Epidemiology of Osteoporosis

Osteoporos Int (1999) Suppl.
2:S2–S8
ß 1999 International Osteoporosis Foundation and National Osteoporosis Foundation
Osteoporosis
International
Epidemiology of Osteoporosis
C. Cooper
MRC Environmental Epidemiology Unit, University of Southampton, Southampton, UK
Introduction prospective studies have shown that the risk of

osteoporotic fracture increases continuously and pro-
gressively as BMD declines. Fracture risk increases 1.5-
Osteoporosis is currently defined as a systemic skeletal to 3-fold for each standard deviation fall in BMD [2].
disorder characterized by low bone mass and micro- However, there does not seem to be a cutoff threshold
architectural deterioration of bone tissue, with a value for BMD above which the risk is stable.
consequent increase in bone fragility and susceptibility
to fracture. Historically, osteoporosis and its sequelae
were recognized by Sir Astley Cooper over 150 years Fracture Epidemiology
ago, when he observed that hip fractures might result
from an age-related reduction in bone mass or quality. Fracture incidence in the community is bimodal, with
However, the term ‘osteoporosis’ first entered medical peaks in youth and in the very elderly [3,4]. In young
parlance in France and Germany in the nineteenth people, fractures of the long bones predominate, often
century, where it was coined as a histologic description following substantial trauma, and the incidence is greater
for aged human bone, emphasizing the apparent porosity in young men than in young women. Above the age of
in the tissue. The histologic term subsequently evolved 35 years, overall fracture incidence in women climbs
to discriminate this condition from that of osteomalacia, steeply, so that rates in women become twice those in
and came to mean bone present in reduced quantity, with men [5]. At least 1.3 million fractures in the United
normal mineralization. States each year have been attributed to osteoporosis [6],
Clinicially, osteoporosis is recognized by the occur- presuming that 70% of all fractures in persons aged 45
rence of characteristic low-trauma fractures, so that any years or over are due to the condition [7]. The three sites
clinically meaningful definition of osteoporosis must most closely associated with osteoporosis are the hip,
include fracture. The main advantage of a fracture-based spine and distal forearm. However, the epidemiologic
definition (with the possible exception of vertebral characteristics of these three types of fracture differ,
fracture) is that this is a discrete event that can be suggesting the influence of different etiologic factors.
diagnosed using a simple algorithm. The obvious
disadvantage with this definition is that diagnosis will
be exceptionally delayed in a disease where currently Hip Fracture
prevention is the optimum treatment. This has led to
present-day attempts to use bone mass, as assessed by In most populations, hip fracture incidence rates increase
noninvasive densitometric techniques, to try to predict exponentially with aging (Fig. 1). In Rochester,
future risk of fracture. Minnesota, rates reach about 3.0% per year among
There is a well-established relationship between bone women aged 85 years and over and 1.9% among men in
mineral density (BMD) and the ability of bone to this age group [8]. At all ages beyond 50 years, the
withstand forces, such that 75–90% of the variance in incidence in women is about twice that in men. Because
bone strength is related to BMD [1]. Advances in there are more elderly women than men, however, about
medical technology have developed highly accurate and 80% of all hip fractures occur in women. Worldwide,
reproducible methods of measuring BMD, but with there were an estimated 1.66 million hip fractures in
minimal radiation exposure, so that they are ideal for 1990 [9] – about 1 197 000 in women and another
diagnosis and monitoring in osteoporosis. Using BMD, 463 000 or so in men.
A minority of such fractures are due to overwhelming
Correspondence and offprint requests to: Cyrus Cooper, MA, DM, trauma or to specific lesions in the proximal femur. In
FRCP, MRC Environmental Epidemiology Unit, University of
Southampton, Southampton General Hospital, Southampton SO16 one study, 10% of hip fractures resulted from severe
6YD, UK. Tel: 44 (0)1703 777624. Fax: 44 (0)1703 704021. e-mail: trauma and another 1% from local pathology such as
[email protected]. metastatic malignancy [10]. In some countries where hip

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Osteoporos Int (1999) Suppl.

Introduction prospective studies have shown that the risk of

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