Austrian osteoporosis report: epidemiology, lifestyle ... - Springer Link

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Wien Med Wochenschr (2009) 159/9–10: 221–229 DOI 10.1007/s10354-009-0649-9 Springer-Verlag 2009 Printed in Austria

Austrian osteoporosis report: epidemiology, lifestyle factors, public health strategies Thomas Dorner, Elisabeth Weichselbaum, Kitty Lawrence, K. Viktoria Stein and Anita Rieder

Centre for Public Health, Institute of Social Medicine, Medical University of Vienna, Vienna, Austria Received August 25, 2008, accepted (after revision) October 2, 2008

Österreichischer Osteoporosebericht. Epidemiologie, Lebensstilfaktoren, Public Health Strategien

Entwicklung von Public Health Strategien zu ermöglichen und Methoden zu entwickeln, um einige der identifizierten Problemfelder zu lösen, um somit letztendlich zu einer verbesserten Knochengesundheit in Österreich beizutragen.

Zusammenfassung. Der erste Österreichische Osteoporosebericht wurde initiiert, um ein umfassendes Referenzdokument für Pathogenese, Diagnose, Therapie und Rehabilitation bei Osteoporose zu schaffen. Weiters war es Ziel dieses Berichts, Ausmaß und Gewichtigkeit von Osteoporose und den damit assoziierten Komplikationen für Österreich darzustellen. Basierend auf aktuellen internationalen Pr€avalenzerhebungen kann für Österreich gesch€atzt werden, dass etwa 740.000 Personen über 50 Jahren von Osteoporose betroffen sind, davon 617.000 Frauen. Eine Analyse der Krankenhausentlassungen aus dem Jahr 2005 zeigte, dass in diesem Jahr 1382 m€ annliche und 8080 weiblich F€alle mit der Hauptdiagnose Osteoporose in Österreich entlassen wurden. Hinzu kommen noch 9711 m€annliche und 54.840 weibliche F€alle mit Osteoporose in einer Nebendiagnose. In Österreich erleiden rund 16.500 Personen j€ahrlich eine Hüftfraktur. Somit liegt Österreich mit einer Rate von 19,7 Hüftfrakturen pro 10.000 Einwohner im Bereich der europ€aischen Spitze. Die Spitalsmortalit€ atsrate bei Oberschenkelfrakturen betr€agt in Österreich 3,8 % bei M€annern und 3,2 % bei Frauen. Die Knochengesundheit kann durch einen vorteilhaften Lebensstil positive beeinflusst werden, der Osteoporosebericht hat allerdings Risikofaktoren bezüglich Lebensstils in der Österreichischen Bevölkerung aufgezeigt. Die mittlere Kalziumaufnahme bei Österreichischen erwachsenen Frauen und bei m€annlichen und weiblichen Seniorinnen und Senioren ist niedriger als empfohlen, lediglich erwachsene M€anner erreichen eine Kalziumaufnahme etwa den Empfehlungen entsprechend. Die durchschnittliche Vitamin D Aufnahme in Österreich ist sehr gering, besonders bei Vorschulkindern und Seniorinnen und Senioren. Der Anteil an österreichischen Personen, die angeben, regelm€aßig körperlich aktiv zu sein ist verbesserungsbedürftig, besonders bei €alteren Menschen. Die Daten aus dem Österreichischen Osteoporosebericht sind nützlich um die

Schlüsselwörter: Osteoporose, Gesundheitsbericht, Pr€avalenz, Mortalit€ at, Krankenhausentlassungen

Correspondence: Thomas Dorner, MD, MPH, Centre for Public Health, Institute of Social Medicine, Medical University of Vienna, Rooseveltplatz 3, 1090 Vienna, Austria. Fax: þþ43-1-4277 64 681, E-mail: [email protected] wmw

