1.
Endo Bridge 2013
OSTEOPOROSIS:
EPIDEMIOLOGY AND DIAGNOSIS
Dilek Gogas Yavuz,MD
Marmara University School of Medicine
Section of Endocrinology and Metabolism
Istanbul ,Turkey

2.
Silent disease until complicated by fractures

3.
Osteoporosis: silent epidemic
385 pts with fragility fractures
Have you ever heard of osteoporosis?
NO:20%
YES:80%
Do you think that the fracture you
have experienced could be due to
fragility of your bones?
NO:73 %
YES:27 %
Chavalley et al. Osteoporosis Int 2002;13:450

4.
Definition of osteoporosis
NIH Consensus Development Conference, March 2000
A skeletal disorder characterized by
 Compromised bone strength
 An increased risk of fracture
Bone strength =bone density+ bone quality
normal
osteoporosis
Low bone mass and microarchitectural deterioration

5.
Osteoporosis Is a Serious
Public Health Problem
Every 3 second
an osteoporotic
fracture occcur
• Worldwide, osteoporosis causes more than
8.9 million fractures annually
• Osteoporosis affects an estimated 75 million people in
Europe, USA and Japan, 2.2 million in Australia, 70
million in China
only 10 to 20%
are diagnosed and treated

6.
Prevalance of osteoporosis in men and women
by gender-spesific scores
Osteoporosis is estimated to affect 200 million women worldwide
approximately one-tenth of women aged 60, one-fifth of women aged 70, two-fifths of
women aged 80 and two-thirds of women aged 90
Schuit et al. Bone 2004;34:195

7.
Prevalance of Osteoporosis
 Over 50% of women and 30-45% of
men over age 50 have
osteopenia/osteoporosis
 Men over age 60 has 25% risk
osteoporotic fracture
 70% over age 80 have osteoporosis
At age 50
lifetime risk of
fracture is
1:2 women
1:5 men

8.
Osteoporotic Fractures in Women:
Comparison with Other Diseases
2000
*annual
incidence all ages
estimate women 29+
‡annual estimate women 30+
•1996 new cases, all ages
Annual incidence x 1000
† annual
1500
1000
1 500 000*
250 000
hip
250 000
forearm
250 000
other sites
513 000†
500
0
750 000
vertebral
Osteoporotic
Fractures
228 000‡
Heart
Attack
Risk of osteoporotic fracture in 1 year is greater
than combined risk of heart attack, stroke, and
breast cancer.
184 300•
Stroke
Breast
Cancer
Hip fracture incidence alone
exceeds that of breast cancer.
Riggs BL, Melton LJ. Bone 1995
Heart and Stroke Facts, 1996, American Heart Association
Cancer Facts & Figures, 1996, American Cancer Society

9.
Osteoporotic Fractures in Men and Women
As with women, hip fractures in men increase dramatically with age
Distribution
of Fractures
Cooper C, Melton LJ. Trends Endocrinol Metab. 1992;3:224–229.

10.
Consequences of fractures
• Death
10%-20% inrease in mortality with hip fractures
• Disability
hip fractures
20% of patients require long-term nursing home care
60% of patients fail to return to prefracture level of function
vertabral fractures
chronic back pain,kyphosis,height loss, impaired pulmonary function
• Reduced quality of life
• Loss of independence
Clinician’s Guide To The Prevention And Treatment Of Osteoporosis
US Department Of Health And Human Sciences

11.
Diagnosis of Osteoporosis
• Based on T score (T Score : standart deviation by which the
individual’s BMD differs from the mean value expected in young
healthy individuals)
• Operational definition of osteoporosis: BMD -2.5 SD or
more below the Young female adult mean
• Reference technique :DXA
• Reference site: femoral neck
• Applies to men and to women
Osteoporosis international 2013;24:23-57

12.
WHO criteria for diagnosis of
osteoporosis
T-score : Difference expressed as standard deviation compared to
young reference population
T score
normal
osteopenia
osteoporosis
-1.0 and above
-1.0 and -2.5
-2.5 and below
Severe (established)
osteoporosis
-2.5 and below ,plus one
or more osteoporotic
fracture(s)
Kanis et al. J Bone Mineral Res 1994;9:1137

13.
WHO classification with a T-score cannot be
applied to:
• premenopausal women
• men under age 50
• children
Z score
Low Z-score (less than -2.0) has been suggested by some to increase
likelihood of secondary osteoporosis

14.
Who Should Have a Bone Density Test?
 Women age 65 and older and men age 70 and older
 Younger postmenopausal women and men ages
50–69 with clinical risk factors
 Adults who have a fracture after age 50
 Adults with a condition (e.g., rheumatoid arthritis)
or taking a medication (e.g., glucocorticoids)
associated with low bone mass or bone loss
1. Sweet MG, et al. Am Fam Physician. 2009;79(3):193-200.
2. National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis.
www.nof.org. Accessed February 2013.

15.
BMD measurements to predict future fracture risk
has a high specificity but a low sensitivity
Most women with hip fractures do not have a T score < -2.5
Wainwright et al JCEM 2005;90:2787

16.
BMD and fracture risk
BMD alone is less optimal as an intervantion
• The fracture risk varies markedly
in different countries ,but T-score
varies by a small amount
• Any given T-score to fracture risk
in women from any one country
Depends on age
• Fracture risk depends of clinical
risk factors
For any BMD, fracture risk higher
in the elderly than in the young
10 –year probability of hip fracture in women
according to age and T-score for femoral neck
BMD
Osteoporosis int 2013,24:23-57

17.
Clinical Risk Factors that Affect Fracture Risk

18.
Fractures and weight
Compston JE et al. Am J Med 2011;124:1043

19.
Fracture risk assessment
Risk engines
Relative fracture risk
BMD
10-year absolute fracture risk
Risk Engines
• Garvan fracture risk calculator
• Q fracture
• FRAX

20.
FRAX
• Computer -based algorithm (http://www.shef.ac.uk/FRAX)
• Objective: To estimate fracture risk in order to help with
treatment decisions
• Rationale: BMD+CRFs predict fracture risk better than
either alone
• Calculates the 10 year probability of a major fracture (hip,
clinical spine,humerus,wrist) and 10-year probability of
hip fracture
• designed only for postmenopausal women and men over
the age of 40 who have not previously received boneprotective therapy

21.
Categorization Based on 10-year Fracture Risk
Absolute fracture risk in 10 years:
low:
<10%
moderate:
10-20%
high:
>20%

22.
Limitations of FRAX™
WHO Fracture Probability Tool
 Not valid in patients on treatment
 Only hip BMD is considered
 Risk is “yes/no” – there is no consideration of “dose”
(e.g., fractures, glucocorticoids, smoking, alcohol)
 Not all risk factors are included (e.g., falls)
 “Major osteoporotic fracture” is not the same as all
osteoporotic fractures
 Clinical judgment is required
Watts NB, et al. J Bone Miner Res 2009;24:975-979.

23.
 Ostoeporosis is a serios health problem
 Osteoporotic fractures are expected to rise
 Lack of awareness
 Risk assesment
 Prevenion of fractures

24.
Thank you