The Epidemiology of Osteoporosis in Men

The Epidemiology of Osteoporosis in Men: History

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Auro Caraffa

Osteoporosis is called the ‘silent disease’ because, although it does not give significant symptoms when it is not complicated, can cause fragility fractures with severe short and long-term consequences until premature death. Men experiencing hip fractures have a higher likelihood of premature death than women during the hospital stay as well as after years from index event.

bone fragility
fractures
male
prevention

1. Fragility Fractures in Men

In 2008, as many as 109,000 men suffered osteoporotic fractures in the US ^[1]. Data from 2005 indicate that, of the 2 million osteoporotic fractures that occur annually in the US, 29% are men. This percentage corresponds to the associated US $ 17 billion in costs ^[2]. In men, the incidence of hip fractures range from 0.56 per 1000 per year at the age of 60 to 13 per 1000 per year in subjects aged 85 was found ^[1]. These data were extracted from the U.S. 2008 Nationwide Emergency Department Sample. Similar results were reported by Diamantopoulos et al., in a Norwegian study covering the years 2004 and 2005: an incidence of 0.49 per 1000 person years of hip fractures at age 60, 12.3 hip fractures per 1000 person years in subjects aged 85 was found ^[3]. It has been calculated that around 80,000 men break their hips every year ^[1]. In a 22-year follow-up study conducted at the Skåne University Hospital, Malmö, Sweden, on 226 hip fractured men, one in three died within a year after the injury and another one-third underwent a new fracture ^[4].

The risk of a hip fracture in elderly men is 5–6%, compared to 16–18% for women. This would mean that 30% of all hip fractures affect men ^[5]^[6]^[7]. This represents a higher percentage than commonly believed.

In 2025, hip fractures are expected to increase by 89% worldwide compared to 2000, with about 800,000 fractures per year ^[8]. The risk of at least one fragility fracture in a 50-year-old man was calculated to be 13% (versus 40% for women), and 25% in an 80-year-old man ^[9]^[10]^[11]^[12]. A prospective observational study showed that the relative risk (RR) of low-impact trauma fractures is higher in men than in women aged 60 years or older ^[12]. For what concerns the age of highest incidence of fractures, in a prospective 12-year study carried out in the Dubbo study (Australia), although men have a higher risk of hip fractures after the age of 80, half of hip fractures in men occur before that age ^[13]. An epidemiological observation showed how, in women, the incidence of vertebral fractures increases rapidly after the age of 55, while this phenomenon occurs in men after the age of 65. As for hip fractures, the incidence shows a rapid growth of its curve after 65 in women and after 75 in men ^[14].

As regards the risk of falling, sustain more fall related injuries women tend to fall more than men and sustain more injuries related to falls than men ^[15]. An epidemiological study by Sattin et al. ^[16] carried out in Miami, Florida, revealed that, in subjects aged 85, the risk of falling is 138.5 per 1000 for men and 156.8 per 1000 for women. According to the data reported by Stevens et al. ^[17], obtained from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP), the annual rates of non-fatal injuries due to falls for women were 48.4% higher than the rates for men (in 2005, average 5466.7 non-fatal falls per 100,000 population for women, average 3674 non-fatal falls per 100,000 population for men).

2. Mortality

Scientific evidence shows that men have more osteoporosis-related complications and a higher mortality rate after osteoporosis fractures than women starting at the time of the hospital admission due to hip fractures ^[18]^[19]^[20]^[21]. Several authors confirm that, in the first year after a hip fracture, there is a higher mortality in men than in women ^[22]^[23]^[24]^[25], but the greatest mortality in men is also present after a vertebral fragility fracture ^[16]. In the prospective cohort from the Dubbo Osteoporosis Epidemiology Study of community-dwelling women and men aged 60 years and older from Dubbo, Australia ^[12], the authors reported that, in women, there were 952 low-trauma fractures followed by 461 deaths (48.4%), and in men, 343 fractures were followed by 197 deaths (57.4%) within 10 years. Kim reported a 6% lifetime risk of hip fracture in men ^[1]. The epidemiological data by Bow et al., showed that, in the Asian race, the lifetime risk is about half compared to the Caucasian race ^[26]. In fact, the causes for which mortality in men is higher than in women have not been clearly demonstrated. Infection is one possible explanation for the observed mortality rate ^[27]. Other studies ^[28]^[29] about mortality rate in osteoporotic men are summarized in Table 1.

Table 1. Summary of studies exploring mortality in men with osteoporosis.

