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Osteoporosis: Identification of High Risk Individuals
Leonard Koh
Consultant Physician & EndocrinologistGleneagles Medical Centre
Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
Regional distribution of hip fractures in women 65 years (%)
2050
20.9
Asia Europe N America Latin America
Russia Middle East Oceania Africa
31.2
28.6
7.1
8.82.3
0.80.2
51.1
13.0
11.9
12.5
4.45.7 0.7 0.6
1990
Cooper, Osteoporos Int 1992;2:285
Population Women
ASIANS• Singapore 1991-98 402• Singapore 1955-62 75• Malaysia 1997-98 199• Malaysia 1989 108• California 1983-84 337
CHINESE• Singapore 1991-98 410• Singapore 1957-63 106• Hong Kong 1997-98 429• Hong Kong 1966 149• Taiwan 1996-2000 451• Shenyang 1994 87• Beijing 1990-92 96
MALAY• Singapore 1991-98 264• Singapore 1957-63 44
INDIAN• Singapore 1991-98 361• Singapore 1957-63 565
Age-adjusted* hip fracture incidence rates per 100,000 in 50 year olds
* to 1985 US population
Population Women
JAPANESE• Wakamaya 1992 332• Tottori 1998-2001 304• Tottori 1986-87 206• Okinawa 1984-85 287• Hawaii 1979-81 247
KOREAN• Honam 2001 176• Honam 1991 41
THAI• Chiang Mai 1997-98 251
ARAB
• Kuwait 1992-95 295• Shiraz 2000-03 505
CAUCASIAN• California 1983-84 553• Hawaii 1979-81 579• Stockholm 1972-81 622
Hip Fractures in Singapore 1991-1998
Koh, Osteoporos Int 2001:12:311-8** 50 year olds, standardized to 1985 US population
168
410
71
264
128
361
0
50
100
150
200
250
300
350
400
450 Chinese
Malay
Indian
Inci
den
ce r
ate
pe
r 1
00,0
00
**
(95%
co
nfid
enc
e in
terv
als)
Males Females
* p<0.05
* **
*
Bone density & hip geometry in a multiracial population
Goh, J Clin Densitom 2004;7:406-412
• n=1575: Chinese 1222 (77.6%), Malays 122 (7.7%), Indian 231 (14.7%)• age 20-59 yr
* p < 0.05
0.941
0.879
0.967
0.888
0.9460.968
0.5
0.7
0.9
1.1
Chinese Malay Indian
20 - 29 yr 50 - 59 yr
Age group (yr)
Fe
mo
ral n
eck
BM
D (
g/c
m2) **
9.879.67 9.69
8
9
10
11
CH MA INH
ip a
xis
len
gth
(cm
)
*
*
Borgstrom, Osteoporos Int 2006;17:1459-71
Hip fracture risk among women in the general population
Barrett-Connor, JBMR 2005;20:185-94
Ethnic differences in fracture risk
National Osteoporosis Risk Assessment (NORA)
Mean T-score (SD) -0.89 -0.39 -1.12 -1.13 -1.22
Incidence of 1.5 0.8 1.8 1.7 0.7all fractures (%)
1 0.55 0.96 1.2 1.051 0.52 0.87 0.95 0.320
0.2
0.4
0.6
0.8
1
1.2
1.4
Caucasian African-American
NativeAmerican
Hispanic-American
Asian-American
Odds of osteoporosis
Relative risk of fracture
Odd
s /
Rel
ativ
e ris
k
Falls among Asian vs Caucasian women
Davis, J Clin Epidemiol 1997;50:589-94. Aoyagi, J Bone Miner Res 1998;13:1468-74
Reference Population Risk ratios (95% CI)
Prudham 1981 65 yr+, Northeast UK 1.8 (1.6-2.1)
Blake 1988 65 yr+, Nottingham UK 2.2(1.9-2.6)
Wickham 1989 65 yr+, National UK 2.2 (1.9-2.6)
Winner 1989 Postal survey, Oxford, UK 1.4 (1.1-1.7)
Campbell 1989 70 yr+, New Zealand 1.8 (1.5-2.2)
O’Loughlin 1993 65 yr+, Montreal, Canada 1.4 (1.1-1.8)
Lukinen 1994 70 yr+, Finland 1.8 (1.4-2.1)
Davis 1997 Japanese, Hawaii, USA 0.8 (0.6-1.1)
Aoyagi 1998 65 yr+, Mitsui-gun, Japan 1.0
Costs of osteoporosis
• Mortality
• Morbidity
• Economic
• Social
Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
Definition
NIH Consensus Development Panel 2001
Osteoporosis:bone disorder
Reducedbone strength
Increasedfracture risk
Bone density
DXA hip & spine
+ Bone quality
?
