20.1

Introduction

Osteoporosis, a disease of old age, is documented to date back to the Bronze age . The demographic explosion, increased life expectancy, global urbanization, and the obesity epidemic are major contributors to the exponential rise in the incidence of chronic noncommunicable diseases (NCDs) and their staggering health burden toll. The World Health Organization identified NCDs as the cause of 71% of the world’s deaths in 2016 . Osteoporosis is no exception to this rising tide, vertebral and hip fractures being the hallmark of this costly disease. Thirty to fifty percent of patients who sustain a hip fracture lose functional dependence, and ten percent fracture the contralateral hip. Previously, survival rates posthip and vertebral fractures were reported to be substantially decreased, by 10%–20% in western countries, and possibly more in developing countries . Recent studies still report an increase by two to eight fold in mortality during the first few months postfracture . A 2019 systematic review on mortality rates 1 year posthip fracture shows a variability between continents ranging from 2.4% to 34.8% .

Although hip fractures only represent 20% of all osteoporotic fractures, they are nevertheless the most serious and costly consequence of osteoporosis and the most reliably identified, because they present to medical attention and require hospitalization, in most regions of the world. Several publications have reported wide geographic differences in age-standardized hip fracture rates worldwide, varying by at least 10-fold . The wide range reported is in part explained by the time frame during which fractures were captured for each specific country, representativeness of population of interest, racial groups and regions captured (urban vs rural), accuracy to identify such fractures, and differences in the reference population used for standardization. Notwithstanding all of the above, the highest rates are still reported in Northern European countries, while the lowest rates are from South Africa and countries from South America.

Conversely, while vertebral fractures are the commonest, accounting for over 50% of all osteoporotic fractures, they are the least well characterized in terms of rates. Unlike hip fractures, the identification of such fractures is not readily available, making accurate characterization of their epidemiology more challenging. Two-third of such fractures are silent, only 10% are hospitalized, and the rates may vary widely depending on whether morphometric and/or clinical fractures were reported . Studies that have evaluated the prevalence of morphometric fractures using the same method have noted much less relative variation in fractures rates between regions of the world, as compared to hip fractures. Prevalence rates varied between 19% and 24% in elderly women from the Middle East, Europe, and North America . Some of the highest rates are from North America and surprisingly Asia . Similar prevalence of morphometric vertebral fractures, of 25%, was also reported in postmenopausal women from three countries in Asia, namely, Hong Kong, Beijing, and Taiwan . Conversely, the mean prevalence of morphometric fractures across countries in the Latin America Vertebral Osteoporosis Study [LAVOS was lower at 15%. Reports on the incidence of vertebral fractures are scarce . Bow et al. reported that vertebral fracture incidence rates were similar or up to twofold higher in Asians (Hong Kong Chinese and Japanese) compared to Swedish Caucasians .

While ageing societies, urbanization, and obesity may in part explain the highest rates of hip fracture previously registered in Northern Europe, America, and Oceania, the demographic and lifestyle changes occurring worldwide are rapidly modifying this landscape. Cooper et al. estimated that the number of hip fractures will increase from 1.66 million in 1990 to 6.26 million in 2050, assuming that age-specific hip fracture rates are stable . However, these authors also reported secular trends in hip fracture rates, and in opposite directions, depending on the region of interest in the world . Indeed, estimates suggest that while hip fracture rates in western regions are stabilizing or are on the decline, they continue to rise in the most populous part of the world, namely, Asia . In 2019 Asia represented 61% of the world population and will still represent 59% in 2050 and thus would account for over half of the total projected number of hip fractures worldwide . The demographic explosion is affecting developing much more than developed countries, regions of the world with the least available, and reliable information on fracture rates worldwide. Indeed, two of the most populous countries in the world, namely, India and Indonesia, have no reliable data on hip fracture rates.