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Summary. The first Austrian Osteoporosis Report was initiated to create a comprehensive reference document for the pathogenesis, diagnostics, therapy, and rehabilitation of osteoporosis. Furthermore, the aim was to present the extent and severity of osteoporosis and the associated complications in Austria. On the basis of current international prevalence, it can be estimated that approximately 740,000 of people in Austria over 50 years are affected by osteoporosis, of whom around 617,000 are women. A special analysis of the hospital discharge statistics showed that, in the year 2005, 1382 men and 8080 women were discharged from Austrian hospitals with the main diagnosis, osteoporosis. Added to these 9711 male cases and 54,840 females cases were documented with osteoporosis as a secondary diagnosis. In Austria around 16,500 people suffer a hip fracture each year. Thus, with a fracture rate of 19.7 fractures per year per 10,000 inhabitants over the age of 65 years, Austria lies within the peak for Europe. The hospital mortality rate amongst patients with fracture of the femur is 3.8% in men and 3.2% in women in Austria. Everybodys bone health can be positively influenced by a healthy lifestyle; however, the Osteoporoses Report revealed insufficiencies regarding lifestyle risk factors in the Austrian population. Average calcium intake amongst Austrian adult women and amongst male and female seniors is lower than recommended and only adult men achieve around the recommended amount. The mean vitamin D intake in Austria is very poor, especially amongst pre-schoolers and seniors. The rate of Austrians reporting regular physical exercise is in need of improvement, especially amongst elderly people. The data presented in the Austrian Osteoporosis Report are useful to enable the development of public health strategies and methods to help resolve some of these problems, and ultimately contribute to improved bone health in the nation. Key words: Osteoporosis, health report, prevalence, mortality, hospital discharge

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Introduction Osteoporosis is a systemic disease of the skeletal system characterised by a reduction in bone mass and change in the micro-architecture of the bone tissue, which in turn results in a decrease in bone strength and an increased risk of bone fractures in particular in the spinal area or of the extremities. Osteoporosis is the outcome following many years of bone loss [1, 2]. Owing to the severity and extent of the disease the World Health Organisation (WHO) dedicated the first decade of the 21st century to bone health: The Bone and Joint Decade – Joint Motion 2000–2010. Osteoporosis is an illness, which rarely leads directly to death. This fact has in many ways contributed to an underestimate of the public health impact of osteoporosis. The illness is, however, commonly accompanied by chronic pain and in many cases makes independent living impossible. The mobility of those affected is frequently severely restricted. Osteoporosis can also be associated with life threatening conditions and ultimately lead to death. Not only demographic developments have led to an increase in the prevalence of osteoporosis and related fractures, but also changes in lifestyle and the increase in lifestyle associated risk factors, in particular in the industrialised nations, have contributed to a rising prevalence. The epidemiology of osteoporosis in Austria, as in other countries, is generally unclear, since osteoporosis is often first diagnosed in the presence of bone fractures. Worldwide the disease is under-diagnosed and, although effective and cost-effective treatment options are available these are frequently not implemented. Belated implementation, or even the complete absence, of prevention measures and poor compliance to treatment mean that attainable outcomes are often forfeited. Poor adherence to medication in turn leads to a decreased quality of life, inability to carry out day-to-day tasks, and increased need for care, resulting in high costs to the health system and society in general, as well as, considerable rehabilitation costs. The first Austrian Osteoporosis Report was initiated with the intention of creating a comprehensive reference document for the pathogenesis, diagnostics, therapy, and rehabilitation of osteoporosis. Furthermore, the aim was to present the extent and severity of osteoporosis and the associated complications in Austria, to enable the development of public health strategies and methods to help resolve some of these problems, and ultimately contribute to improved bone health in the nation. As such particular attention was paid to preventive aspects in the report. 222

Dorner et al. – Epidemiology, lifestyle factors, public health strategies

The first Austrian osteoporosis report had the following objectives: * to compile and present the most recent scientific findings regarding factors involved in the development of osteoporosis, * to identify the extent and severity of osteoporosis in Austria based on epidemiologic data, as well as, the status of various factors connected with the development of osteoporosis, * to suggest possible strategies for the prevention of osteoporosis at an individual and community level, as well as, for the Austrian health system, * to strengthen awareness regarding the extent of osteoporosis and its associated problems, * to provide a basis for the conception of plans/strategies in terms of integrated health care [3]. This paper presents the most important findings relating to epidemiology of osteoporosis and its related risk factors, mortality, and quality of life in Austria and in relation to international figures, as well as, public health strategies.

