
in Europe [55]: Armenia, Austria, Republic of shown in figure 12.
Belarus, Belgium, Croatia, Czech Republic,
Denmark, Estonia, Finland, France, Germany, The IOF Eastern European and Central Asian
Greece, Hungary, Iceland, Ireland, Israel, Italy, Regional Audit noted that access to osteoporosis
Lithuania, Malta, Moldova, Netherlands, treatments was extremely limited throughout
Norway, Poland, Portugal, Romania, the Russian the region, including in the Eastern European/
Federation, Slovakia, Spain, Sweden, Switzerland, Western Asian countries [129].
UK and Ukraine.

Regarding access to treatments for osteoporosis,

the IOF-EFPIA EU Audit noted that most
interventions were reimbursed in most countries
[134]. However, significant variation in the degree
of reimbursement was evident, with only 7
member states providing full reimbursement. An

Figure 12. Ranking and score for access to medical intervention in the European Union [134]

Sweden
Slovenia
Netherlands
Italy
Ireland
Cyprus
Austria
UK ★
Germany ★
Slovakia
Portugal
Malta
Luxembourg
Latvia
Finland
Denmark
Czech Republic
Spain
Romania
Poland
Lithuania Good access
Hungary
Greece Moderate access
France
Estonia Poor access
Bulgaria
Belgium

0 1 2 3

Treatment score

(Reproduced from Arch Osteoporos. 2013;8:144 with kind permission of Springer)

Osteoporosis by region
 50

Euripedes, from Brazil, lost 19 cm in height

as a result of painful vertebral fractures
caused by osteoporosis. He now finds daily
activities more difficult and can’t sit for long
periods of time because of the pain.

IOF Compendium of Osteoporosis - First Edition

 51

Latin America increase to 76,000 cases by 2050 [143, 144].

In 2015, the United Nations report on the ageing –– Brazil: Zerbini and colleagues estimated
of the world’s population stated [117]: that 80,640 hip fractures occurred in 2015
[145]. By 2040, the number of cases is
projected to be almost 198,000 per year.

–– Colombia: Jaller-Raad and colleagues

estimated that 7,900 hip fractures
occurred in 2010 [146]. By 2035, the
number of cases is projected to exceed
“Over the next 15 years, the number of 22,700 per year.
older persons is expected to grow fastest
–– Mexico: Johansson and colleagues
in Latin America and the Caribbean with
estimated that more than 29,700
a projected 71 per cent increase in the hip fractures occurred in 2005 [147].
population aged 60 years or over.” Assuming no change in the age- and
sex-specific incidence of hip fracture, the
number of hip fractures was expected
to increase to almost 156,000 cases by
2050. Should the age-specific incidence
continue, the number of hip fractures
would increase by a further 46% to
almost 227,000 by 2050.
The report estimated that 71 million individuals in
Mortality
this region were aged 60 years or older in 2015, a
figure which is set to rise to 200 million by 2050.
Studies from several Latin American countries
Further, the number of individuals classified as the
have reported high rates of post-hip fracture
“oldest-old” (i.e. 80 years or older) will increase
mortality as compared to European and North
from 10 million in 2015 to 45 million in 2050.
American countries. In 2000, a study conducted in
Luján, Argentina reported in-hospital mortality of
In 2012, IOF published the Latin America Regional
10% and 1-year mortality of 33% [148]. In 2010,
Audit which provided an overview of the
Pereira and colleagues described mortality rates
epidemiology, costs and burden of osteoporosis
for individuals aged 60 years and over who were
for 14 countries [142]: Argentina, Bolivia, Brazil,
admitted with hip fracture to hospitals in Rio de
Chile, Columbia, Costa Rica, Cuba, Guatemala,
Janeiro, Brazil [149]. Nine percent of patients died
Mexico, Nicaragua, Panama, Peru, Uruguay and
in hospital and a further 26% died within a year
Venezuela. Key findings from the IOF Audit, and
of discharge. In 2016, a description of outcomes
more recent studies where available, relating to
for an Orthogeriatric Care Program in a Colombian
epidemiology, mortality, health expenditure, and
Hospital was very encouraging [150]. The annual
access and reimbursement follow.
survival rate increased from 80% to 89% (p = .039)
Epidemiology 4 years after implementation of the program.