An accurate assessment of fracture rates is critical for the assessment of the contribution of osteoporosis to the health care burden, and the appropriate allocation of health care resources, be it at the country, regional, or global level. Furthermore, reliable country-specific hip fracture rates are essential for the development of country-specific fracture risk assessment tool (FRAX) calculator which serves as a major advancement for the development of a clinical care pathways, guidelines, and public health policies. Accurate crude country-specific fracture rates are helpful to guide countries without FRAX models in their selection of the best surrogate country (country with the closest crude incidence rates of hip fractures and closest life expectancy) with a FRAX model, as recommended by the International Osteoporosis Foundation (IOF)-International Society for Clinical Densitometry (ISCD) Position Statement . For these the use of a surrogate model will help in the estimation of the 10-year major osteoporotic and hip fracture risk. FRAX allows the calculation of a 10-year hip fracture probability or major osteoporotic fracture probability (hip, spine, forearm, and humerus), taking into account an individual risk factor profile or country-specific longevity and fracture incidence rates. As of Jan 2020, there are 65 country-specific FRAX worldwide and 2 specify ethnic-specific calculators; Singapore (with 3) and United States (US with 4) posted on line : 10 countries in Asia; 35 countries in Europe; 9 countries in the Middle East and Africa; 2 in North America; 7 in Latin America; and 2 countries in Oceania (FRAX calculator accessed on-line February 06, 2020; http://www.shef.ac.uk/FRAX/ ).

In this chapter, we review key points captured in the previous chapter version in the Background section and aim to provide updated crude and age-standardized hip fracture rates in countries across the world. We also examine secular trends in such fractures, overview the epidemiology of vertebral fractures, and explore possible factors accounting for variability in such fractures across the world.

20.2

Background on hip fracture incidence

Evidence for substantial variability in the incidence of hip fractures worldwide is supported by numerous country-specific and regional studies. Incidence is highest in the Northern part of the globe (Scandinavia), and lowest in countries from Asia, and some from Southern Europe, Latin America, and South Africa . Within the same region, rates also vary markedly. A study of national register sources in Europe, covering the period between 1979 and 1987, showed an 11-fold variation in the age-standardized hip fracture incidence rates within the same continent, with a North to South gradient . The highest rates were reported in Northern Europe with the exception of Finland, which was found to have rates similar to those reported in countries from central Europe. Similarly, slightly lower rates were observed in central Europe with the exception of Poland, a country with rates similar to those reported in southern Europe. Such North to South trend is not as consistent in this update as will be discussed later. The Mediterranean Osteoporosis Study (MEDOS) reported incidence rates from 12 Mediterranean regions in 1988 . The differences in age-standardized incidence of hip fractures varied more than 4-fold among men and 11-fold among women, with the highest rates observed in Seville, Crete, and Rome approaching those of Northern Europe and the lowest rates in Turkey. A review on geographic trends in the incidence of hip fractures involving 46 publications until 2009, that spanned 33 countries and used rates standardized to the 2005 United Nations estimates of the world population, again showed that the highest rates occurred in Scandinavian countries and the lowest rates in Africa, Latin America, and Asia . However, the following exceptions were noted: in Austria, rates were more similar to those found in Scandinavian than in its neighboring countries.

