Epidemiology of osteoporotic fractures in Brazil: what we have and what we need

Epidemiologia de fraturas pela osteoporose no Brasil: o que temos e o que precisamos

REVIEW

Epidemiology of osteoporotic fractures in Brazil: what we have and what we need

Epidemiologia de fraturas pela osteoporose no Brasil: o que temos e o que precisamos

Marcelo de Medeiros Pinheiro^I; Sérgio Ragi Eis^II

^IMédico-assistente e coordenador da Clínica de Doenças Osteometabólicas e do Serviço de Densitometria Óssea, Disciplina de Reumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp/EPM), São Paulo, SP, Brasil

^IIInvestigador chefe e diretor médico, CEDOES Diagnóstico e Pesquisa, Vitória, ES. Diretor da Sociedade Internacional de Densitometria Clínica (ISCD) e da Sociedade Brasileira de Densitometria (SBDens), São Paulo, SP, Brasil

^{Correspondence}

SUMMARY

The epidemiology of osteoporotic fractures varies widely among countries and is primarily related to differences in the population and utilization of public healthcare services. Since 1994, over 200 studies about osteoporosis and fractures have been conducted in Brazil, among which 60 have described the current epidemiological status. This work is a compilation of studies published in scientific journals (PubMed, MedLine, Lilacs, SciELO Database) with the respective highlights. Overall, these studies show moderate incidence of hip fracture in subjects over 50 years old. However, the prevalence of all types of bone fragility fracture is higher, ranging from 11% to 23.8%. In addition, there is a high incidence of recurrent falls, which are the main extra-skeletal factor associated with these fractures. According to the national studies, 12 months after femoral fractures, the mortality rate ranged between 21.5% and 30%, and there was also a high rate of physical impairment, deterioration of the quality of life and excessive burden to the healthcare system. Considering its high prevalence and associated mortality and physical impairment, osteoporosis and its main consequence, bone fragility fractures, must be considered a major public health problem in our country.

Keywords: Epidemiology; fracture; osteoporosis; Brazil

SUMÁRIO

A epidemiologia das fraturas por osteoporose varia amplamente entre os países, principalmente em decorrência das diferenças entre as populações e da utilização de recursos públicos de saúde. Desde 1994, mais de 200 estudos sobre osteoporose e fraturas foram feitos no Brasil, dos quais 60 descreveram a situação epidemiológica atual. Esse manuscrito é a compilação de estudos publicados em revistas científicas (PubMed, MedLine, Lilacs, SciELO Database) com seus principais achados. Em geral, esses trabalhos mostram moderada incidência de fratura de quadril em indivíduos acima de 50 anos de idade. No entanto, a prevalência de todos os tipos de fratura por fragilidade óssea é elevada, variando de 11% a 23,8%. Além disso, é observada alta incidência de quedas recorrentes, um dos principais aspectos extraesqueléticos associados com essas fraturas. De acordo com os estudos nacionais, 12 meses após a fratura de fêmur, a taxa de mortalidade variou de 21,5% a 30%, com elevada taxa de incapacidade física, deterioração da qualidade de vida e grande impacto sobre o sistema de saúde. Diante da elevada prevalência, associação com mortalidade e incapacidade física, a osteoporose e sua principal consequência, a fratura por fragilidade óssea, deveriam ser consideradas um problema de saúde pública em nosso país.

Descritores: Epidemiologia; fratura; osteoporose; Brasil

The incidence of osteoporotic fractures varies widely among countries and is primarily related to differences in the population and utilization of public healthcare services (Table 1). In Latin America, studies have shown a prevalence of hip fracture of 4 to 36.2 for every 10,000 people (1). However, little is known on the epidemiology of osteoporosis and bone fragility fractures in representative samples of the Brazilian population. From 1994 to October 2009, over 200 national osteoporosis studies have been conducted and published in reference scientific journals by PubMed, MedLine, Lilacs, SciELO Database, among which 60 specifically described the epidemiological status of these conditions.

Some regional studies in Brazil suggest low to moderate incidences of hip fractures in subjects over 50 years old (Table 2). The annual age-adjusted incidence rates in the cities of Porto Alegre - RS (2), Sobral - CE (3), and Fortaleza - CE (4) were approximately four times lower than that reported in Caucasian populations of the Northern hemisphere. However, in Marília, SP, the incidence was higher, especially among women and subjects over 70 (5).