Kung, J Bone Miner Res 2007;22:1080-7
Ten-year probability of osteoporotic fractures in Chinese women according to risk factors & BMD
• 1435 community dwelling, post-menopausal women• Mean age 63 years
Bone mass life-line
0 10 20 30 40 50 60 70
BO
NE
MA
SS
Full genetic potential Menopause
Inadequate environmental factors High fracture risk
AGE
modified from Heaney, Osteoporos Int 2000
HEREDITY
EXERCISE / LOADING
CALCIUM & VIT D INTAKE
STRUCTURAL ERRORS
Increased bone loss
Determinants of BMD
Pre-menopausal Post-menopausal p
Subject number 262 269 -
Age (yr) 33 65 <0.0001
Height (cm) 159 152 <0.0001
Weight (kg) 54 55 ns
Age at menarche (yr) 13 15 <0.0001
Age at menopause (yr) - 49 -
Calcium intake (mg/d) 605 635 ns
Isoflavone intake (mg/d) 33 25 ns
Smoker % 4 3 ns
Drinker % 7 1 <0.05
Physical activity score 3.4 3.5 ns
LS BMD (g/cm2) 0.977 0.733 <0.0001
FN BMD (g/cm2) 0.744 0.597 <0.0001
Lau, Bone 2005;36:700-9
ER, ER, CASR, COLIA1, LRP5, VDR
Premenopausalwomen
Postmenopausalwomen
Determinants of BMD
Lau, Bone 2005;36:700-9
80.6
15.9
3.5
Weight
Genetic
Age
Menarche age
Calcium intake
Others4.4
2.2
25.1
68.3
LS BMD LS BMD
24.3
75.7
14.158.8
23
1.10.7
FN BMD FN BMD
Factors affecting bone mass
Other (weight, medication, etc)
Exercise
Calcium deficiencyHeredity
Heaney, AJCN 1991 Pocock JCI 1987, Pocock JCI 1986, Kelly BMJ 1990
Specker, Am J Clin Nutr 2000
Heredity75-80%
Diet40%
Exercise40% Other (weight,
medication, etc)
Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
Risk factors for low bone mass & fracture:� Personal history of fracture as an adult� History of fracture in a first degree relative (especially maternal)� Low body weight & older age � Early natural or surgical menopause (< 45 yr), prolonged amenorrhea >1 yr� Drugs e.g. corticosteroids, excess thyroxine, anticonvulsants� Ongoing disease e.g. hypogonadism, rheumatoid arthritis, malabsorption� Prolonged immobilization, poor health or frailty� Current cigarette smoking� Alcohol abuse� Lifelong low calcium intake � Lack of regular physical activity
Risk factors for fracture independent of bone mass:� Previous falls in the past year� Strokes, poor balance, weak quadriceps muscle strength� Impaired eyesight despite adequate correction� Drugs e.g. sedatives, polypharmacy� Environmental factors e.g. slippery floors, inadequate lighting
Risk Factors for Osteoporosis
MOH CPG 2002
Measure BMD
More risk factors for osteoporosis
More likely to have osteoporosis
Bone densitometry indications Prevalence (%)Prolonged amenorrhea <1Late puberty after age 15 yr 5.6Menopause before age 45 yr 19.2Menopause after age 45 yr with 2 or more additional risk factors 44.1 (No HRT, FHx OP, BMI<25, cigarettes>10/d, alcohol>4 glasses/d,