The rapid ageing of the Latin American Health expenditure

population in the coming decades is projected to
The costs of fragility fractures in this region are
result in 12.5% of all hip fractures occurring in
currently significant, and set to rise substantially
this region by 2050 [120]. Estimates of the annual
in the coming decades:
incidence of hip fracture in the most populous
countries in the region are as follows:
–– Argentina: In 2009, hospitalization costs of
hip and vertebral fractures were estimated
–– Argentina: The incidence of 34,000 cases
to exceed US$190 million per year [144].
of hip fracture in 2009 is projected to

Osteoporosis by region
 52

–– Brazil: In 2014, Moraes and colleagues Access and reimbursement

analysed expenditure by the Ministry of
Health in the Brazilian Public Health System The IOF Latin American Audit documented
on osteoporosis and related fractures [151]. considerable variation in access and
During the period 2008-10, more than 3.2 reimbursement for diagnosis of osteoporosis and
million procedures resulted in expenditure treatment [142]. As illustrated in figure 13, the
of almost R$289 million (US$92 million). number of DXA scanners per million of population
varied from 10 in Brazil and Chile to approximately
–– Colombia: The IOF Audit estimated that 1 in Bolivia, Guatemala and Nicaragua.
the direct hospital cost for treating a hip
fracture in Colombia was US$6,457 [142]. Country-specific FRAX® Fracture Risk Assessment
Accordingly, this would suggest that more Tools are available for the following countries
than US$51 million was spent on hip in Latin America [55]: Argentina, Brazil, Chile,
fracture care in 2010 [146]. Columbia, Ecuador, Mexico and Venezuela.

–– Mexico: In 2010, Carlos and colleagues Bisphosphonate therapies were reported to be

estimated the cost of fragility fractures in widely available throughout the region [142].
Mexico to be US$256 million [152]. These However, there was considerable variability
costs are projected to rise to US$305 in reimbursement policy. Other osteoporosis
million and US$364 million in 2015 and therapies such as selective estrogen receptor
2020, respectively. modulators (SERMs), recombinant forms
of parathyroid hormone (PTH), hormone
replacement therapy (HRT) were also available,
but access was often restricted.

Figure 13. Number of DXA scanners per million of population in Latin America [142]

Bolivia
Guatemala
Nicaragua
Cuba
Colombia
Uruguay
Mexico
Peru
Costa Rica
Panama
Vanezuela
Argentina
Brazil
Chile

0 2 4 6 8 10

DXA scanners/million

IOF Compendium of Osteoporosis - First Edition

 53

Maria-Grazia, 62 years old, developed osteoporosis

after taking cortisone injections for rheumatoid
arthritis over the course of 10 years. Rheumatoid
arthritis and long-term glucocorticoid therapy are
major risk factors for osteoporosis.

Osteoporosis by region
54

Middle East and Africa

In 2011, IOF published the Middle East and
Africa Regional Audit which provided an
overview of the epidemiology, costs and burden
of osteoporosis for 17 countries [153]: Bahrain,
Egypt, Kuwait, Iran, Iraq, Jordan, Kenya,
Lebanon, Morocco, Palestine, Qatar, Saudi
Arabia, South Africa, Syria, Tunisia, Turkey and
United Arab Emirates. At the time of writing,
8-20% of the population of this region was
aged over 50 years, which is set to increase to
25% and 40% by 2020 and 2050, respectively.
Key findings from the IOF Audit, and more
recent studies where available, relating to
epidemiology, mortality, health expenditure, and
access and reimbursement follow.

