Osteoporosis Int (1992) 2:267-268 © 1992European Foundation for Osteoporosis
Osteoporosis International
Editorial
The Growing Problem of Osteoporosis
The public health impact of osteoporosis has been recognised only- comparatively recently. Since osteoporosis is primarily a disorder of the Caucasian female population it has generally been implied from the epidemiological data that the greatest impact would be felt in countries with a primarily white population. Cummings [1], basing his argument upon conservative data, indicated, for example, that in the USA the aging of the population would result in a dramatic increase in the cost of osteoporotic fractures early in the twentyfirst century. Costs would be expected to increase from $7 billion in 1986 to $62 billion by the year 2020. It is not clear how the USA could afford such an increase if it were indeed to occur, even though the USA is still one of the richer countries in the world. Medicare, the system of health care that pays for the majority of the care of the aged population in the USA, is already experiencing fiscal woes and the growth rate in Medicare spending is insufficient to encompass the proposed increases in fracture rate expected among the elderly. A feature, however, that is often forgotten is the growth in the population in other parts of the world. The aging of the population in the USA and Europe will presumably follow similar trends in the Asian and African continent. Although osteoporosis is less frequent among these populations the growth rate will mean a significant increase in the world's fracture load, as noted in an analysis of the world impact of osteoporosis in the current issue of this journal [2]. The authors used age- and sex-specific incidence rates for hip fracture from Africa, Latin America and Asia to assess the global impact of fractures up to the year 2050. The conclusions are staggering. The growth of the elderly is most marked in Asia and it is there that the greatest increments in hip fracture are projected. Currently the authors estimate that 0.5 million hip fractures occur each year in Asia, or 31% of the global load. By 2050, based on population growth rates, this figure will
increase to 3.25 million fractures per year, or 51% of the expected 6.26 million. In contrast Europe and North America will contribute 0.7 and 0.3 million to the final fracture figure. There are those who doubt the size of the problem, but it is not one that we can afford to ignore, even if the magnitude is in doubt. In recent years the age-specific incidence of hip fracture has been found to be increasing in North America and Europe. Recent data suggest that that trend has changed and that age-specific incidences are now steady. This may not be true in the developing countries, and the figures suggested here might be an underestimate of the true magnitude of the problem. As the authors point out the costs of caring for these patients would be excessive for relatively affluent countries, but impossible for those less affluent segments of the world where the magnitude of increase is greatest. It would be more appropriate to utilize programs in public health to reduce the risk, but no proven strategies for this exist. We urgently require evaluatioJa of nutritional and lifestyle changes that could retard the loss of bone with age. In addition, strategies to reduce the risk of falling and injury among the elderly seem likely to lend themselves to use on a population basis. The most probable candidate appears to be increased physical activity, but the hope of effecting this on a general basis is unrealistic. Devices that are worn to reduce the effects of impact in a fall are currently being evaluated. Reduction in injury risk by modifying the external environment (for example by improving lighting, eliminating trailing cords, and slippery floors and baths) has yet to be proven effective, and would require to be tested in a population-specific way, since extrinsic hazards would be expected to vary across the world. In the United States there are available only two therapeutic approaches to osteoporosis, namely estrogen and salmon calcitonin. Other strategies are variably available elsewhere, including fluoride, bis-
268
phosphonates, intranasal calcitonin and anabolic agents. Several of these are under clinical investigation in the USA, including several of the bisphosphonates. The rigor with which these agents are tested prior to marketing varies considerably throughout the world. However, two important lessons are clear from the data available. First it is clear that prevention is likely to be more effective than therapy for the established disease, for although intervention at any stage appears to prevent further loss of bone and in some circumstances may even replace lost bone, the biomechanical competence of that bone remains in doubt. Further neither therapeutic approach will straighten the spine of the kyphotic patient. Secondly, a greater choice of therapeutic approaches is clearly required, for the postmenopausal population as well as those presenting with other forms of osteoporotic skeletons. It is important, there-
Editorial
fore, in evaluating health care needs for the next century that we not only plan for the increase in disorders of aging such as osteoporosis that are likely to occur, but also develop strategies that address the health care issues prevalent in those geographic areas where the increase is greatest - often, as we see here, those areas least equipped to deal with the problem. Robert Lindsay
Editor-in-Chief References 1. Cummings SR, Rubin SM, Black D. The future of hip fractures in the United States. Clin Orthop Ref Res 1990;252:163-76. 2. Cooper C, Campion G, Melton LJ, III. Hip fractures in the elderly: a world-wide projection. Osteoporosis Int 1992;2:285-9.
