1. The epidemiology of fractures in Asia Dr. Lau EMC, MD President, Asian Pacific Osteoporosis Foundation Board member, International Osteoporosis Foundation Director, CEMED, Hong Kong

2. 1 in every 3 women 1 in every 8 men suffer from osteoporosis 1 in every 3 women 1 in every 8 men suffer from osteoporosis The global epidemic of osteoporosis

3. Osteoporosis is an epidemic disease in Hong Kong, it affects ….. 1/3 women 1/5 men

6. Hip fracture is most important from the public health perspective Mortality Rate 20 % Morbidity Rate 30%

7. Life time risk of osteoporotic fracture AllHipSpineforearm Women 40%18%16% Men 13%6%5%3%

8. 1 500 000 1 0 500 1000 1500 2000 Osteoporotic Fractures 1 National Osteoporosis Foundation (2000) 2 National Institutes of Health (2000) 3 US Department of Health and Human Services (2000) 500 000 2 240 000 3 180 000 3 Annual incidence (per 1000) Heart Attack Stroke Breast Cancer Osteoporotic Fractures in Women: Comparison With Other Diseases

9. Percentage of women who rank the following disease to be most threatening (N=1045) Breast Cancer54% Cardiovascular DS38% Osteoporosis8%

10. Men (1.8 million) Asia51% Hip fracture for men and women in 2050 Asia54% Europe11% Others8% LatinAmerica6% NorthAmerica13% Women (4.5 million) Middle East 8% Europe12% Others6% LatinAmerica12% NorthAmerica12% 6%

11. Global projection of hip fracture Assuming no increase, > 2 millions in Asia by 2050 Assuming an intermediate rate between Hong Kong and Korea (Gullberg, 1997)

12. 1966 2001 1985 Incidence of hip fracture in Hong Kong 2006 Per 100,000 50-5960-6970-7980+ Age Women

13. Per 100,000 50-5960-6970-7980+ Age 1966 2001 1985 Incidence of hip fracture in Hong Kong Men 2006

14. Age-adjusted incidence rates in women Adjusted Rates (100,000) US (White)Hong KongSingaporeThailandMalaysia 535 459 442 269 218 Beijing 88

15. Age-adjusted incidence rates in men Adjusted Rates (100,000) 187 180 164 114 88 97 US (White) Hong Kong SingaporeThailandBeijingMalaysia

16. Korea Hip fracture incidence increased by 4 folds (Rowe, 2002) 19913.3/ 10, 000 200113.3 / 10, 000

17. Japan Incidence of hip fracture in increased by 1.6 folds in men and 1.5 folds in women (rates per 100, 000 in 2005) MenWomen 70 – 74108249 75 – 79209505 80 – 844491115 > 847802066 (Hagino, 2005)

18. Singapore Incidence of fracture increased by 1.5 folds in men and 5.0 folds increase in women Rates per 100, 000 in 2005 (Koh, 2001) Men152 Women402

19. Fracture incidence in elderly men (per 100,000)(Mr Os Hong Kong and US) SiteHong Kong ChineseUS Caucasian Hip271281 Wrist194172 Ribs/ chest/ sternum104374 Leg104133 Ankle/ Foot/ Toes78278 All sites10221818

20. Fracture incidence in elderly women (Ms Os Hong Kong) Incidence of fracture (per 100,000 person-years) SiteHong Kong ChineseCaucasian (Dubbo * ) Hip296771 Wrist610709 Ribs/ chest/ sternum141277 Leg183216 Ankle/ Foot/ Toes197385 All sites21593250 *>=60 years old, Dubbo Osteoporosis Epidemiology Study (DOES), 1994

21. Prevalence of vertebral fracture in Chinese and Americans Chinese Americans Women 30% 25% (Black et al) Men 16%10% (Mann et al) (using – 3SD VHR as cut-off)

22. Prevalence of vertebral fractures in China (Beijing) in 2000 Age GroupPrevalence 50 – 594% 60 – 6910% 70 – 7915% 80 +31% (Xu Ling, 2000)

23. Prevalence of vertebral fractures in Japanese (Hiroshima) women in 1995 (Ross, 1995) Age GroupPrevalence 60 – 644% 65 – 698% 70 – 7425% 75 – 7937% 80 – 8443%

24. FRAX – The Brand New WHO Tool for diagnosing Osteoporosis Prof John Kanis www.shef.ac.uk/FRAX

25. Risk factor for osteoporotic fx Family history Prior fx history Tobacco smoking Alcohol consumption for 3 units or more Oral Glucocorticoid use Rheumatoid arthritis Diseases : DM, hyperthyroidism, etc

26. Dual X ray densitometry

28. Methodology of FRAX Poisson Regression Hazard functions exp (β 0 + β 1 -x 1 +…+ β k – X k ) The probability of a hip fx event t v P = ∫h (v) exp ( - ∫g (u) du ) dv. 0 0

29. Methodology of FRAX Global cohort data from 9 cohort studies Rotterdam study European Vertebral Osteop Study Canadian MC Osteo Study Rochester Sheffield Dubbo Hiroshima Gothenberg

30. WHO FRAX MODEL Input Sex Nationality Age No. of CRF’s Femoral Neck BMD Outcome 10 year probability of Osteoporotic fx 10 year probability of hip fx

31. Ten year probability of osteoporotic fractures in women aged 65 years, BMD T-score = -2.5 Number of cRF’sChinaSweden 04.29.8 16.115 28.821 31330 41741 52453 63167

32. Why is FRAX a breakthrough? Allows for selecting patients for treatment in a cost-effective manner on a national scale Quantify fracture risk for communication between doctors and patient

33. Conclusions Osteoporosis is a major health problem in Asia Cost-effective means of fracture prevention are required Evidence-based research are vital for Asia