Epidemiology Worldwide it has been estimated that in the year 2000, 9 million osteoporotic fractures were sustained, of which about 1.6 million were hip fractures, 1.7 million radius fractures, and 1.4 million vertebral fractures. The highest number of osteoporotic fractures was documented in Europe (34.8%). Worldwide osteoporotic fractures represent 0.83% of all non-infectious diseases. In Europe this proportion is 1.75% [4]. In the United States 50% of women and one in four men over the age of 50 years suffer a fracture due to osteoporosis during the remainder of their lives, whereby vertebral fractures are most frequently observed. The incidence of vertebral fractures is two to three times higher amongst European women and women in the USA, from the age of 60 years and upwards, compared with men. The lifetime risk of incurring a vertebral fracture is 16% for Caucasian women and 5% for men [5]. A study carried out in the USA found that 45% of women over 50 years had a bone mineral density, which, according to WHO criteria, would be classified as osteoporosis. On the basis of this study the lifetime risk for a hip, vertebral or radius fracture was specified as 40% for Caucasian women and 13% for Caucasian men aged 50 years and over [6]. In Germany it was estimated that 7.8 million people, of whom 6.5 million were women, suffered from osteoporosis in 2003. Of these just short of 22% were treated with osteoporosis medication [7]. Springer-Verlag

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Men

Women

1000

500

04 510 9 -1 15 4 -1 20 9 -2 25 4 -2 30 9 -3 35 4 -3 40 9 -4 45 4 -4 50 9 -5 55 4 -5 60 9 -6 65 4 -6 70 9 -7 75 4 -7 80 9 -8 85 4 -8 90 9 -9 4 95 +

0

Age groups Fig. 1: Hospital discharge data with the main diagnosis osteoporosis (ICD-10 M80-M82) in Austria, 2005, by sex and age group per 100,000 inhabitants (own calculations based on data supplied by Statistics Austria [3])

20000

Men

Women

15000 10000 5000 0

0-

4 510 9 -1 15 4 -1 20 9 -2 25 4 -2 30 9 -3 35 4 -3 40 9 -4 45 4 -4 50 9 -5 55 4 -5 60 9 -6 65 4 -6 70 9 -7 75 4 -7 80 9 -8 85 4 -8 90 9 -9 4 95 +