Epidemiology

Epidemiological studies in this region are

limited. Estimates of the annual incidence of
hip fracture in two countries in the region are
as follows:

–– Saudi Arabia: The incidence of more

than 7,500 cases of hip fracture in 2013 is
projected to increase to more than 9,700 by
2025 [154].

–– Turkey: In 2009, there were approximately

24,000 cases of hip fracture in Turkey
[155]. Assuming no change in the age- and
sex-specific incidence, the number of hip
fractures was expected to increase to nearly
64,000 by 2035.

Mortality

Mortality rates post-hip fracture may be higher

in this region than those reported from western
populations. In 2004, El-Hajj Fuleihan and
colleagues reported 1-year mortality among
Lebanese hip fracture patients to be 33% [156].
In 2006, a retrospective study from Saudi Arabia
reported an average 2-year mortality rate of 27%
[157]. In 2008, a case series from Turkey reported
a 3-year mortality rate of 61% in females and
50% in males [158]. A more recent Turkish study
reported 3-year mortality of 37% [159].
 55

Health expenditure Access and reimbursement

In 2010, the IOF Audit noted that information The IOF Audit documented considerable variation
on costs relating to osteoporosis and fragility in access and reimbursement for diagnosis of
fractures was practically non-existent [153]. In osteoporosis and treatment [153]. As illustrated in
Iran, it was estimated that the direct costs of figure 14, the number of DXA scanners per million
hip fractures would increase from US$28 million of population varied from 27 in Lebanon to none
in 2010 to US$250 million by 2050. In Turkey, in Kenya.
similar estimates suggested that direct costs
for hip fracture would increase from US$72 Country-specific FRAX® Fracture Risk Assessment Tools
million in 2010 to US$205 million in 2050. A are available for the following countries in the Middle
more recent study from Saudi Arabia estimated East and Africa [55]: Abu Dhabi, Iran, Jordan, Kuwait,
the overall hospital cost due to hip fractures, Lebanon, Morocco, Palestine, Tunisia and Turkey.
including the indirect costs for the first year, to
be SR2.4 billion (US$629 million) [154]. This cost Bisphosphonates, SERMs, HRT and strontium
was projected to increase to SR3.9 billion (US$1 ranelate were available in most countries.
billion) by 2025. However, reimbursement varies from 100% to 0%.

Figure 14. Number of DXA scanners per million of population in the Middle East and Africa [153]

Kenya
Iraq
Morrocco
Egypt
Palestine
Syria
Iran
South Africa
Qatar
Jordan
Saudi Arabia
Tunisia
Kuwait
Bahrain
UAE
Turkey 27
Lebanon

0 2 4 6 8 10 12 14 16 18 20

DXA scanners/million

Osteoporosis by region
56

North America
In 2015, the United Nations report on the
ageing of the world’s population stated that the
proportion of the North American population
aged 60 years and over will increase by 41% by
2030 [117]. The report estimated that 75 million
individuals in this region were aged 60 years
or older in 2015, a figure which is set to rise
to 123 million by 2050. Further, the number of
individuals classified as the “oldest-old” (i.e. 80
years or older) will increase from 14 million in
2015 to 37 million in 2050. Key findings of studies
from Canada and the United States relating to
epidemiology, mortality, health expenditure, and
access and reimbursement follow.

Epidemiology

In 2016, Hopkins and colleagues described the

incidence of osteoporosis attributable fractures
during financial year 2010-11 in Canada [160].
A total of 131,443 fractures resulted in 64,884
acute care admissions and 983,074 acute hospital
days. The proportion of fractures by type was
hip (18.1%), wrist (20.8%), vertebral (5.7%),
humerus (6.4%), other (41.4%) and multiple
(7.5%), respectively.