physical activity<30 min/d, low calcium diet)Hypogonadism <1History of non-traumatic fractures <1Fortuitous discovery of osteopenia <1History of diseases affecting the skeleton 6.9History of long-term immobilization (>3 mth) <1Long-term use of medication affecting the skeleton 12.8
Use of risk factors in screening for osteoporosis
• n =3,998, female 92%, age ~60 yr
• Prevalence of osteoporosis: FN 23%, LS 23%, any site 31%
Ben Sedrine, Osteoporos Int 2002;13:434-442
Presence of at least one risk factor 66.6
Probability of having osteoporosis with at least one risk factor : 35%
Probability of having osteoporosis with 2 or more risk factors : 36%
Year Instrument Factors used in scoring system
1992 Ribot et al age, wt, ht, age at menarche, menopause, yr since menopause, OA
1998 NOF age 65 or age <65 & one of: low wt, # after age 40, FHx #, smoking
1998 SCORE age, wt, race, RA, # after age 45, estrogen
1998 SOFSURF age, wt, smoking, # after age 50
2000 ORAI age, wt, no estrogen
2000 ABONE age, wt, never estrogen
2001 OSTA / OST age, wt
2002 OSIRIS age, wt, prior #, estrogen
2004 DOEScore age, wt, prior #
Scoring systems to select postmenopausal women for BMD
Osteoporosis Self-assessment Tool for Asians
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
45-49 50-54 55-59 60-64 65-69 70-74 75-7940-44
Weight (kg)
Age(yr)
LOW RISK*probability 1 - 3%
HIGH RISK*probability 46 - 61%
MODERATE RISK*probability 10 - 15%
* probability of finding osteoporosis on BMD
Koh, Osteoporos Int 2001;12:699
RISK FACTORS
� Previous fracture
� Family history of fracture
� Poor health & frailty
� Cigarette smoking
� Early menopause
� Alcohol abuse
� Prolonged immobilization
� Drugs e.g. corticosteroids
� Ongoing disease
Send for DXA+ risk factors
Truncate [Weight (kg) x 0.2] – Truncate [Age (yr) x 0.2]Truncate 0.2 x [Weight (kg) – Age (yr)]
-1
-2
-3
-4
-5
-6
0 1 3 4 5 62
Osteoporosis Self-Assessment Tool (OST) Validation
Author Study population Cut-offs Low risk Medium risk High risk
Koh 2001 8 Asian countries -1, -4 3 15 61
Japan -1, -4 1 10 44
Koh 2001 Singapore -1, -4 1 10 46
Saetung 2008 Thailand -1, -4 2 6 40
Geusens 2002 USA multicentre 1, -3 4 23 57
Rotterdam 1, -3 4 22 57
Richy 2004 Belgium 1, -3 6 22 60
Cadarette 2004 Canada (chart) 1, -3 4 17 58
Canada (equation) 1, -3 2 19 56
Gourlay 2005 Belgium (45-64 yr) 3, -2 1 6 28
Belgium (65 yr) 1, -5 3 16 57
Percent with osteoporosison FN BMD (%)
What OSTA/OST does and does not do
Guides decision to do BMD
Does not guide lifestyle decisions
Does not guide decision to treat
van Staa, Q J Med 2006;99:673
THIN index
FRACTURE index
Rotterdam risk score
Body weight criteria
ORAI
OST
Clinical score for estimating 5-year hip fracture risk
Risk factors for THIN index:Age, fracture history, fall history, BMI, smoking,chronic disease, CNS meds, early menopause
“A simple scheme that only included age and weight (the Osteoporosis Self-Assessment Tool) found (hip) fracture risks similar to our more complex scheme.”