/100,000 inhabitants

In a German telephone survey the prevalence of osteoporosis amongst women over 45 years was determined to be 14.2%, of these 15.0% reported having suffered osteoporotic fractures [8]. In its report on the prevalence of osteoporosis in the USA, the National Osteoporosis Foundation [9] presented calculations relating to the development of the prevalence of osteoporosis. According to these calculations it is estimated that 10.5 million women and 3.3 million men (a total of 13.9 million) will have developed osteoporosis by 2020, compared with 7.8 million women and 2.3 million men (a total of 10.1 million) in 2002 [9]. A reason for the rise in the prevalence of osteoporosis and associated bone fractures is certainly demographic change – people are getting older – although even age standardised calculations show an increasing incidence of fractures following light trauma. This may be explained by an increase in risk factors for osteoporosis and for falls [10]. For Austria epidemiological data on osteoporosis are scanty and mainly based on estimates or calculations determined from hospital discharge statistics. Data regarding fractures are more specific, since these are more frequently treated in hospital and are therefore better documented. Taking the current prevalence figures for Germany and factoring them for Austria, it can be estimated that approximately 740,000 of over 50 year olds are affected by osteoporosis, of whom around 617,000 are women. A special analysis of the hospital discharge statistics showed that, in the year 2005, 1382 men and 8080 women were discharged from Austria hospitals with the main diagnosis osteoporosis (ICD-10 M80–M82). Added to these 9711 male cases and 54,840 females cases were documented with osteoporosis as a secondary diagnosis at hospital discharge. 1280 male and 7279 female cases were discharged with the main or secondary diagnosis osteoporosis with pathological fracture (ICD-10 M80), 9752 male and 55,485 female cases with the diagnosis osteoporosis without pathological fracture (ICD-10 M81) and 61 male and 156 female cases with the diagnosis osteoporosis in diseases classified elsewhere (ICD-10 M82). The male to female ratio of cases with the diagnosis osteoporoses in general was 1:5.7. This ratio was, however, not that marked within the diagnoses of secondary osteoporosis like osteoporosis in diseases classified elsewhere (ICD10 M82) with 1:2.6, postsurgical malabsorption osteoporosis (ICD-10 M80.3 and M81.3) with 1:2.4, drug-induced osteoporosis (ICD-10 M80.4 and M81.4) with 1:1.8 and osteoporosis of disuse (ICD10 M80.2 and M81.2) with 1:1.6.

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Age groups Fig. 2: Hospital discharge statistics with the secondary diagnosis osteoporosis (ICD-10 M80-M82) in Austria, 2005, by sex and age group per 100,000 inhabitants (own calculations based on data supplied by Statistics Austria [3])

The frequency of osteoporosis in hospitals, by age group and gender, is presented in Figs. 1 and 2. Age adjusted statistics showed that more hospital cases of osteoporosis were documented in the federal states of Vienna, Styria and Carinthia compared with Tyrol and Vorarlberg. The mean duration of hospital stay due to osteoporosis with a pathological fracture was 13.4 days for men and 13.6 days for women. For osteoporosis without a pathological fracture this was 4.8 days for the men and 6.3 days for the women [3]. The most accurate data on osteoporosis-related fractures in Austria come from a study carried out by the Main Association of Austrian Social Security Institutions on secondary prevention of osteoporosisrelated fractures. An interim evaluation of the project in September 2006 showed that in Austria around 16,500 people suffer a hip fracture every year. Thus, with a fracture rate of 19.7 fractures per year per 10,000 inhabitants over the age of 65 years, Austria lies within the peak for Europe [11]. According to hospital discharge data from Statistics Austria, 5243 male and 12,551 female cases, were discharged with the main diagnosis fracture of the femur (ICD-10 S72) in 2004. 58% of the male and 89% of the female cases were people aged 65 years and older. The mean hospital stay with this diagnosis was 16.4 days for the men and 18.4 days for the women [12]. From these data it is, however, not apparent whether the fractures are linked to osteoporosis, or to other reasons for fractures independent of osteoporosis. Dorner et al. – Epidemiology, lifestyle factors, public health strategies

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Mortality Osteoporotic fractures, in particular hip, vertebral, or humerus fractures, are frequently linked to a higher mortality. One study showed that female mortality during the first year following a hip fracture was 10–20% higher than expected in general for women of the same age group, whereby the mortality risk was highest immediately after the fracture was sustained. Indeed in the case of vertebral fractures mortality remains elevated long after the first year following fracture. The most frequent causes of death following a hip fracture are chronic diseases that can lead to death themselves, but can also course hip fractures. Women with vertebral fractures have a higher risk of mortality from cardiovascular and pulmonary diseases, and the risk increases with the number of vertebral fractures [13]. A further study of women showed that the relative mortality risk was 6 times higher following a hip fracture and as much as 9 times higher following a vertebral fracture, compared with people with no fractures [14]. Mortality following a hip fracture is higher for men than women [15]. In a retrospective cohort study of patients over 60 years, cause of death following a hip fracture operation was evaluated. Of the 8930 patients 1737 (19%) had postoperative medical complications. The most frequent complications were cardiac (8%) and pulmonary (4%) complications. 2% and 3% of patients suffered severe cardiac or pulmonary complications respectively. 2% suffered gastrointestinal bleeding. 1% suffered either combined cardio-pulmonary complications, venous thrombosis, or cerebrovascular complications (transient ischemic attack TIA, or stroke) [16]. In an analysis of Austrian hospital data from 1995 and published in 2001 it was shown that, of the cases with osteoporostic hip fractures, 6.8% (778 people) died in hospital. Twenty-four percent of men and 19% of women over 95 years died in hospital [17]. More recent data from 2004 showed that, hospital mortality amongst patients with the main diagnosis fracture of the femur was 3.8% in men and 3.2% in women [12]. There are no data available in Austria regarding osteoporosis mortality outside the hospital.