The 2010 US Census population suggested that

there were 99 million adults aged 50 years and
over living in the US in 2010. Based on this data
and osteoporosis prevalence rates taken from
the National Health and Nutrition Examination
Survey (NHANES) 2005-2010, 10.2 million older
adults were estimated to have osteoporosis [6].
A further 43.4 million older adults had low bone
mass (i.e. osteopenia). The most recent estimate of
the incidence of all osteoporosis-related fractures
occurring in the US was published a decade ago
[112]. Burge and colleagues’ study suggested that
more than 2 million fractures occurred among
Americans aged 50 years and over in 2005. This
included almost 297,000 hip fractures, 547,000
vertebral fractures, 399,000 wrist fractures, 135,000
pelvis fractures and 675,000 other fractures. By
2025, the total number of fractures was projected
to exceed 3 million cases per year. A more recent
study based on data from the National Hospital
Discharge Survey estimated the incidence of hip
fracture in the US to be 258,000 cases in 2010,
which was projected to rise to 289,000 cases by
2030 [161].
 57

Mortality On an annual basis, the total population facility-

related cost resulting from hospitalisation of
Efforts are ongoing in Canada and other countries osteoporotic fractures was US$5.1 billion. Another
to expedite surgery for hip fracture patients study estimated the cost burden of second fracture
with a view to improve outcomes. In Manitoba, to the US health system [168]. On an annual basis,
a coordinated, region-wide effort to improve nationwide, this amounted to $834 million for
timeliness of hip fracture surgery reported pre- patients with commercial insurance and $1.1 billion
and post-intervention mortality rates in-hospital for Medicare patients. This study clearly highlighted
and at 1 year [162]. The crude in-hospital mortality the need for widespread implementation of FLS.
rate reduced from 9.6% to 6.8%, while the
crude mortality rate at 1 year was not significant Access and reimbursement
difference between groups (pre- 25.7% vs. post-
24%, p=0.12). Another study evaluated excess The current number of DXA scanners in Canada
mortality associated with second hip fracture in or the United States is not documented. In 2005
British Columbia, hazard of death was 55% higher it was estimated that there were 16.3 and 35.8
for patients with second hip fracture compared DXA scanners per million of population in Canada
to those without second hip fracture [163]. This and the United States, respectively [169]. Country-
study highlighted the need for effective post-hip specific FRAX® Fracture Risk Assessment Tools are
fracture secondary prevention programmes. available for Canada and the United States.

In 2009, Brauer and colleagues examined trends In Canada, there is no single national healthcare
in hip fracture incidence and mortality for the system. Health care falls under the independent
period 1985-2005 in the US Medicare population jurisdiction of each of the 10 provinces and 3
[164]. Thirty-day mortality in women decreased by territories. There is reimbursement for many of
11.9% during the entire course of the study, from the oral bisphosphonates in all Canadian provinces
5.9% to 5.2%. The adjusted 360-day mortality for seniors who are indicated for such treatment.
decreased by 8.8% from 24.0% in 1986 to 21.9% However, coverage for other osteoporosis
in 2004. A more recent study evaluated mortality medications such as denosumab and zoledronic acid
among postmenopausal women who sustained is quite variable depending on the province/territory.
hip fractures in the period 2000-2010 and were
managed in an integrated healthcare delivery In the USA, reimbursement for screening, treatment
system [165]. The crude all-cause mortality rate and other bone health interventions varies greatly
was 6.3% and 22.8% at 1 month and 12 months, depending on each patient’s health plan. In 2007,
respectively. The adjusted odds of death in 2010, Medicare initiated a series of cuts to reimbursement
as compared to 2004, were 27% and 30% lower at for DXA services performed in the non-facility
6 months and 1 year, respectively. In 2016, a study setting. By 2010, payments for these services had
from California reported similar findings [166]. been reduced by more than 60% compared with
2006 levels. Analyses showed that as compared to
Health expenditure the 2-year period prior to the cuts in reimbursement,
in the 2-year period after the cuts, both the number
The most recent estimate of the economic burden of DXA scans and prescriptions for FDA-approved
of osteoporosis in Canada provides information osteoporosis drugs had declined [170].
for financial year 2010-11 [160]. The total cost of
CN$4.6 billion (US$3.5 billion) included CN$1.5 To address these gaps, the National Bone Health
billion (US$1.1 billion) for acute care costs and CN$1 Alliance (NBHA) convened a bone health ‘payer
billion (US$0.8 billion) for long-term care costs. summit’ in May 2017 comprising the major
payers to solicit their feedback on the scientific
In 2005, Burge and colleagues estimated the cost of and clinical evidence needed to reconsider these
the 2 million cases of fragility fracture annually to coverage and reimbursement decisions. This
be US$17 billion [112]. By 2025, this was projected feedback will be used to inform the development
to increase to US$25 billion. In 2016, Singer and of an evidence report that will provide evidence
colleagues analysed data from the US Nationwide of the cost-effectiveness of these interventions to
Inpatient Sample for the period 2000-2011 [167]. reduce future fracture risk.