An extensive review , published in 2012, was based on an update of a systematic search conducted by the FRAX International Task Force 2010 for the Official IOF and ISCD Positions on FRAX and simply added one additional year up until November 2011. It derived age-standardized rates to the 2010 United Nations world population for 63 countries and revealed some unexpected major changes in the landscape for the world map for hip fractures. In Europe, Austria again showed rates in the same range as Scandinavian countries; Turkey had rates close to those in Germany and United Kingdom (UK) and well above those of North America, while Finland, France, Canada, and New Zealand ranged in the lower end of the rates reported for Europe, and close to those reported for several countries in Asia and Latin America. Conversely, age-standardized rates in countries from North America were in the moderate-risk category, and well below those calculated for many South East Asian and Southern European countries. While previously reported to have some of the lowest rates of hip fractures, South East Asia, except for China and Philippines, had rates in the moderate-risk category, while Taiwan fell in the high-risk category. In the Middle-East, Iran and Oman fell in the high-risk category, close to Scandinavian countries, and Lebanon, previously placed at the lower end of risk for hip fractures, was assessed to fall in the moderate-risk category, with rates comparable to the US when combining both genders. In Latin America, Argentina stood out among neighboring countries with rates similar to countries in Central Europe. The above review used the best quality data available for each country and national as compared to regional data in 37 out of 63 countries. When only regional data was available, the average for all the regions was calculated. These findings raise the question about the accuracy of previous epidemiologic data based on which regions and countries were risk-stratified for hip fracture, and whether one is witnessing a true makeover of the world map for the epidemiology of hip fractures, or whether the changes noted above reflect the influence of database selection, the more readily available superior quality of epidemiologic studies in many of the developing countries, the impact of an ageing population worldwide as the target population to which standardization of rates are calculated, or a combination of all of the above.

20.3

Methodology

20.4

Crude hip fracture incidence rates

Table 20.1 provides a summary of age and gender specific crude incidence rates for hip fractures, by continent [(A) Asia, (B) Oceania, (C) Middle East and Africa, (D) Europe, (E) North America, (F) Latin America] and by country. It captures information on the relevant study period and quality of data. For studies/countries providing age and gender specific rates by 5-year age group increments and to avoid excessively lengthy summary tables, only the rates for the 70–74 and 75–79 years age ranges are reported. These specific age groups are selected as the most enriched and thus representative of the population at risk for hip fractures. Similarly, for studies/countries providing rates in 10-year age group, the ranges of 60–69 and 70–79 are considered the most relevant. Invariably, and as expected, crude rates increase with increasing age in both genders ( Table 20.1 ). In general, rates are 1.5–2 fold lower in men than in women, for most age groups, with few exceptions and select age groups, including indigenous Australia, Kuwait, Spain, and Finland. Comparison of rates within the same continent, and exclusively focusing on good-quality studies, show that in Asia the highest age-specific rates for both genders in patients aged 70–74 and 75–79 are in Taiwan , followed by Singapore and Hong Kong . Korea and Japan are comparable for age groups 60–69 years and 70–79 years. In Oceania, previous studies reporting incidence rates in the 1990s in South Eastern Australia and national data from New Zealand showed similar hip fracture rates for the same age groups. However, the more recent data from the same regions do not report rates for the same age groups to allow similar comparisons. Surprisingly, a study in Western Australia , spanning 10 years, reports age-specific rates in nonindigenous residents closer to those in New Zealand; while, rates in indigenous residents are closer to those of Northern Europe ( Table 20.1B ). The authors underscored several risk factors in indigenous populations such as vitamin D insufficiency, diabetes, smoking, excessive alcohol consumption, physical inactivity, as well as their belonging to underserved areas that could potentially account for the higher rates . For the Middle-East and Africa, comparison becomes even more challenging, because fewer countries report data for comparable age groups. However, some studies reported unexpectedly high rates like Saudi Arabia and Oman . While an older study conducted in Shiraz, Iran (2000–03) shows very high rates in both genders for the 70–74 and 75–79 age groups, a more recent study in the same region shows rates more than 50 times lower . Indeed, the previously reported rates were 403/100,000 in men and 932/100,000 in women versus 11/100,000 for men and 15/100,000 for women in the more recent study for the 70–74 age group. This raises concerns about the methodology used in these studies.

Table 20.1

Crude yearly incidence rates of hip fractures by continent, country, gender, and age group in order.