BRAZOS (BRAZilian Osteoporosis Study) was the first epidemiological study conducted in a representative sample of Brazilian men and women over 40, with the purpose of estimating the prevalence and identifying the main clinical risk factors associated with low-impact fractures and recurrent falls. Over 2,400 subjects (70% women) from all regions in Brazil, including urban and rural populations, and from all social and economic levels, were randomly assessed by means of quantitative, personal household interviews. According to data from this piece of research, the prevalence of low-impact fractures (humerus, femur, spine, forearm and ribs) in subjects over 50 was 12.8% for men and 15.1% for women (6).

A general study of the population of the state of Rio Grande do Sul showed a fracture prevalence of 28.3%, predominantly of the upper limbs and feet. The fracture prevalence throughout life was 37.5% in men, resulting primarily from sports and recreational activities and 21.3% in women, particularly in association with falls at home. It is important to point out that all fractures were included in the study, and not only the low-impact fractures (7).

The LAVOS (Latin American Vertebral Osteoporosis Study) was the first epidemiological study performed in Latin America to assess morphometric vertebral fractures and the main risk factors associated. Clark and cols. (8), when randomly assessing 1922 women over 50 from five Latin American countries (Argentina, Brazil, Colombia, Mexico and Porto Rico), found a prevalence of morphometric vertebral fractures (11.18; 95% CI 9.23-13.4) similar to data from Beijing and some regions in Europe. Furthermore, there was no significant difference between countries, but vertebral deformities increased with age (from 6.9% at 50-59 to 27.8% in women over 80, p < 0.001). Specifically in Brazil, the population studied showed a mean prevalence of 14.8% of morphometric vertebral fractures and 23.8% of nonvertebral fractures (excluding feet, hands, skull and those resulting from accidents or trauma), including hip (2.5%) (8).

Lopes and cols. (9), when assessing 769 elderly subjects in the community, have also verified similar prevalence of morphometric vertebral fractures among women (16.7%; 95% CI 13.3-20.1). In men, the prevalence was 21.2% (95% CI 16.6-25.7%) (9). On the other hand, Bandeira and cols. (10) found higher prevalence of vertebral fractures (37%) in 627 postmenopausal women, of whom 9% had Grade I and 10.9% had Grade III. It is important to emphasize that this high prevalence may be justified by origin from the reference center of these women and not from the general population (10).

More recently, Pinheiro and cols. (11), when studying a large cohort (SAPOS - SAo Paulo Osteoporosis Study) including more than four thousand pre and postmenopausal women in metropolitan São Paulo found a history of bone fragility fracture in 11.5% of this population, with mean age at event of 65.5 ± 10 years. Vertebral fractures were reported by 6% of the women and nonvertebral fractures were reported by 86%, including humerus, forearm, metacarpus, metatarsus, ribs and hips. Femur fractures were reported by 8% and a history of hip fracture after 50 years of age in first-degree relatives was reported by 15% of the women, particularly by those with previous fracture (p < 0.001) (11).

BONE DENSITY AND OSTEOPOROSIS

The prevalence of osteopenia and osteoporosis shown in Brazilian studies is widely variable because of different sample sizes, eligibility criteria and methodologies (Table 3). Most of these studies used convenience samples and populations from tertiary health institutions. SAPOS cohort found osteoporosis in 33% of the women, according to bone densitometry findings (11).

The incidence of osteoporosis and osteopenia among women in the Brazilian sample of the epidemiological study LAVOS (8), recruited in metropolitan Vitória and Vila Velha, ES by randomized sample planning was 33.6% and 33.8%, respectively, according to the densitometric criteria proposed by the World Health Organization in 1994 (12).

The national epidemiological study (BRAZOS) showed that 6% of the general adult population knew about the diagnosis of osteoporosis (6). However, since no bone densitometry scans were performed, this low prevalence is not likely to reflect the reality. Additionally, there was a high rate of low-impact fractures. Therefore, if we adopt the definition of osteoporosis (12) in which the diagnosis of established osteoporosis can be determined in the presence of low-impact fractures, we will have at least 12.8% of osteoporosis in men and 15.1% in women.