Osteoporosis by region
 58

BLUEPRINT FOR
ACTION
59
 60

BLUEPRINT FOR ACTION

At the time of writing of this Compendium, the world’s population was approaching
7.4 billion individuals [171]. In 2015, the United Nations report on World Population
Ageing highlighted the unprecedented change to the age structure of our civilisation
that is set to unfold this century [117]:

“Between 2015 and 2030, the number of people in the world aged 60 years
or over is projected to grow by 56 per cent, from 901 million to 1.4 billion,
and by 2050, the global population of older persons is projected to more
than double its size in 2015, reaching nearly 2.1 billion.”

Considering the dramatic influence this demographic shift will have upon the
prevalence of osteoporosis - and the fragility fractures it causes – it is imperative
that all nations develop and implement a strategy to improve the bone health of
their populations.

During the last year, IOF has developed two key initiatives to support national
level policymakers, government representatives, healthcare professionals and their
organizations, national osteoporosis societies and the healthcare industry to improve
the bone health of the populations that they serve:

–– The IOF Global Patient Charter.

–– The IOF Global Framework for Improvement.

Details of these potentially transformational initiatives follow.

IOF Compendium of Osteoporosis - First Edition

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Launched in 2017, the IOF Global Patient Charter articulates the rights and responsibilities of all key
stakeholders to ensure that the right patient receives the right treatment at the right time [77]:

IOF Global Patient Charter

Through this Charter, as a patient or family member of a patient, I call for the rights to:

DIAGNOSIS: PATIENT CARE:

1 Timely and accurate 2 Access to effective
assessment of intervention
fracture risk, falls options (treatment,
risk and diagnosis lifestyle changes)
of osteoporosis. and to regular drug
treatment review
by appropriate
healthcare
professional.

PATIENT VOICE: SUPPORT:

3 Involvement and 4 Care and support
choice in a long- from society
term management and healthcare
plan with defined providers, to
goals. ensure active and
independent living.

Help drive improvement, and show your support:

POLICYMAKERS, HEALTHCARE
HEALTHCARE AUTHORITIES AND NATIONAL
PATIENTS: PROFESSIONALS: GOVERNMENTS:

Speak to your Protect communities’ Support the establishment of

physician to identify bone health coordinated models of care (Fracture
your risk, and take through appropriate Liaison Services) to help reduce the
action for change. assessment and global human and socioeconomic
treatment. burden of fragility fractures.

Show your commitment by signing the IOF Global Patient Charter. Your signatures will help raise
the profile of this insidious disease and make fracture prevention a global health priority.

Visit https://www.iofbonehealth.org/iof-global-patient-charter now.

