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Aging, Systemic Disease and Oral Health: Implications for Women Worldwide (Part I)

Course Number: 302

Osteoporosis: A Global Concern for Women

Osteoporosis is not typically seen or felt by the patient, referred to as “the silent disease,” since it oftentimes progresses slowly without symptoms. Bone density loss or osteoporosis is characterized by porous bone causing bones to become fragile, thin, and high risk for fracture. From the loss of bone, fractures occur more easily, and the accompanying loss of height and severe back pain can leave the patient suffering from permanent disabilities and even death if serious spinal or vertebral fractures occur.

Osteoporosis is a disease marked by significant bone loss and reduced bone strength leading to increased risk of fractures. It affects people of all races/ethnicities and both sexes. In the United States, an estimated 10 million people age 50 years and older have osteoporosis. Most of these people are women, but about 2 million are men. Just over 43 million more people — including 16 million men — have low bone mass, putting them at increased risk for osteoporosis.58 It is estimated that one in two females over age 50 will suffer with a broken bone due to osteoporosis. Two million broken bones yearly have been attributed to osteoporosis and nearly 80% of older American women who have suffered broken bones are not tested or even treated for osteoporosis. A woman can lose up to 20% of bone density within five to seven years following menopause. In the US alone an estimated 52% of postmenopausal white women are osteopenic and 20% are osteoporotic.58

Osteoporosis can indirectly lead to death, since fractures and related complications can cause an older person’s health to quickly deteriorate. Risk factors include: advancing age; a prior fracture, osteopenia (low bone density); family history of fractures; medications that may weaken bones, such as steroids; rheumatoid arthritis; diabetes; current smoking; and excessive use of alcohol.59 Black women have a lower incidence of osteoporosis, however, they experience worse outcomes after fractures caused by osteoporosis. Reasons for this may include: higher incidence of lupus and sickle cell anemia; less likely to be screened; lactose intolerance is a lare percentage of black women, leading to less consumption of dairy products with calcium and vitamin D; less likely to receive medication for prevention and treatment; and less likely to engage in physical therapy after a fracture.59 The risk of developing breast, uterine, and ovarian cancers varies depending on several factors such as age, family history, and lifestyle choices. However, the combined risk of developing these cancers is not equivalent to the risk of osteoporotic fractures.

Table 2. The Bone Health & Osteoporosis Foundation Guidelines indicate BMD Testing for:

  • Women age 65 years and older
  • Men age 70 years and older
  • Anyone who has broken a bone after age 50 years
  • Women age 50-64 years with risk factors*
  • Men age 50-69 years with risk factors*
*Examples of risk factors for osteoporosis and fractures include family history of osteoporosis and/or fracture, frequent falling, vitamin D deficiency, smoking, excessive alcohol intake, malabsorption, and some medications, such as prednisone.

Morbidity rates are reported to occur more from hip fractures, and mortality rates occurring after hip fractures are up to 24% in the first year from the fracture;58 for at least 5 years afterwards a greater risk of death may exist. Loss of independence and function can be profound among survivors along with the inability to walk independently. For those ambulatory prior to the hip fracture, now one in five require some form of long-term care. Up to six months following the fracture incidence, 85% require assistance in walking across the room and 33% are solely dependent on nursing home care for one year. Among women over 45 years of age, osteoporosis accounts for more days being spent in hospitals than any other disease including diabetes, myocardial infarction, and breast cancer.58 As indicated by statistics across Asia, Europe, Latin America and North America (Figure 9), osteoporosis and its associated morbidity is a growing concern worldwide.

Charts showing osteoporosis – Global Spotlight on Latin America, North America, Europe and Asia

Figure 9. Osteoporosis – Global Spotlight on Latin America, North America, Europe and Asia.

United States

According to the International Osteoporosis Foundation, osteoporosis and low bone mass are currently estimated to be a major public health threat for almost 54 million U.S. women and men aged 50 and older (2010 data). Among the 54 million, 10.2 million adults are estimated to have osteoporosis, of which more than 80% were women. Economic burden was estimated at 17 billion USD in 2005. In a study based on almost 380,000 fractures in female Medicare beneficiaries, 10% had another fracture within 1 year, 18% within 2 years, and 31% within 5 years.61 Broken bones and serious falls in age 50 and over is the first sign of low bone density and often osteoporosis related.60 According to a study by Harvard Medical School, the number of hip fractures worldwide is projected to nearly double by 2050 compared to 2018. The study reviewed more than 4 million cases and highlights an urgent need for better strategies in hip fracture prevention and care. Hip fracture remains a global public health concern contributing to increased dependency, morbidity, and mortality and placing a burden on patients, their families, and health care systems.62

The International Osteoporosis Foundation (IOF) reported that the age-standardized incidence rates in females in Europe ranged from 246 in Romania in 2005–2009 to 677 in Denmark in 2004, per 100,000 population. Compared with Europe, countries in Asia reported lower age-standardized incidence rates in females, ranging from 133 in Philippines in 2001–2005 to 355 in Taiwan in 1996–2000, per 100,000 population. Stable or declining trends have been reported in Europe, Oceania, and North America, but increasing trends have been observed in Asia. Overall, 4,115,046 hip fractures were identified from 20 databases. Over 70% of fractures occurred in females and more than 40% occurred in people aged ≥85 years.62

All of the data reported and reviewed reported incidence rates of hip fractures. The highest age- and sex-standardized incidence rate per 100,000 population was observed in Denmark (315.9), followed by Singapore (314.2) and Taiwan (253.4) (Table 2 and Fig. S1), and the lowest incidence rate was observed in Brazil (95.1), followed by Thailand (95.2) and the UK (134.0). 54b The age-standardized incidence rates were higher in females than in males in all populations. The incidence of hip fractures increased markedly with increasing age.62

All databases contributed to the projected number of hip fractures in 2030, 2040, and 2050. Excluding Japan and the US Medicare populations, the total number of hip fractures in all databases projected in 2050 is nearly double the number in 2018 (1.9-fold increase).56 Surprisingly, the increase in males (2.4-fold increase) was relatively larger than that in females (1.7-fold increase) (Table 4), and only in Denmark had fewer projected hip fractures in 2050 than in 2018.62