Lifestyle

Osteoporosis, and the resulting fractures, are frequently linked with a greatly diminished quality of life for those affected, often having negative repercussions for a persons social life and psychological well-being. Vertebral and hip fractures have a considerably greater

Bone structure and later bone loss are affected by a number of factors. Some risk factors for the development of osteoporosis can be influenced positively in every individual by a healthy lifestyle. These factors are responsible for an estimated 10–50% of bone mass and structure [22]. The lifestyle factors with the greatest influence on bone health are nutrition, physical activity, smoking and alcohol consumption, as well as, body weight. With respect to nutrition above all the vitamin D plays a central role in bone health. Also other nutrients like calcium and the intake of fruit and vegetables can


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Quality of life

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negative influence on a persons quality of life, over a longer period of time, than upper or forearm fractures [18]. Vertebral fractures are mostly associated with severe back pain, kyphosis and reduction in body height [13], with those affected frequently remaining long-term pain patients. For these people restriction in physical functionality is the strongest determinant for a poor quality of life. Hip fractures tend to have an even worse effect on quality of life [19]. Half the people who were fully mobile prior to an osteoporotic hip fracture suffer enduring restricted mobility following a hip fracture. Of the women who were able to lead an independent life prior to a hip fracture, around half live in a longterm nursing home a year following a hip fracture, and require help for their activities of daily living. Around a third of people with a hip fracture become completely dependent and the risk of institutionalisation is high [13]. Besides the restrictions in body function and the pain, above all the social isolation, the dependency on others, and the influence of these on mental health are serious consequences of this disease. Many of those affected refrain from going out and can no longer enjoy their leisure time. They are also frequently robbed of their social roles, since they are no longer able to perform various tasks. A survey of over 75-year-old women showed that 80% of those questioned would rather die than lose their independence as a result of a hip fracture and in turn forfeit quality of life [20]. Disability Adjusted Life Years (DALYs) are the sum of life years lost due to illness through premature mortality and reduced quality of life. The total number of DALYs (lost due to osteoporotic fracture) is given as 5.8 million worldwide. Fractures in Europe and the USA account for 51% of these. In Europe osteoporotic fractures are responsible for more DALYs than the most common forms of cancer (except lung cancer) [21].

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Tab. 1: Comparison of desired nutritional intakes (optimised mixed food intake) with actual nutritional intakes amongst Austrian pre-school children (3–6 yrs) [23] Food group

Recommended amounts

Study results

% of recommended amount

Milk, dairy products (ml/d)

350

281

80

Fruit (excl. fruit juices) (g/d)

180

113

63

2

1

50

Fish (g/week)

100

36

36

Vegetables (g/d)

180

49

27

Eggs (number/week)

Tab. 2: Comparison of desired nutritional intakes (optimised mixed food intake) with actual nutritional intakes amongst Austrian apprentices (15–18 J) [23] Food group

Recommended amounts

Study results


90

151

168

Fruit (excl. fruit juices) (g/d)

300

135

45


500

193

39

3

1

33

Vegetables (g/d)