Blueprint for action

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63

The IOF Global Framework for

Improvement
The 2016 World Osteoporosis Day Report
provided a new Global Framework for
Improvement to equip national policymakers,
leaders within the healthcare professions and
national osteoporosis societies to deliver optimal
management of bone health for all [18, 73].
The Report identified 10 key gaps pertaining to
delivery of optimal care for all, and proposed
evidence-based solutions to close those gaps:

Case finding and management:

Gap 1: Secondary fracture prevention

Gap 2: Osteoporosis induced by medicines
Gap 3: Diseases associated with osteoporosis
Gap 4: Primary fracture prevention for
individuals at high risk of fracture

Public awareness:

Gap 5: The importance of staying on treatment

Gap 6: Public awareness of osteoporosis and
fracture risk
Gap 7: Public awareness of benefits versus risks
of osteoporosis treatment

Government and health system issues:

Gap 8: Access and reimbursement for

osteoporosis assessment and treatment
Gap 9: Prioritization of fragility fracture
prevention in national policy

Lack of data:

Gap 10: The burden of osteoporosis in the

developing world
 64

Priority Actions
The IOF Compendium of Osteoporosis, to be progress in its the implementation. During the
updated periodically, provides an opportunity period 2017-2020, IOF would recommend that all
for ongoing review of the components of the stakeholders prioritise the following actions in
Global Framework and a platform to document their jurisdictions.

Secondary fracture prevention

The majority of individuals who suffer fragility repeatedly to deliver best practice in a highly
fractures are neither assessed nor treated for cost-effective manner, and reduced mortality.
osteoporosis [18]. This global care gap has These models of care have been endorsed
persisted despite publication of numerous clinical by governments and healthcare professional
guidelines in many countries which advocate organisations in a growing number of countries,
secondary fracture prevention. including Australia, Canada, New Zealand,
Singapore, Sweden, United Kingdom and the
Effective models of care are required to reliably United States [67]. The IOF Capture the Fracture®
implement the recommendations made in Programme provides a comprehensive suite of
clinical guidelines. As described previously in this resources to support development of new FLS and
Compendium, Orthogeriatric Services (OGS) and optimisation of existing FLS [68, 69, 172].
Fracture Liaison Services (FLS) have been shown

PRIORITY 1:
Policymakers, healthcare professional
organisations and national osteoporosis
societies must collaborate to provide
Orthogeriatric Services and Fracture Liaison
Services to all older people who suffer fragility
fractures in their jurisdictions.

Osteoporosis induced by medicines

While a range of treatments are available to prevent BMD testing or received osteoporosis
osteoporosis induced by medicines, guidelines based treatment in more than 80% of studies.
care is frequently not delivered, as has been reported This is disappointing given that clinical
for several commonly used drug classes: guidelines for the prevention and
treatment of GC-induced osteoporosis are
–– Glucocorticoids: A systematic review available in many countries [174].
evaluated the proportion of patients
receiving chronic oral glucocorticoid –– Androgen Deprivation Therapy:
(GC) therapy who received osteoporosis Approximately one third of prostate cancer
management for studies published patients receive androgen deprivation
between 1999 and 2013 [173]. Less therapy (ADT). Information from the Texas
than 40% of GC users underwent Cancer Registry was linked to the Medicare

IOF Compendium of Osteoporosis - First Edition

 65

database to establish what proportion –– Aromatase inhibitors: Aromatase

of men diagnosed with prostate cancer inhibitors (AIs) are considered to be the
underwent BMD testing and/or received gold standard adjuvant treatment for
osteoporosis treatment [175]. Less than postmenopausal women with hormone
a tenth of these men had a BMD test receptor-positive breast cancer. A study
within 6 months of initiation of ADT, and conducted in Seattle in the United States
among those enrolled in the Medicare reported that less than half of women
part D scheme, only 5.6% received bone underwent BMD testing within 14 months
sparing drugs when they were initiated of continuous AI use for at least 9 months
on ADT. Many guidelines have been [177]. As for GCs and ADT, many guidelines
published on the prevention and treatment are available to inform best practice in
of ADT-induced osteoporosis, such as osteoporosis management for AI users,
those produced by the IOF Committee of such as those published by the European
Scientific Advisors (CSA) Working Group on Society for Clinical and Economical Aspects
Cancer-induced Bone Disease [176]. of Osteoporosis (ESCEO) in 2012 [23].