Osteoporosis International
Editorial
The Growing Problem of Osteoporosis
The public health impact of osteoporosis has been recognised only- comparatively recently. Since osteoporosis is primarily a disorder of the Caucasian female population it has generally been implied from the epidemiological data that the greatest impact would be felt in countries with a primarily white population. Cummings [1], basing his argument upon conservative data, indicated, for example, that in the USA the aging of the population would result in a dramatic increase in the cost of osteoporotic fractures early in the twentyfirst century. Costs would be expected to increase from $7 billion in 1986 to $62 billion by the year 2020. It is not clear how the USA could afford such an increase if it were indeed to occur, even though the USA is still one of the richer countries in the world. Medicare, the system of health care that pays for the majority of the care of the aged population in the USA, is already experiencing fiscal woes and the growth rate in Medicare spending is insufficient to encompass the proposed increases in fracture rate expected among the elderly. A feature, however, that is often forgotten is the growth in the population in other parts of the world. The aging of the population in the USA and Europe will presumably follow similar trends in the Asian and African continent. Although osteoporosis is less frequent among these populations the growth rate will mean a significant increase in the world's fracture load, as noted in an analysis of the world impact of osteoporosis in the current issue of this journal [2]. The authors used age- and sex-specific incidence rates for hip fracture from Africa, Latin America and Asia to assess the global impact of fractures up to the year 2050. The conclusions are staggering. The growth of the elderly is most marked in Asia and it is there that the greatest increments in hip fracture are projected. Currently the authors estimate that 0.5 million hip fractures occur each year in Asia, or 31% of the global load. By 2050, based on population growth rates, this figure will
increase to 3.25 million fractures per year, or 51% of the expected 6.26 million. In contrast Europe and North America will contribute 0.7 and 0.3 million to the final fracture figure. There are those who doubt the size of the problem, but it is not one that we can afford to ignore, even if the magnitude is in doubt. In recent years the age-specific incidence of hip fracture has been found to be increasing in North America and Europe. Recent data suggest that that trend has changed and that age-specific incidences are now steady. This may not be true in the developing countries, and the figures suggested here might be an underestimate of the true magnitude of the problem. As the authors point out the costs of caring for these patients would be excessive for relatively affluent countries, but impossible for those less affluent segments of the world where the magnitude of increase is greatest. It would be more appropriate to utilize programs in public health to reduce the risk, but no proven strategies for this exist. We urgently require evaluatioJa of nutritional and lifestyle changes that could retard the loss of bone with age. In addition, strategies to reduce the risk of falling and injury among the elderly seem likely to lend themselves to use on a population basis. The most probable candidate appears to be increased physical activity, but the hope of effecting this on a general basis is unrealistic. Devices that are worn to reduce the effects of impact in a fall are currently being evaluated. Reduction in injury risk by modifying the external environment (for example by improving lighting, eliminating trailing cords, and slippery floors and baths) has yet to be proven effective, and would require to be tested in a population-specific way, since extrinsic hazards would be expected to vary across the world. In the United States there are available only two therapeutic approaches to osteoporosis, namely estrogen and salmon calcitonin. Other strategies are variably available elsewhere, including fluoride, bis-
268
phosphonates, intranasal calcitonin and anabolic agents. Several of these are under clinical investigation in the USA, including several of the bisphosphonates. The rigor with which these agents are tested prior to marketing varies considerably throughout the world. However, two important lessons are clear from the data available. First it is clear that prevention is likely to be more effective than therapy for the established disease, for although intervention at any stage appears to prevent further loss of bone and in some circumstances may even replace lost bone, the biomechanical competence of that bone remains in doubt. Further neither therapeutic approach will straighten the spine of the kyphotic patient. Secondly, a greater choice of therapeutic approaches is clearly required, for the postmenopausal population as well as those presenting with other forms of osteoporotic skeletons. It is important, there-
Editorial
fore, in evaluating health care needs for the next century that we not only plan for the increase in disorders of aging such as osteoporosis that are likely to occur, but also develop strategies that address the health care issues prevalent in those geographic areas where the increase is greatest - often, as we see here, those areas least equipped to deal with the problem. Robert Lindsay
Editor-in-Chief References 1. Cummings SR, Rubin SM, Black D. The future of hip fractures in the United States. Clin Orthop Ref Res 1990;252:163-76. 2. Cooper C, Campion G, Melton LJ, III. Hip fractures in the elderly: a world-wide projection. Osteoporosis Int 1992;2:285-9.
![[A growing problem worldwide].](/assets/img/hold.png)