300

77

26

Fish (g/week)

200

41

21

Meat, sausage (g/d)

Eggs (number/week)

Tab. 3: Comparison of desired nutritional intakes with actual nutritional intakes (mean) amongst Viennese seniors. Modified from Ref. [24] Food group

Recommended amounts

Study results


Meat, sausage (g/d)

300

651

217

Fruit (excl. Fruit juices) (g/d)

250

220

88


200

213

107

Vegetables (g/d)

400

145

36

Fish (g/week)

150

112

75

positively affect the bones. Conversely a high protein and salt intake can have a negative effect on calcium balance, although it must be noted that older people often suffer from protein deficiency, which, in terms of bone health and for other reasons, is totally undesirable. A comparison of recommended and actual nutritional intake amongst Austrian pre-school children (aged 3–6 years), Austrian apprentices, and Viennese seniors are shown in Tabs. 1–3. Calcium intake is relatively good in Austrian preschoolers (3–6 years), although the average intake is still

lower than the recommended value. Boys and girls in this age group take in 646 mg and 663 mg calcium per day, respectively [23]. The recommended intake is 700 mg [25]. For older children and adolescents the average intake of this important bone mineral is markedly below the recommendations. Adult men have, on average, a sufficient calcium intake, ranging between 987 and 1045 mg, depending on age group [23] compared with a recommended 1000 mg [25]; however, the average intake for women is much too low. Austrian women have an average

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exercised regularly. Furthermore, men were generally more active than women. Thirty-seven percent of women reported never exercising compared to 29% of men. The proportion of men and women reporting physical activity on a daily basis was the same for both; however, twice as many men than women reported being physically active on several days per week [30]. European comparison shows Austria as lying below the EU average [31]. In terms of smoking Austria still shows an undesirable trend. Over the last 30 years the number of smokers in Austria has risen steeply. This is above all attributable to the increasing numbers of women who smoke, the proportion of whom has almost tripled since the 1970s. The proportion of female smokers has doubled over the last ten years alone. Meantime there is barely a difference between the proportion of women who smoke and the proportion of men. Amongst the men a decrease in smoking was even been observed since the 1990s, although by the end of the 90s this rose again sharply [32]. In a Viennese survey (Wiener Gesundheits- und Sozialbericht), the highest proportion of smokers was found amongst the younger age group. 56.1% of 16–24 year old men and 51.6% of 16–24 year old women smoked on a daily basis [33].

calcium intake of only 844 to 938 mg [23] compared with the recommended 1000 mg [25]. Amongst seniors the situation is particularly drastic; here intake for men falls much further below recommendations than for women. Men aged 65 years and over, have a daily calcium intake of 661 mg and women in this age group, 727 mg [23]. Again the recommendation lies at 1000 mg [25]. The Austrian Study Group on Normative Values of Bone Metabolism found in 648 female and 400 male subjects (age 21–76 years) a mean calcium intake of 569 mg, ranging from 40 to 2170 mg. Serum Ca2 þ was less than normal in 7.8% of the tested subjects [26]. Vitamin D intake is distinctly lower than the recommended intake for all age groups. The recommended daily vitamin D intake is 5 mg. For the age group 65 years and over the recommended daily intake is 10 mg [25]. Here too the situation is particularly serious, not only amongst the elderly, but also amongst children and adolescents. The mean vitamin D intake in Austrian pre-schoolers is 2.1 or 1.9 mg per day. Amongst the 65þ adults the daily vitamin intake lies at a mere 5.4 and 2.6 mg for men and women respectively [23]. On a more positive note the consumption of dairy products and also fish, the main suppliers of calcium and vitamin D, has risen over the past 4 decades [27]. The average vitamin D intake found by the Austrian Study Group on Normative Values of Bone Metabolism was 101 IU, ranging from 0.2 to 320 IU. 26% of the subjects had hypovitaminosis D with serum 25(OH) D < 12 ng/ml [26]. The prevalence of underweight, a risk factor of osteoporosis, is relatively low in Austria, although it should not be underestimated as a problem amongst older people. According to the Austrian nutrition report the prevalence of underweight (BMI < 18.5 kg/m2) amongst Viennese senior lies at between 10% and 29%, increasing with increasing age group [23, 28]. Amount of physical activity undertaken appears to be ever decreasing in Austria, which, in connection with osteoporosis, is an unwelcome trend. Children and adolescents are becoming more and more sedentary. In 1991/92 Austrian children spent 76 minutes per day in front of the television and 16 minutes per day in front of the computer. In comparison to 1998 this had risen to 148 and 90 minutes respectively [29]. The approach to exercise amongst Austrian adults leaves a lot to be desired. In a study of 1000 participants carried out in 2000 only 40% of Austrians reported undertaking regular physical exercise that is being physically active on least one day and up to seven days per week, whereby most of these were in the younger age groups. Amongst the over 50 year olds only 16% were regularly physically active. Amongst the 14–29 year olds, on the contrary, 62%