PRIORITY 2:
Where treatments are licensed to prevent
osteoporosis induced by medicines, and
guidelines have been published to inform best
clinical practice, osteoporosis management
must become a standard consideration for
clinicians when prescribing medicines with
bone-wasting side effects.

Primary fracture prevention

The advent of absolute fracture risk calculators risk. FRAX®, in combination with access to axial
such as FRAX® provide individuals and their DXA scanning, provides primary care providers
clinicians with a readily accessible, online tool to with an opportunity to stratify fracture risk
estimate fracture risk. Individuals can visit https:// within their practice population.
www.sheffield.ac.uk/FRAX/ to access their own

PRIORITY 3:
National osteoporosis societies to incorporate
messaging regarding self-assessment of fracture
risk with FRAX® into public awareness and
education initiatives, as advocated in Priority 6.
National osteoporosis societies to collaborate
with healthcare professional organisations for
primary care providers (PCPs) to jointly advocate
for PCPs to routinely undertake fracture risk
assessment when interacting with patients aged
50 years and over.

Blueprint for action

 66

Nutrition and exercise

Nutrition has a profound effect on bone health –– Adults: Avoid premature bone loss
throughout the life course. Primary objectives for through a nutritious diet with adequate
specific populations are: calcium intake, maintaining a healthy
body weight and participation in regular
–– Expectant mothers: Must be well nourished weight-bearing activity.
to support an infant’s development in utero.
–– Seniors: Avoid malnutrition, ensuring
–– Children and adolescents: Achieve genetic adequate dietary intake of calcium, vitamin
potential for peak bone mass through D and protein, and participation in regular
a nutritious diet with adequate calcium weight-bearing activity.
intake and regular physical activity.

PRIORITY 4:
Specific initiatives encompassing nutrition and exercise are required for particular age groups:

Expectant mothers: National osteoporosis adolescents on achieving their genetic

societies to collaborate with national potential for peak bone mass.
obstetrics organisations to advise
government on optimising bone health of Adults and seniors: National osteoporosis
mothers and infants. societies to collaborate with government
Ministries for Seniors, national nutrition
Children and adolescents: National foundations/councils, national dietician/
osteoporosis societies to collaborate with nutritionist organisations, non-governmental
government Ministries of Education, organisations concerned with seniors’
national teachers’ organisations, national welfare and government Ministries of Sport
nutrition foundations/councils, national and Recreation, national sports councils
dietician/nutritionist organisations, and relevant private sector corporations
government Ministries of Sport and and providers to inform adults on their
Recreation, national sports councils and nutritional and exercise needs to maintain a
relevant private sector corporations healthy skeleton, avoid premature bone loss
and providers to educate children and and avoid malnutrition in the elderly.

IOF Compendium of Osteoporosis - First Edition

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Healthcare professional education

The pervasive and persistent care gaps relating and trainees. In countries which have
to individuals who are at high risk of sustaining implemented nationwide, systematic
fragility fractures suggests a new approach is approaches to fragility fracture care and
needed to healthcare professional education prevention, orthopaedic surgeons – and
concerning osteoporosis. Osteoporosis is a very their professional organisations - have
common condition and, as such, most healthcare played leading roles in the development
providers need to be able to reliably identify high of clinical guidelines, care standards,
risk individuals and understand their own clinical fracture registries and workforce training
role and responsibility to enable their patients to initiatives. In this regard, best practice
achieve optimal outcomes. The following groups should be shared between national
of clinicians should be primary targets to be orthopaedic associations to expedite
engaged in professional education activities: development of effective national
professional education programmes for
–– Lead Clinicians in Osteoporosis: Whether orthopaedic surgeons worldwide.
an endocrinologist, rheumatologist,
geriatrician, orthopaedic surgeon or other –– Primary care providers: Osteoporosis is
specialist, the individual who takes the a long-term condition which requires
role of “Lead Clinician in Osteoporosis” development of, and adherence to a
in their institution is vital to the success long-term care plan. Just as primary care
of quality improvement initiatives. Where providers (PCPs) have played a leading
secondary fracture prevention services role in the long-term management of
do not exist, these individuals should be individuals with cardiovascular disease,
targeted to participate in educational PCPs are central to the delivery of
programmes to drive widespread efficient, long-term care for individuals
adoption of OGS and FLS. Such education who are living with osteoporosis. National
could be delivered through face-to-face osteoporosis societies and national
meetings hosted by existing Centres of primary care organisations should
Excellence, virtual interactions through collaborate to develop educational
webinars and other internet-based programmes which enable PCPs to audit
programmes, or a combination of the two their practice population to identify high
approaches. risk individuals, navigate local referral
pathways for diagnostic assessment, and
–– Orthopaedic Surgeons: Successful be confident in the initiation guidelines-
OGS and FLS are highly reliant on based care. Practical, user-friendly
orthopaedic surgeons being supportive guidance and maximum leverage of
of both service models. Accordingly, a information technology should underpin
major global effort is required to share these educational initiatives to minimise
experience of successful OGS and FLS the time commitment required by PCPs to
with all practicing orthopaedic surgeons deliver best clinical care.