Prevalence of vertebral deformities according to OSTA index group
Saetung, J Bone Miner Metab 2008;26:47
19.2
7.9
2.8
0
2
4
6
8
10
12
14
16
18
20
High risk Medium risk Low risk
Pre
vale
nce
(%)
Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
Risk factors for hip fracture in women
Asian Osteoporosis Study
• (451 men) & 725 women with hip fractures• Age 50 yr and over• Singapore, Malaysia, Thailand, Philippines
Risk factor Risk ratio (95% CI)
Dietary calcium intake
Highest quartile 1.0
Lowest 3 quartiles (<498 mg/d) 2.0 (1.5-2.8)
Load-bearing activity in immediate past
Everyday 1.0
Weekly 1.1 (0.7-1.7)
None 2.0 (1.4-2.7)
Vigorous sports activity at 25-49 yr (no vs yes) 7.2 (4.0-13.0)
Smoking (Ex- or current vs non-) Not included
Alcohol (7 days/wk vs non-) 2.9 (1.0-8.6)
Lau, JBMR 2001;16:572-80
Risk factors for hip fracture in women
Risk factor Risk ratio (95% CI)
Falls in last 12 months: None 1.0
Once 1.4 (0.9-2.1)
Twice or more 3.0 (1.8-4.8)
History of fractures from age 50 yr (yes vs no) 1.8 (1.1-2.9)
History of stroke (yes vs no) 3.8 (2.0-7.1)
Drug history: Sedatives 2.5 (1.0-6.3)
Thyroid drugs 7.1 (2.0-25.9)
Body height quartile:
highest (men ≥1.69m, women ≥1.56m) vs
lowest (men <1.59m, women <1.48m) 2.0 (1.3-3.0)
Age at menopause 1.5 (1.0-2.1)
Lau, JBMR 2001;16:572-80
Asian Osteoporosis Study
Kung, J Bone Miner Res 2007;22:1080-7
Ten-year probability of osteoporotic fractures in Chinese women according to risk factors & BMD
Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
Definition BMD T-score Action
Normal -1 SD Repeat BMD after a time interval
Osteopenia -1 to -2.5 SD Consider prevention. With multiple risk factors: consider treatment
Osteoporosis -2.5 SD Consider treatment
Severe Osteoporosis
-2.5 SD + fracture Advisable to treat
Most guidelines*
Treatment based on BMD & Fractures
* NOF, AACE, EFFO, UK, Australian, Singapore, Malaysia
Definition BMD T-scoreat baseline
Treatments shown to reduce vertebral fractures
Normal -1 SD nil
Osteopenia -1 to -2.5 SD• Unselected• <-1.5 SD
HRT** RLX, STR
Osteoporosis -2.5 SD, no fracture ALN*, RIS*, RLX, STR
Severe osteoporosis Vertebral fracture ALN**, RIS**, ZOL**, STR**, RLX, PTH*, HRT*, IBNETI, CTN, PAM
Results of Treatment Trails by BMD & Fractures
Multiple clinical riskfactors for fracture
If BMD not known nil
* also reduce non-vertebral fractures** also reduce non-vertebral and hip fractures
Subgroup:elderly, osteoporotic
-2.5 SD, no fracture, Age 80 yr
STR*, RIS, PTH
Wainwright, J Clin Endocrinol Metab 2005;20:1185-94
Hip fracture and BMD
Study of Osteoporotic Fractures
54% of women with incident hip fractures (n=243) did not have
osteoporosis
17% of women (n=8065)had osteoporosis
Proportion with
fractures 8.2%
Proportion with fractures
2.0%
Better way to assess fracture risk?
