Osteoporos Int (1999) Suppl.
2:S2–S8
ß 1999 International Osteoporosis Foundation and National Osteoporosis Foundation
Epidemiology of Osteoporosis
C. Cooper
MRC Environmental Epidemiology Unit, University of Southampton, Southampton, UK
Introduction
Osteoporosis is currently defined as a systemic skeletal
disorder characterized by low bone mass and micro-
architectural deterioration of bone tissue, with a
consequent increase in bone fragility and susceptibility
to fracture. Historically, osteoporosis and its sequelae
were recognized by Sir Astley Cooper over 150 years
ago, when he observed that hip fractures might result
from an age-related reduction in bone mass or quality.
However, the term ‘osteoporosis’ first entered medical
parlance in France and Germany in the nineteenth
century, where it was coined as a histologic description
for aged human bone, emphasizing the apparent porosity
in the tissue. The histologic term subsequently evolved
to discriminate this condition from that of osteomalacia,
and came to mean bone present in reduced quantity, with
normal mineralization.
Clinicially, osteoporosis is recognized by the occur-
rence of characteristic low-trauma fractures, so that any
clinically meaningful definition of osteoporosis must
include fracture. The main advantage of a fracture-based
definition (with the possible exception of vertebral
fracture) is that this is a discrete event that can be
diagnosed using a simple algorithm. The obvious
disadvantage with this definition is that diagnosis will
be exceptionally delayed in a disease where currently
prevention is the optimum treatment. This has led to
present-day attempts to use bone mass, as assessed by
noninvasive densitometric techniques, to try to predict
future risk of fracture.
There is a well-established relationship between bone
mineral density (BMD) and the ability of bone to
withstand forces, such that 75–90% of the variance in
bone strength is related to BMD [1]. Advances in
medical technology have developed highly accurate and
reproducible methods of measuring BMD, but with
minimal radiation exposure, so that they are ideal for
diagnosis and monitoring in osteoporosis. Using BMD,
Correspondence and offprint requests to: Cyrus Cooper, MA, DM,
FRCP, MRC Environmental Epidemiology Unit, University of
Southampton, Southampton General Hospital, Southampton SO16
6YD, UK. Tel: 44 (0)1703 777624. Fax: 44 (0)1703 704021. e-mail:
gis@mrc.soton.ac.uk.
Osteoporosis
International
prospective studies have shown that the risk of
osteoporotic fracture increases continuously and pro-
gressively as BMD declines. Fracture risk increases 1.5-
to 3-fold for each standard deviation fall in BMD [2].
However, there does not seem to be a cutoff threshold
value for BMD above which the risk is stable.
Fracture Epidemiology
Fracture incidence in the community is bimodal, with
peaks in youth and in the very elderly [3,4]. In young
people, fractures of the long bones predominate, often
following substantial trauma, and the incidence is greater
in young men than in young women. Above the age of
35 years, overall fracture incidence in women climbs
steeply, so that rates in women become twice those in
men [5]. At least 1.3 million fractures in the United
States each year have been attributed to osteoporosis [6],
presuming that 70% of all fractures in persons aged 45
years or over are due to the condition [7]. The three sites
most closely associated with osteoporosis are the hip,
spine and distal forearm. However, the epidemiologic
characteristics of these three types of fracture differ,
suggesting the influence of different etiologic factors.
Hip Fracture
In most populations, hip fracture incidence rates increase
exponentially with aging (Fig. 1). In Rochester,
Minnesota, rates reach about 3.0% per year among
women aged 85 years and over and 1.9% among men in
this age group [8]. At all ages beyond 50 years, the
incidence in women is about twice that in men. Because
there are more elderly women than men, however, about
80% of all hip fractures occur in women. Worldwide,
there were an estimated 1.66 million hip fractures in
1990 [9] – about 1 197 000 in women and another
463 000 or so in men.
A minority of such fractures are due to overwhelming
trauma or to specific lesions in the proximal femur. In
one study, 10% of hip fractures resulted from severe
trauma and another 1% from local pathology such as
metastatic malignancy [10]. In some countries where hip