Authors, Year	Study Design and Sample	Outcomes
Brown et al., 2021 ^[28]	Population-based retrospective 1:1 matched-cohort to controls using ICD-10 diagnostic codes for fractures from 1 January 2011 to 31 March 2015, in Ontario, Canada.	- Crude relative mortality risk 2.47- and 3.22-fold higher in matched fractured vs. non-fractured women and men, respectively. - 1 year absolute mortality risk post-fracture was 19.5% in men and 12.5% in women with fractures - absolute risk difference of 7.4% (95% CI 7.1–7.7%) in women and 13.5% (95% CI 12.9–14.0%) in men when compared to matched non-fracture controls
Lee et al., 2021 ^[29]	Korean National Health Insurance Research Database, the researchers analyzed the cohort data of 24,756 patients aged > 60 years who sustained fractures between 2002 and 2013.	Mortality risk is higher in men than in women depending on the type of fracture: - the first hip fracture (HR, 2.25; 95% CI, 1.92–2.64 in women and HR, 1.96; 95% CI, 1.60–2.41 in men) - the first vertebral fracture (HR, 1.33; 95% CI, 1.15–1.53 in women and HR, 1.23; 95% CI, 1.01–1.48 in men) and the the number of subsequent fractures: in women - one, HR, 1.63; 95% CI, 1.48–1.80; - two, HR, 1.75; 95% CI, 1.47–2.08; - three or more, HR, 2.46; 95% CI, 1.92–3.15 in men - one HR, 1.42; 95% CI, 1.28–1.58; - two, HR, 2.03; 95% CI, 1.69–2.43; - three or more, HR, 1.92; 95% CI, 1.34–2.74
Bliuc et al., 2015 ^[21]	The Dubbo Osteoporosis Epidemiology Study prospective study Women and men ≥ 60 years followed from 1989 to 2011 with incident osteoporotic fractures (528 women and 187 men)	Similar distribution of fracture type in men and women - hip fracture (13% to 17%) - vertebral fracture (31% to 32%), - non-hip non-vertebral fracture (51% to 56%) RR of subsequent fracture is >2.0-fold for all levels of BMD - normal BMD: 2.0 (1.2 to 3.3) for women and 2.1 (1.2 to 3.8) for men; - osteopenia: 2.1 (1.7 to 2.6) for women and 2.5 (1.6 to 4.1) for men; - osteoporosis 3.2 (2.7 to 3.9) for women and 2.1 (1.4 to 3.1) for men. Post-fracture age-adjusted standardized mortality ratio is higher in men than women and increase with bone loss - osteopenia 1.3 (1.1 to 1.7) and 2.2 (1.7 to 2.9) for women and men, respectively, - osteoporosis 1.7 (1.5 to 2.0) and 2.7 (2.0 to 3.6) for women and men, respectively
Jiang et al., 2005 ^[22]	Population-based cohort of 3981 hip fracture patients ≥60 years admitted to hospitals in a large Canadian health region from 1994 to 2000	In-hospital mortality is 6.3%; 10.2% for men and 4.7% for women (adjusted odds ratio, 1.8; 95% CI, 1.3–2.4). Mortality at 1 year is 30.8%; 37.5% for men and 28.2% for women (adjusted p < 0.001)
Kiebzak et al., 2002 ^[25]	medical records from 363 patients (110 men and 253 women) aged 50 years and older with fragility hip fracture St Luke’s Episcopal Hospital between 1 January 1996, and 31 December 2000.	The 12-month mortality was 32% in men, compared with 17% in women (p = 0.003)
Center et al., 1999 ^[18]	5-year prospective cohort study in the semi-urban city of Dubbo, Australia, of all residents aged 60 years and older (2413 women and 1898 men).	Age-standardised mortality ratios are higher in men than in women for proximal femur (OR 3.17; CI95% 2.90–3.44 vs. OR 2.18; 95% CI 2.03–2.32); for vertebral sites (OR 2.38; 2.17–2.59 vs. OR 1.66; 95%CI1.51-1.80; and, for other major fractures (OR 2.22; 95%CI 1.91–2.52 and OR 1.92; 95% CI 1.70–2.14).
Diamond et al., 1997 ^[23]	Cohort study: 51 men aged ≥60 years and 51 age-matched women presenting to St George Hospital (a 650-bed tertiary care centre) with hip fractures, recruited retrospectively in 1995 from medical records and evaluated prospectively at 6 and 12 months after fracture.	14% men died in hospital compared with 6% of women (p = 0.06); men had more risk factors for osteoporosis (p < 0.01).

This entry is adapted from the peer-reviewed paper 10.3390/ijms22042105

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