Osteoporosis/Bone Health in Adults as a National Public Health Priority
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 metabolic bone disease characterized by decreased bone mass and poor bone quality. It leads to an increased frequency of fractures of the hip, spine, and wrist. Osteoporosis is a global public health problem currently affecting more than 200 million people worldwide. In the United States alone, 10 million people have osteoporosis, and 18 million more are at risk of developing the disease. Another 34 million Americans are at risk of osteopenia, or low bone mass, which can lead to fractures and other complications.
Eighty percent of people who suffer osteoporosis are women.1 Although more commonly seen in women, the burden of osteoporosis in men remains underdiagnosed and underreported.8
The lifetime risk for fracture may be rising in certain populations, specifically Hispanic women. According to the 2004 Surgeon General’s Report on Bone Health and Osteoporosis, the prevalence of osteoporosis in Hispanic women is similar to that found in Caucasian women. Recent data has shown that the prevalence of osteoporosis and related fractures was highest among Asian Americans, especially those ages 70 and older. In addition, the study indicated a low proportion of African Americans and males of any race with fractures typically associated with osteoporosis or with previous diagnoses of osteoporosis. This likely reflects low rates of osteoporosis recognition and testing among these patient populations. There is little information available regarding racial differences in osteoporosis in men.
Each year, 1.5 million fractures are attributed to osteoporosis, including 350,000 hip fractures.3,4,10 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 cost the nation an estimated $17 billion in 2005.9 The cumulative cost over the next two decades is estimated to be $474 billion. In addition to a financial burden, osteoporosis-related fractures bring a burden of pain and disability, resulting in lost work time or inability to perform daily living activities.9
People in the United States are living longer. World Health Organization (WHO) data from 2006 predicts the average life expectancy of men to be 75 and that of women to be 80 years.7 With 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 (more common in women) 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; and
- Idiopathic osteoporosis affecting premenopausal women and middle-aged men.
Secondary osteoporosis (more common in men) 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; and
- 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
Lack of adequate vitamin D contributes to poor bone health. Worldwide, 1 billion people have vitamin D deficiency or insufficiency. In the United States and Europe, 40 to100 percent of elderly men and women still living in the community (not in nursing homes) are deficient in vitamin D. More than 50 percent of post menopausal women being treated for osteoporosis had suboptimal level of vitamin D. Children, young adults, and breast fed infants are also at risk for bone health problems due to vitamin D deficiency, theoretically putting them at risk for development of full blown osteoporosis later in life.
The American Academy of Orthopaedic Surgeons (AAOS) believes 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 physician education programs should include information about:
- Risk factors associated with osteoporosis including
- Insufficient calcium intake
- Vitamin D deficiency
- Sedentary lifestyle
- Excessive alcohol consumption
- Family history of fractures
- A small, slender body, fair skin and a Caucasian or Asian background that can increase the risk of osteoporosis
- All ethnic groups need to be considered at risk for metabolic bone disease, including, but not limited to osteoporosis.
- The importance of adequate dietary intake of calcium, vitamin D and other nutrients, starting at an early age, especially for young girls
- Testing of blood levels of these nutrients should be considered even in the young and in all ethnic groups, especially if there is significant fracture history.
- Emphasis on diagnosis of other, possibly co-existing metabolic bone diseases
- 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
- Fall prevention strategies and rehabilitation, including safety education, vision, and hearing checks
Clinicians need to be cognizant that all ethnic groups are susceptible to osteoporosis, and the disease is under diagnosed in the African American population. Based on nationally representative estimates, a considerable proportion of people with osteoporotic fractures have not received a diagnosis of osteoporosis (prior to their fracture). This is especially true among men and African Americans.
Early diagnosis of osteoporosis usually established by a combination of a complete medical history and physical examination, skeletal X-rays, bone densitometry and specialized laboratory tests.
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
- 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. 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 recommends 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 strengthen aging bones.
- Lane JM, Serota AC, Raphael B: Osteoporosis: Differences and Similarities in Male and Female Patients. Orthop Clin N Am 37 2006; 601–609.
- National Osteoporosis Foundation, “1996 and 2015 Osteoporosis Prevalence Figures. State by State Prevalence Report,” 1997.
- Brody JA: Prospects for an aging population, Nature 1985; 315:463-466.
- Riggs BL, Melton LJ III: The prevention and treatment of osteoporosis. New Engl J Med, 1992; 327:620-627.
- Riggs BL, Melton LJ III: Evidence for two distinct syndromes of involuntional osteoporosis. Am. J. Med 1983; 75:899-901.
- Lane JM, Nydick M: Osteoporosis: Current Modes of Prevention and Treatment. JAAOS Vol.7: 1,1931,1999.
- World Health Organization. World health statistics 2008.
- Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost. Rosemont, IL, American Academy of Orthopaedic Surgeons. February 2008.
- Mauck KF, Clarke BL: Diagnosis, Screening, Prevention, and Treatment of Osteoporosis. Mayo Clin Proc. 2006; 81(5):662-672.
- Holick, Michael F: Vitamin D Deficiency. New Engl J Med, 357:266-281, July 19,2007, Number 3.
- Bone Health and Osteoporosis: A Report of the Surgeon General, 2004. Available at http://www.surgeongeneral.gov/library/bonehealth/content.html
- Cheng H,Gary LC,Curtis JR, Saag KG, Kilgore ML, MorriseyMA et al: Estimated prevalence and patterns of presumed osteoporosis among older Americans based on Medicare data. Osteoporos Int. 2009 Feb 3.
February 1993 American Academy of Orthopaedic Surgeons.
Revised December 1999 and September 2009.
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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