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  • Review Article
  • Published:

Geographic and ethnic disparities in osteoporotic fractures

Nature Reviews Endocrinology volume 10, pages 338–351 (2014)Cite this article

Subjects

Key Points

  • Hip fracture rates increase with age, especially in women; rates in younger and older patients are not correlated, perhaps reflecting differences in the aetiology of hip fracture

  • When comparing countries, age-standardized rates of hip fracture vary >200-fold in women and >140-fold in men; the hip fracture rate ratio in women to men is approximately 2:1

  • Radiographic incidence of vertebral fractures is much higher than that of hip fractures, whereas the incidence of clinical vertebral fracture is similar to that of hip fractures in most countries where data are available

  • Differences in the incidence of hip fractures between individuals of different ethnic backgrounds have been reported throughout the world

  • Secular hip fracture rate declines have been reported since the 1990s in Europe, North America and Oceania; rates are increasing in Mexico and China but decreasing in Hong Kong and Taiwan

  • Countries with higher socioeconomic development indices have higher hip fracture rates than less developed regions, suggesting that lifestyle might contribute to hip fracture risks

Abstract

Osteoporotic fractures are a major worldwide epidemic. Here, we review global variability, ethnic differences and secular changes in osteoporotic fractures. Worldwide, age-standardized incidence rates of hip fracture vary >200-fold in women and >140-fold in men when comparing the country in which incidence rates are the highest with that in which they are the lowest. Median age-standardized rates are highest in North America and Europe, followed by Asia, Middle East, Oceania, Latin America and Africa. Globally, rates of hip fracture are greater in women than in men, with an average ratio of ∼2:1. The incidence of radiographic vertebral fractures is much higher than that of hip fractures, whereas the incidence rates of clinical vertebral fractures mirror hip fracture rates in most countries. Methodological challenges of defining and ascertaining vertebral fractures limit the interpretation of these data. Secular declines in hip fracture rates have been reported in populations from North America, Europe and Oceania. These declines are especially notable in women, suggesting that reproductive factors might contribute to this reduction. By contrast, hip fracture rates are increasing in parts of Asia and Latin America. Global indicators of health, education and socioeconomic status are positively correlated with fracture rates suggesting that lifestyles in developed countries might contribute to hip fracture. Improvements in fracture assessment, in particular for nonhip fractures, and identification of factors that contribute to this variability might substantially influence our understanding of osteoporotic fracture aetiology and provide new avenues for prevention.

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Figure 1: Age-standardized hip fracture incidence rates in women and men according to country.
Figure 2: Ratio of age-standardized hip fracture incidence compared with that of white women from the USA, according to country and organized by continent or geographic region in men and women.
Figure 3: Correlation between age-standardized hip fracture incidence rates in men and women combined and GNI per capita, Human Development Index or life expectancy at birth.

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Acknowledgements

The authors would like to acknowledge Ms S. Happe for her assistance with referencing and formatting the manuscript and Ms K. Fitzgerald for her assistance with the figures.

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Authors and Affiliations

  1. Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 DeSoto Street, Crabtree A510, Pittsburgh, 15261, PA, USA

    Jane A. Cauley, Didier Chalhoub & Ahmed M. Kassem

  2. Department of Internal Medicine, Division of Endocrinology, WHO Collaborating Centre for Metabolic Bone Disorders, American University of Beirut, PO Box 11-0236, Riad El Solh, 1107 2020, Beirut, Lebanon

    Ghada El-Hajj Fuleihan

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  1. Jane A. Cauley
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  2. Didier Chalhoub
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  3. Ahmed M. Kassem
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Contributions

J.A.C., D.C. and A.M.H. researched data for the article. J.A.C. wrote the manuscript. All authors made substantial contribution to discussion of the content, reviewed and edited the manuscript before submission.

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Correspondence to Jane A. Cauley.

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Supplementary information

Supplementary Table 1

Studies used to complete Supplementary Table 2 and Table 3 (DOCX 42 kb)

Supplementary Table 2

Age-Specific Incidence of Hip Fracture (per 100,000) by Age (DOCX 45 kb)

Supplementary Table 3

Age-standardized Incidence of Hip Fracture (per 100,000) by country; Ratio of Rates in Women to Men (DOCX 26 kb)

Supplementary Table 4

Incidence of Clinical Vertebral Fracture (per 100,000) by Age (DOCX 21 kb)

Supplementary Table 5

Incidence of Forearm (per 100,000) by Age (DOCX 22 kb)

Supplementary Table 6

Summary of Differences in Hip Fracture within Country by Age in the US (6a), Singapore (6b) and New Zealand (6c). Incidence per 100,000 (DOCX 21 kb)

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Cauley, J., Chalhoub, D., Kassem, A. et al. Geographic and ethnic disparities in osteoporotic fractures. Nat Rev Endocrinol 10, 338–351 (2014). https://doi.org/10.1038/nrendo.2014.51

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