2.4
3.2
4.3
4.6
4.0
2.6
4.2
4.5
1.8
3.0
4.1
5.5
6.0
5.0
3.3
5.4
5.8
2.3
3.8
5.1
7.1
7.7
6.3
4.1
7.0
7.4
2.8
4.7
6.5
9.0
9.9
8.0
5.3
9.1
9.4
3.5
5.9
8.2
11.5
12.7
10.0
6.7
11.8
12.0
4.3
7.4
10.4
14.6
16.2
12.6
8.5
15.2
15.3
5.6
9.2
13.0
18.3
20.5
15.6
10.7
19.4
19.1
6.6
11.3
16.2
22.8
25.6
19.3
13.4
24.5
23.8
8.1
14.1
20.2
28.4
31.8
23.9
16.8
30.8
29.4
10.0
21.3
30.6
42.3
46.4
35.5
26.0
46.2
42.7
15.0
2.4
3.2
4.3
4.6
4.0
2.6
4.2
4.5
1.8
3.0
4.1
5.5
6.0
5.0
3.3
5.4
5.8
2.3
3.8
5.1
7.1
7.7
6.3
4.1
7.0
7.4
2.8
4.7
6.5
9.0
9.9
8.0
5.3
9.1
9.4
3.5
5.9
8.2
11.5
12.7
10.0
6.7
11.8
12.0
4.3
7.4
10.4
14.6
16.2
12.6
8.5
15.2
15.3
5.6
9.2
13.0
18.3
20.5
15.6
10.7
19.4
19.1
6.6
11.3
16.2
22.8
25.6
19.3
13.4
24.5
23.8
8.1
14.1
20.2
28.4
31.8
23.9
16.8
30.8
29.4
10.0
21.3
30.6
42.3
46.4
35.5
26.0
46.2
42.7
15.0
Kanis, Osteoporos Int 2001;12:989-95
Ten-year probability of any osteoporotic fracture (hip, spine, forearm, humerus) according to BMD
Swedish women
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
50
60
70
80
65
55
75
85
45
Ag
e (y
r)
Age-adjusted* hip fracture incidence rates per 100,000 in 50 year olds
Population Women
JAPANESE• Wakamaya 1992 332• Tottori 1998-2001 304• Tottori 1986-87 206• Okinawa 1984-85 287• Hawaii 1979-81 247
KOREAN• Honam 2001 176• Honam 1991 41
THAI• Chiang Mai 1997-98 251
ARAB• Kuwait 1992-95 295• Shiraz 2000-03 505
CAUCASIAN• California 1983-84 553• Hawaii 1979-81 579• Stockholm 1972-81 622
Population Women
ASIANS• Singapore 1991-98 402• Singapore 1955-62 75• Malaysia 1997-98 199• Malaysia 1989 108• California 1983-84 337
CHINESE• Singapore 1991-98 410• Singapore 1957-63 106• Hong Kong 1997-98 429• Hong Kong 1966 149• Taiwan 1996-2000 451• Shenyang 1994 87• Beijing 1990-92 96
MALAY• Singapore 1991-98 264• Singapore 1957-63 44
INDIAN• Singapore 1991-98 361• Singapore 1957-63 565
* to 1985 US population
International variations in hip fracture probabilities
Kanis, J Bone Miner Res 2002;17:1237-44
1.5
2.0
2.7
2.9
2.5
1.6
2.6
2.8
1.1
1.9
2.5
3.4
3.7
3.1
2.0
3.3
3.6
1.4
2.4
3.2
4.4
4.8
3.9
2.5
4.3
4.6
1.7
2.9
4.0
5.6
6.1
5.0
3.3
5.6
5.8
2.2
3.7
5.1
7.1
7.9
6.2
4.2
7.3
7.4
2.7
4.6
6.4
9.1
10.0
7.8
5.3
9.4
9.5
3.5
5.7
8.1
11.3
12.7
9.7
6.6
12.0
11.8
4.1
7.0
10.0
14.1
15.9
12.0
8.3
15.2
14.8
5.0
8.7
12.5
17.6
19.7
14.8
10.4
19.1
18.2
6.2
13.2
19.0
26.2
28.8
22.0
16.1
28.6
26.5
9.3
Extrapolation for Singapore women
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
50
60
70
80
65
55
75
85
45
Ag
e (y
r)
1.5
2.0
2.7
2.9
2.5
1.6
2.6
2.8
1.1
1.9
2.5
3.4
3.7
3.1
2.0
3.3
3.6
1.4
2.4
3.2
4.4
4.8
3.9
2.5
4.3
4.6
1.7
2.9
4.0
5.6
6.1
5.0
3.3
5.6
5.8
2.2
3.7
5.1
7.1
7.9
6.2
4.2
7.3
7.4
2.7
4.6
6.4
9.1
10.0
7.8
5.3
9.4
9.5
3.5
5.7
8.1
11.3
12.7
9.7
6.6
12.0
11.8
4.1
7.0
10.0
14.1
15.9
12.0
8.3
15.2
14.8
5.0
8.7
12.5
17.6
19.7
14.8
10.4
19.1
18.2
6.2
13.2
19.0
26.2
28.8
22.0
16.1
28.6
26.5
9.3