Martini and cols. (13), when analyzing data from VIGITEL (chronic diseases risk and protection factor surveillance by phone, a program under the Ministry of Health), described the prevalence of osteoporosis reported by 54,369 adult subjects, both male and female, from all the state capitals and the Federal District, as well as the main risk and protection factors associated. In 2006, the frequency of osteoporosis reported was 4.4%, predominantly among women (7% vs. 1.3%). Reports of osteoporosis increased significantly with age (from 5.2% between 45 and 54 to 32.7% in women over 65) (13). It is important to highlight that the data presented are approximate prevalence based only on the medical diagnosis of osteoporosis reported by the subjects, which is more representative of the access to healthcare services than of the actual prevalence of the disease.

RISK FACTORS

Overall, the clinical risk factors found in Brazilian studies (6,8,11,13-16) are similar to those observed in the international scenario. The main clinical risk and protection factors associated with low bone density and bone fragility fractures, according to national data, are presented in Table 4.

Genetic and dietary factors have been associated with increased risk of osteoporosis and fractures. Some national studies have investigated the genetic polymorphism of collagen 1 α1 (COL1A1) (17), a receptor of vitamin D (VDR) (18-21) and estrogen (ERα) (22), but did not demonstrate any significant association with bone density or fractures. The only national epidemiological study showing an association between dietary aspects and low-impact fractures was the BRAZOS study (6,23) (Table 5).

Several recent works have pointed to a higher prevalence of hypovitaminosis D in all continents, genders, age ranges and social and economic levels. Hypovitaminosis D was also observed among noninstitutionalized elderly subjects in the city of São Paulo, especially during the winter and fall. Vitamin D deficiency occurred in 15.4% of patients, insufficiency in 41.9% and secondary hyperparathyroidism in 55% (24), although the relationship between these conditions and the fractures was not investigated by the authors.

Falls

As the population ages, falls represent an ever increasing impact on the public healthcare system. Approximately 30% of the elderly fall every year and nearly half of them have recurrent events. However, the incidence of falls varies widely and depends on different parameters of the population under study, such as gender, age range, genetic factors, life habits and personal background. The individual impact of each of these parameters has not yet been fully described, but they can be cumulative and increase the risk of serious and tragic outcomes in the lives of the elderly, particularly cranioencephalic trauma, hospitalization, institutionalization, fractures and death.

Falls are associated with vertebral and non-vertebral fractures, especially of the hips, regardless of bone density. The combination of risk factors, bone density and falls is relevant for determination of the individual fracture risk of each patient, and also increases the sensitivity and specificity of instruments used for identifying subjects with fractures in population studies. The strategies currently used to prevent osteoporotic fractures must fully contemplate these aspects.

In Brazil, the prevalence of recurrent falls within the previous 12 months may vary from 10% to 40% (25-33) (Table 6). The prevalence may also vary according to the region (30) (Figure 1). Overall, the incidence of recurrent falls among subjects in the South is lower than that among subjects in other regions. Recurrent falls among men from rural regions is significantly higher than in metropolitan areas (16.3 and 13.1, respectively). However, this finding was not observed among women (24.5% and 25.5%, respectively).

The main clinical risk factors associated with falls identified in Brazilian studies were dementia (25), delirium (26), current use of calcium channel blockers, benzodiazepines (27,28), physical household environment (29), advanced age, regular alcohol consumption, lower quality of life, previous fracture, diabetes mellitus, lower dietary consumption of vitamin D and lack of physical activity (30).

Mortality

It is known that 15% to 30% of the patients with hip fractures die during the first year after the event, usually due to fracture complications such as infection, venous thrombosis and pressure ulcers, or associated conditions, especially cardiovascular diseases. In addition, these patients have an increased risk of becoming dependent or institutionalized after the fracture. The main factors related to the increased risk of death in these subjects are related to male gender, advanced age, lower functional capacity before the event, higher number of concomitant diseases, sarcopenia and frail phenotype (34). A recent prospective cohort with a 5-year follow-up has shown clear association between lower bone mass and higher overall and cardiovascular mortality among elderly women, regardless of age, which suggests some similarity between vascular calcification and atherosclerosis with osteogenesis and osteoporosis (35).

In the first year after hip fractures, the overall mortality observed in a study performed in Rio de Janeiro was 21.5% (36). Most of deaths (55.1%) occurred after medical discharge, especially due to cardiovascular events and infections (37-38). Recently, Fortes and cols. (39) showed a mortality rate of 23.2% after 6-month follow-up of hip fractures in 56 elderly patients. Furthermore, they showed that only 30% of patients were able to return to their previous activities and 11.6% became completely dependent (39).

