Position Statement

Osteoporosis as a National Public Health Priority

A Joint Position Statement of the American Academy of Orthopaedic Surgeons and the National Osteoporosis Foundation

This Position Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

Osteoporosis is a widespread disease characterized by decreased bone mass and poor bone quality, which leads to increased numbers of fractures typically of the hip, spine and wrist. Osteoporosis is a global public health problem currently affecting more than 200 million people worldwide.¹

The United States alone, 10 million already have the disease and 18 million are at risk, 80 percent of whom are women.² Although the incidence of osteoporotic fractures among African American and Hispanic women is less than that of Caucasian and Asian women, their risk is still significant. Each year, 1.5 million fractures are attributed to osteoporosis, including 350,000 hip fractures.^3,4 Seventy percent of those suffering from osteoporosis do not return to previous pre-injury status. The acute and long-term medical care expenses associated with these fractures costs the nation an estimated $10 billion - $18 billion.⁴ Due to the dramatic growth of the elderly population and the rise in the incidence of fractures at earlier ages, osteoporosis has become a major public health problem of epidemic proportions.

Osteoporosis can be classified into two broad categories: primary and secondary osteoporosis.⁵

Primary osteoporosis is, by far, the most common form of the disease and includes:

• postmenopausal osteoporosis
• age-associated osteoporosis, previously termed senile
• osteoporosis, affecting a majority of individuals age 70 and older
• idiopathic osteoporosis affecting premenopausal women and middle-aged men

Secondary osteoporosis is a disease in which an identifiable agent or disease process causes loss of bone tissue and includes:

• inflammatory disorders
• disorders of bone marrow cellularity
• endocrine disorders of bone remodeling
• medication induced

Osteoporosis reflects the inadequate accumulation of bone during growth and maturation, excessive losses thereafter, or both. Although knowledge of the causes of osteoporosis is incomplete, genetic, endocrine and life style factors are contributory.⁴ Since today’s effective and safe treatments primarily preserve existing bone tissue, prevention, which involves maximizing maturational gains in bone density and minimizing post-maturity losses, emerges as the crucial current disease prevention strategy.⁴

The American Academy of Orthopaedic Surgeons (AAOS) and the National Osteoporosis Foundation believe that increased federal funding for research and education programs are essential to reduce the growth rate of osteoporotic fractures.

Based upon current scientific knowledge about osteoporosis, it is further believed such education programs should include information about:

• risk factors associated with osteoporosis, including, insufficient calcium intake, sedentary lifestyle, smoking and excessive alcohol consumption. A family history of fractures, a small, slender body, fair skin and a Caucasian or Asian background can increase the risk of osteoporosis.
• early diagnosis of osteoporosis usually made by your doctor using a combination of a complete medical history and physical examination, skeletal X-rays, bone densitometry and specialized laboratory tests.
• the importance of adequate dietary intake of calcium, vitamin D and other nutrients, starting at an early age, especially young girls
• efficacy and safety of current estrogen and other hormone and estrogen antagonists (SERMs) to prevent and treat osteoporosis.
• efficacy and safety of bisphosphonates, calcitonin and evolving therapies to prevent and treat osteoporosis.
• sufficient exercise and activity.
• adverse effects of social behaviors such as using tobacco and alcohol
• fall prevention strategies and rehabilitation.

The care for patients with established osteoporosis should include: early diagnosis of potentially treatable secondary types of osteoporosis, protection against further bone loss by utilizing medications such as estrogen, SERMs, bisphosphonates and calcitonin, exercise and activity programs, and injury prevention strategies.

While there is much to be learned about the causes of osteoporosis, there is sufficient current knowledge to undertake therapeutic action today. Estrogen, bisphosphonates, intranasal calcitonin and SERMs provide a wide range of therapeutic choices for prevention and treatment of osteoporosis. Effective regimens that stimulate bone formation will require increased federal research support.

To minimize future predicted costs, morbidity, and mortality from increasing numbers of osteoporotic fractures in our rapidly aging population, the AAOS and the National Osteoporosis Foundation recommend that osteoporosis should become a national public health priority.⁶ While current research demonstrates that pharmacological therapies can decrease the risk of fractures, new research is required to evaluate the role of each of our current therapies and to allow us to develop new therapeutic agents that can eliminate the underlying skeletal diseases.

References

1. Chestnut, CH III: Osteoporosis: A world-wide problem, in Christiansen C, Overgaard K (eds): Osteoporosis 1990. Kobenhavn K, Denmark, Osteopress ApS, 1990, pp 33-35.
2. National Osteoporosis Foundation, “1996 and 2015 Osteoporosis Prevalence Figures. State by State Prevalence Report,” 1997.
3. Brody, JA: Prospects for an aging population, Nature 1985; 315:463-466.
4. Riggs, BL, Melton, LJ III: The prevention and treatment of osteoporosis. New Engl J Med, 1992; 327:620-627.
5. Riggs, BL, Melton LJ III: Evidence for two distinct syndromes of involuntional osteoporosis. Am. J. Med 1983; 75:899-901.
6. Lane, JM, Nydick M Osteoporosis: Current Modes of Prevention and Treatment. JAAOS Vol.7: 1,1931,1999

February 1993. Revised December 1999 American Academy of Orthopaedic Surgeons

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons^®.

Position Statement 1113

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