Relative probability for Singapore = 0.62
Ten-year probability of any osteoporotic fracture (hip, spine, forearm, humerus) according to BMD
Based on Swedish data
Kung, J Bone Miner Res 2007;22:1080-7
Ten-year probability of osteoporotic fractures in Chinese women according to risk factors & BMD
1.5 1.9 2.4 2.9 3.7 4.6 5.7 7.0 8.7 13.2
2.0 2.5 3.2 4.0 5.1 6.4 8.1 10.0 12.5 19.0
2.7 3.4 4.4 5.6 7.1 9.1 11.3 14.1 17.6 26.2
2.9 3.7 4.8 6.1 7.9 10.0 12.7 15.9 19.7 28.8
2.5 3.1 3.9 5.0 6.2 7.8 9.7 12.0 14.8 22.0
1.6 2.0 2.5 3.3 4.2 5.3 6.6 8.3 10.4 16.1
2.6 3.3 4.3 5.6 7.3 9.4 12.0 15.2 19.1 28.6
2.8 3.6 4.6 5.8 7.4 9.5 11.8 14.8 18.2 26.5
1.1 1.4 1.7 2.2 2.7 3.5 4.1 5.0 6.2 9.3
50
60
70
80
65
55
75
85
45
Age
(yr
)
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
Extrapolated fromKanis, Osteoporos Int 2001;12:989-95 Kung, J Bone Miner Res 2007;22:1080-7
Ten-year probability of any osteoporotic fracture according to age and BMD
Hong KongExtrapolation for Singapore
Relevant databases for Asians:• China• Japan• US (Asian)
http://www.shef.ac.uk/FRAX/index.htm
Fracture risk for countries other than US
(Asian), Japan & China?
What threshold for intervention?
Are osteoporosis drugs effective based on
clinical fracture prediction models?
Issues
Age
(yr
)
BMD T-score
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
Hong KongExtrapolation for Singapore
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
FRAX (Japan)FRAX: US (Asian)
Age
(yr
)
Wt 54.9 kgHt 152 cm
Any fracture
10%
15%
20%
Any fracture
Absolute 10-year hip fracture risk (vertical bars) at which it is cost-effective to treat (lines) in the USA
Tosteson, Osteoporos Int 2008;19:437-47
0
3
6
9
12
15
50 60 70 80
Age (yr)
10-
yr H
ip F
ract
ure
Pro
bab
ility
, %
Tosteson, Osteoporos Int 2008;19:437-47
Cost-effectiveness thresholds for US white women based on treatment cost and willingness-to-pay (per QALY gained)
Age
(yr
)
BMD T-score
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
Hong KongExtrapolation for Singapore
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
FRAX (Japan)FRAX: US (Asian)
Age
(yr
)
Wt 54.9 kgHt 152 cm
Hip fracture
2%
3%
5%
Any fracture
10%
15%
20%
• Fracture incidence is rising in Asians
Conclusions
• Epidemiological differences in hip fracture risk exist between Asians and other races, and within Asian ethnicities
• Risk factors for low BMD appear similar to other populations, but many occur in a minority
• Risk factors for low BMD could be used in clinical scoring systems as part of screening strategies for detecting osteoporosis
• Risk factors for fracture appear similar to other populations, are quantifiable, and have been used in models to predict 5- to 10- year fracture risk to assist in treatment decisions
• These models need to be tailored for each country
• There are limitations in BMD-based treatment algorithms