Quality of life

Osteoporosis has a significant deleterious impact on the quality of life of patients, particularly after bone fragility fractures. However, the study conducted by Cantarelli and cols. (40) did not demonstrate deterioration of the quality of life as assessed by OPAQ (Osteoporosis Assessment Questionnaire) in elderly women with osteoporosis or low-impact fractures (40).

On the other hand, Lemos and cols. (41) found a significant correlation between general (SF-36, The Medical Outcomes Study 36 - Item Short Form Health Survey) and specific (OPAQ) quality of life questionnaires applied to 40 women with postmenopausal osteoporosis, especially for pain, social aspects and mental health domains (41).

Costs

Osteoporosis-related costs vary widely among different countries, not only due to different incidence rates of the disease but also to the emphasis placed on prevention, hospitalization and treatment. Among postmenopausal women with osteoporosis, the utilization of health resources and the annual osteoporosis treatment costs were equivalent to 775 dollars per patient, and the drug-related costs required 9% of the monthly family income (42). Direct costs with hospitalization for osteoporotic hip fractures in subjects over 50 admitted into private hospitals were 12 thousand dollars, mainly related to medical and surgical instrumentation (61%). Femur fractures were observed in 4.99% of the total 129,611 osteoporosis cases managed by the national supplementary healthcare system, with a mean stay of 9.21 days. The annual economic impact of these fractures for health insurance companies was estimated at approximately 6 million dollars (43). Although extremely relevant, these findings do not provide consistent inputs about total mid-term and long-term costs. In Latin America, including São Paulo, direct costs of hip fractures range between 4.5 and 6 thousand dollars (1).

FINAL CONSIDERATIONS AND CONCLUSION

An important strategy for implementation of health education and promotion-related measures is to know the prevalence, incidence and specific risk factors of the Brazilian population. Particularly, in Brazil, the main clinical risk factors associated with osteoporotic fractures were not known and were usually extrapolated from European and American studies. In view of the studies presented, the identification and inclusion of these risk factors in routine medical practice may facilitate evaluation of the risk of fractures as well as individualized decision-making.

Using a combination of clinical risk factors and bone density measurements, Kanis and cols. (44) have recently proposed the use of FRAX^TM as an objective and useful tool for quantification of the likelihood of fractures within the following 10 years, which directly impacts the decision-making process and the osteoporosis-related costs (44). However, calculation of the absolute risk of fractures depends on the population studied, and the use of this tool has not yet been approved in Brazil, once there is no reference database available (45).

Despite the many treatments available for prevention and management of osteoporosis, with effective reduction of vertebral (50% to 65%) and non-vertebral (25% to 40%) fractures, most of the Brazilian population still has no access to early diagnosis or appropriate therapeutics for the disease (34,39,46). Practical measures for minimization of the risk of fractures can be easily implemented by a multidisciplinary team of physicians, physical educators, nutritionists, physical therapists and psychologists.

Considering its high prevalence and associated mortality and physical impairment, osteoporosis and its main consequence, bone fragility fractures, must be considered a major public health problem in our country. Public health policies must consider the results of the national studies presented before establishing prevention measures and strategies for early management of the disease as well as for utilization and allocation of financial resources, with a view to minimize the direct and indirect costs related to osteoporotic fractures.

In order to prepare the country for the economic and social costs that will be and have been imposed by osteoporosis on the Brazilian society, additional prospective epidemiological data is required, among other data, to allow assessment of the impact of each of the risk factors identified in our population as determinants of the incidence of different types of fractures. This will allow a better pharmacoeconomic understanding of the treatments currently approved for osteoporosis in our society. We will also be able to define intervention criteria based on the absolute risk of fractures. A group of Brazilian investigators and experts are currently designing a broad epidemiological study of osteoporosis and bone fragility fractures to provide the country with such relevant information.

Disclosure: no potential conflict of interest relevant to this article was reported.

Received on Dec/8/2009

Accepted on Mar/3/2010

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Publication Dates

• Publication in this collection
  21 May 2010
• Date of issue
  Mar 2010

History

• Received
  08 Dec 2009
• Accepted
  03 Mar 2010