(A) Asia
Country	Reference	Study years	Level of evidence	Rates for men/100,000	Rates for women/100,000
70–74
China a	Wang et al.	2010	F	88	174
	Fa-ming Tian et al.	2015	F
Hong Kong	Tsang et al. d	2000–04	G	212	364
Japan	Hagino et al. b	2004–06	G	124	254
Singapore	Chionh	2007–09	G	228	432
Taiwan	Chen et al. d	2004–11	G	320	480
Thailand	Wongtriratanachai et al.	2006	F	165	389
75–79
China a	Wang et al.	2010	F	167	322
	Fa-ming Tian et al.	2015	F
Hong Kong	Tsang et al. d	2000–04	G	450	831
Japan	Hagino et al. b	2004–06	G	271	621
Singapore	Chionh	2007–09	G	478	896
Taiwan	Chen et al. d	2004–11	G	550	950
Thailand	Wongtriratanachai et al.	2006	F	223	793
60–69
Korea a	Lim et al.	2004	G
	Yoon et al. b	2005–08	G	92	106
	Park et al. b	2001, 2011	G
	Ha et al. d	2008–12	G
Japan	Orimo et al. b	2002, 2007, 2012	G	50	86
70–79
Korea a	Lim et al.	2004	G
	Yoon et al. b	2005–08	G
	Park et al. b	2001, 2011	G	252	401
	Ha et al. d	2008–12	G
Japan	Orimo et al. b	2002, 2007, 2012	G	175	391
65–74
India	Dhanwal et al.	2009	P/F	95	163
75+
India	Dhanwal et al.	2009	P/F	290	375

 

(B) Oceania
60–69
Australia	Brennan et al.	2006–07	G	30	50
Australia, Western	Wong et al. d	1999–2009	G
Indigenous				247	237
Nonindigenous				47	66
70–79
Australia	Brennan et al.	2006–07	G	260	300
Australia, Western	Wong et al. d	1999–09	G
Indigenous				811	588
Nonindigenous				166	337
70–74
New Zealand	Brown et al. f / d	2003–05	G	155	278
75–79
New Zealand	Brown et al. f / d	2003–05	G	357	654

 

(C) Middle-East and Africa
70–74
Iran a	Soveid et al. d	2000–03	F	207	474
	Maharlouei et al.	2011–12	F
Lebanon a	Sibai et al. b	2006–09	G
	Saad et al. b	2006–17	G	88	212
South Africa	Paruk et al.	2010–11	G	50	57
Saudi Arabia	Sadat-Ali et al.	2013	F	491	574
75–79
Iran a	Soveid et al. d	2000–03	F	470	618
	Maharlouei et al.	2011–12	F
Lebanon a	Sibai et al. b	2006–09	G
	Saad et al. b	2006–17	G	195	426
South Africa	Paruk et al.	2010–11	G	171	110
Saudi Arabia	Sadat-Ali et al.	2013	F	628	862
70–74
Morocco a	El Maghraoui et al.	2002	F	144	141
	El Maghraoui A et al. d	2006–09	F
75+
Morocco a	El Maghraoui et al.	2002	F	254	295
	El Maghraoui et al. d	2006–09	F
60–69
Kuwait	Azizieh b	2009–12	G	90	136
70–79
Kuwait	Azizieh b	2009–12	G	380	316
60–69
Oman	Shukla et al. b	2002–07	F	170	310
70+
Oman	Shukla et al. b	2002–07	F	720	730

 