Osteoporosis presents a public health challenge on many levels. Public health aims are promoting bone health, achieving the highest possible peak bone mass and maintaining a high bone mass to prevent or hinder the development of osteoporosis. Screening high-risk groups to ensure timely diagnostics and integrated care, including therapeutic and rehabilitative measure, as well as, prevention of falls for patients with osteoporosis are key aims. These require population campaigns targeting all age groups, and which occur at individual, community and health care level. Public Health strategies on all three levels are summarised in Tab. 4. Public health measures at individual level aim at informing and motivating large population groups, to contribute positively to their own personal bone health and thus achieve osteoporosis prevention. Each individual can, through adequate lifestyle measures, significantly influence their bone health. In a statement from the National Osteoporosis Foundation following public health recommendations were made for each age group: * Calcium intake amongst adults should be between 1000 and 1500 mg/day. This intake is also warranted for both people taking specific medication


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Public health strategies

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Tab. 4: Public health strategies with regard to osteoporosis at individual, health care and community level. Modified from Refs. [25, 37, 39, 40] Individual level

Health care level

Community level

*

*

*

*

* * *

Optimised nutrition with sufficient amounts of calcium and vitamin D, fruits and vegetables and moderate amounts of salt More and more regular physical exercise in all age groups Maintenance of a healthy body weight Avoidance of cigarette smoking Alcohol if, than only in moderate amounts

*

*

*

Risk assessment: draw attention to alarm signals! Regular assessment of risk factors for the calculation of 10-year fracture risk (age, BMI, fracture after age of 50, cigarette smoking, use of alcohol, hip fracture in parents medical history, therapy with glucocorticoids, rheumatoide arthritis) Bone densitometry measurement only after a structured risk assessment Initiation of adequate therapy

*

*

*

Specific bone health promotion and osteoporosis prevention awareness campaigns Osteoporosis prevention in all age groups (e.g. in schools and for seniors) Possibly enrichment of foodstuff, but only under stricked controls Plans for sustained prevention of osteoporosis have been developed by the EU

for osteoporosis and those not on medication. If calcium supplementation is necessary, low price preparations should be used for reasons of cost effectiveness. * People at risk of vitamin D deficiency should receive 400–800 IU Vitamin D per day. * Population information should be made available, which can contribute to increasing level of exercise, reduction or hindrance of fractures, as well as, all the other benefits that exercise brings with it. * Smokers should be encouraged to stop smoking and remain abstinent [34]. A very comprehensive concept for osteoporosis prevention has been developed by the initiative Arznei & Vernunft. According to this initiative, every health promotion activity is also primary osteoporosis prevention. This stretches across all five pillars of health promotion and preventive medicine: healthy nutrition, sufficient exercise, positivity, non-smoking, and avoidance of accidents. To obtain and maintain the highest possible peak bone mass, osteoporosis prevention must begin in childhood, with physical exercise, above all high impact sports and appropriate nutrition, and sufficient intake of milk and dairy products [35]. Health care professionals in many different areas have an important role in the prevention of bone diseases. On the one hand, their frequent contact with people place them in an ideal situation to provide information on nutrition, exercise and other behaviours having a positive influence on bone health. On the other hand, it is important that health experts are also able to estimate the level of risk their patients have of developing osteoporosis and suffering a bone fracture in order that appropriate measures may be initiated soon enough. Within the health system expensive diagnostic techniques and treatment methods should ideally only be applied in specific cases where patients are exposed