PRIORITY 5:
National osteoporosis societies and healthcare
professional organisations to collaborate
to develop and encourage widespread
participation in national professional education
programmes designed for 3 distinct audiences:
Lead Clinicians in Osteoporosis, orthopaedic
surgeons and primary care providers.

Blueprint for action

 68

Public awareness and education

The 2016 World Osteoporosis Day Report identified –– Gap 6: Public awareness of osteoporosis
three major gaps in public awareness relating to and fracture risk
osteoporosis [18, 73]:
–– Gap 7: Public awareness of benefits versus
–– Gap 5: The importance of staying on risks of osteoporosis treatment
treatment

PRIORITY 6:
National osteoporosis societies, healthcare
professional organisations, policymakers
and regulators to collaborate to develop
impactful public awareness campaigns which
empower consumers to take ownership of
their bone health.

Improving access and reimbursement for diagnosis and treatment

This Compendium has documented considerable countries is untenable. Health Technology
variation across the world in terms of access Assessment (HTA) is an important tool to help
and reimbursement of BMD measurement policymakers to allocate healthcare resources
and osteoporosis treatments. In light of the efficiently. HTA is increasingly being used to
burgeoning impact of osteoporosis upon our inform development of policy relating to the
older people, their families and carers, and management of osteoporosis to prevent fragility
national economies, the status quo in many fractures [178].

PRIORITY 7:
Osteoporosis must be designated a national
health priority in all countries, with
commensurate human and financial resources
to ensure that best practice is delivered for
all individuals living with this condition. In
countries where the current disease burden is
not known, epidemiological studies must be
commissioned as a matter of urgency.

IOF Compendium of Osteoporosis - First Edition

 69

Formation of national falls and

fracture prevention alliances
In recent years, national alliances focused on the –– Australia: The SOS Fracture Alliance [179].
development and implementation of systematic
approaches to falls and fragility fracture –– New Zealand: The Live Stronger for
prevention have formed in a growing number of Longer alliance [180].
countries. These alliances have been comprised of
national osteoporosis societies and other relevant –– UK: The Falls and Fractures Alliance [181].
non-governmental organisations, policymakers
and healthcare professional organisations, and –– USA: The National Bone Health Alliance
some include private sector companies. Alliances [182].
combine expertise, resources and the desire to
improve outcomes for those who have sustained
falls and fragility fractures. Examples from several
countries include:

PRIORITY 8:
In countries without an existing national
alliance, national osteoporosis societies to
initiate dialogue with other relevant non-
governmental organisations, policymakers,
healthcare professional organisations
and private sector companies to propose
formation of a national falls and fracture
prevention alliance modelled on successful
examples from elsewhere. Formation of a
national alliance has the potential to facilitate
delivery of Priorities 1-7.

Blueprint for action

 70

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