(D) Europe
70–74
Austria	Dimai et al. b	2000–08	G	280	469
Armenia	Lesnyak et al. c	2011–13	G	190	210
Czech	Stepan et al.	2008–09	G	260	383
Denmark	Abrahamsen et al. b	2000–06	G	350	684
France	Couris et al.	2004	G	145	277
Germany	Icks et al. b	2000–04	G	205	369
Hungary	Pentek et al. d	1999–2003	G	212	351
Iceland	Siggeirsdottir et al. d	1989–2008	G	239	453
Ireland a	Dodds et al. d	2002–04	G	171	365
	Karayiannis et al. b	2001, 2011	G
Italy	Piscitelli et al.	2008	G	167	371
Lithuania	Tamulaitiene et al.	2010	F	230	261
The Netherlands a	Lalmohamed et al.	2004–05	G	138	240
	Klop et al. d	2002–11	G
Norway a	Emaus et al. d	1994–2008	G	360	600
		1999–2003
	Søgaard et al. c	2004–08 2009–13	G
Poland	Czerwinski et al.	2005	F	125	168
Portugal	De Pina et al. d	2000–02	G	132	316
Romania	Grigorie et al.	2010	F	219	283
Russia	Lesnyak et al.	2008–09	G	251	273
Spain	Azagra et al. b	2000–10	G	262	124
Sweden	Bergstrom et al.	2001–05	F/G	269	590
Switzerland a	Lippuner et al.	2000	G	216	403
	Lippuner et al. b	2000–07	G
Turkey	Tuzun et al.	2009	F	137	257
United Kingdom	van der Velde R.Y. et al. b / g	2000–12	G	94	207
75–79
Austria	Dimai et al. b	2000–08	G	514	964
Armenia	Lesnyak et al. c	2011–13	G	258	386
Czech	Stepan et al.	2008–09	G	507	876
Denmark	Abrahamsen et al. b	2000–06	G	673	1317
France	Couris et al.	2004	G	302	621
Germany	Icks et al. b	2000–04	G	376	797
		2008–09
Hungary	Pentek et al. d	1999–2003	G	487	695
Iceland	Siggeirsdottir et al. d	1989–2008	G	395	892
Ireland a	Dodds et al. d	2002–04	G	382	812
	Karayiannis et al. b	2001, 2011	G
Italy	Piscitelli et al.	2008	G	351	774
Lithuania	Tamulaitiene et al.	2010	F	330	484
The Netherlands a	Lalmohamed et al.	2004–05	G	254	446
	Klop et al. d	2002–11	G
Norway a	Emaus et al. d	1994–2008	G	657	1199
	Søgaard et al. c	1999–2003
		2004–08 2009–13	G
Poland	Czerwinski et al.	2005	F	199	320
Portugal	De Pina et al. d	2000–02	G	269	649
Romania	Grigorie et al.	2010	F	311	490
Russia	Lesnyak et al.	2008–09	G	278	487
Spain	Azagra et al. b	2000–10	G	259	611
Sweden	Bergstrom et al.	2001–05	F/G	657	1061
Switzerland a	Lippuner et al.	2000	G	434	835
	Lippuner et al. b	2000–07	G
Turkey	Tuzun et al.	2009	F	191	722
United Kingdom	van der Velde et al. b / g	2000–12	G	197	439
60–69
Estonia	Jürisson et al. b	2005–12	G	173	107
Finland	Lonnroos et al.	2002–03	F	125	70
Greece	Lyritis et al. b	2002, 2007	F	88	165
Spain	Sosa et al. d	2007–11	G	55	77
70–79
Estonia	Jürisson et al.	2005–12	G	319	368
Finland	Lonnroos et al.	2002–03	F	479	523
Greece	Lyritis et al. b	2002, 2007	F	294	639
Spain	Sosa et al. d	2007–11	G	161	348
65–74
Slovenia	Dzajkovska et al.	2003	F	NA	308
United Kingdom	Wu et al. b	2000–09	G	102	209
Finland	Korhonen et al. b	2000, 2005, 2010	G	225	250
75–84
Slovenia	Dzajkovska et al.	2003	F	NA	900
United Kingdom	Wu et al. b	2000–09	G	399	907
France	Briot et al. b	2002–13	G	362	792
Finland	Korhonen et al. b	2000, 2005, 2010	G	725	1136
65–74
Italy	Piscitelli et al. b	2000–05	G	149	322
75+
Italy	Piscitelli et al. b	2000–05	G	848	1835
65–79
Sweden	Nilson et al. b	2000–09	G	346	714
80+
Sweden	Nilson et al. b	2000–09	G	2106	3514

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