to particular risk. Screening for personal risk, for example, within the framework of a health examination could serve to identify people with a high risk for osteoporosis or fracture, regardless of whether they belong to a particular risk group or not, and further diagnostic steps be taken when necessary. Screening people at risk would be desirable in Austria in order, on the one hand, to avoid unnecessary costs of bone density measurements and treatment, and on the other hand to identify high risk cases where a bone density examination is in fact necessary, and which may previously have been missed. In this vein national and international organisations have provided recommendations for structured risk assessments, prior to referral for further expensive examinations [35–39]. Factors considered as part of a risk assessment prior to possible referral for a bone mineral densiometry include age, body mass index (BMI), fracture at aged 50 years or over, nicotine consumption, alcohol abuse, hip fracture in a parent, glucocorticoid therapy, and the presence of rheumatoid arthritis [37]. At present most of the instruments developed for rapid risk assessment include only a few factors associated with osteoporosis risk, indeed some only include two factors (age and sex), although many also include factors such as oestrogen intake, weight, ethnic origin, and personal fracture history. A further screening instrument is the falls assessment which is currently only a part of geriatric history taking and the basic geriatric assessment. It helps to identify patients with a higher risk of falls in order to provide them with targeted diagnostics and above all information on preventive measures. Besides adequate tools for the assessment of personal risk, training and provision of information on preventive measures are sensible for both doctors and health care professional alike, as well as, the population in general. For Austria consensus statements have been published, wherein the most

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recent scientific results have been incorporated into recommendations on preventive measures and treatment [35–38]. Owing to the enormous costs that osteoporosis and the associated fractures place on the health system, it is not only in an individuals interest to pay attention to bone health. The provision of, and advice on, preventive measures should, also be high on the political agenda. According to the prognoses of incidence of osteoporotic fractures over the coming decades a vast increase in costs may be expected. Recommendations for the prevention of metabolic bone diseases have also been set out by the EU [40]. In the EU Action Plan further steps for the implementation of these recommendations have been suggested. These steps include campaigns for raising awareness of osteoporosis, preventive measures (lifestyle factors), development of guidelines for the prevention of osteoporosis-related fractures, treatment of fractures, rehabilitation and prevention of falls, compilation of economic data, as well as, the evaluation of preventive activities [40]. Public health strategies for healthy bones are also described in European Action towards Better Musculoskeletal Health. In this case these are tailored to particular target groups. Thus there are strategies for the total population, strategies for high-risk groups, as well as, strategies for those people already affected [41]. A further Public Health intervention measure is the enrichment of foodstuffs. In Austria there are as yet no legal requirements with regard to enrichment with calcium or vitamin D. In the USA and Canada, for example, the enrichment of food products with vitamin D has been largely successfully implemented [42–44]. Numerous prevention studies show that awareness campaigns and exercise programmes with both children and adults, as well as older adults can bring about a change in lifestyle and subsequently promote bone health [45–49]. The Austrian Osteoporosis Report reveals that osteoporosis is a disease which places a severe burden on the health system. Furthermore, the prevalence of modifiable risk factors is high in all age groups. The data of the Austrian Osteoporosis Report help to reveal demands for action in the public arena. The public health recommendations incorporated in the report provide important sources for strategic development in health care and of preventative measures.

The authors declare that there is no conflict of interest.

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