Defining ethnic and racial differences in osteoporosis and fragility fractures

Abstract

Background: Osteoporotic fractures are a major public health issue. The literature suggests there are variations in occurrence of fractures by ethnicity and race.

Questions/purposes: My purpose is to review current literature related to the influence of ethnicity and race on the (1) epidemiology of fracture; (2) prevalence of osteoporosis by bone mineral density; (3) consequences of osteoporotic hip fracture; (4) differences in risk fracture for fracture; and (5) disparities in screening, diagnosis, and treatment of osteoporosis.

Methods: Current literature was selectively reviewed related to osteoporosis, ethnicity, and race.

Results: Ethnicity and race, like sex, influence the epidemiology of fractures, with highest fracture rates in white women. Bone mineral density is higher in African Americans; however, these women are more likely to die after hip fracture, have longer hospital stays, and are less likely to be ambulatory at discharge. Consistent risk factors for fracture across ethnicity include older age, lower bone mineral density, previous history of fracture, and history of two or more falls. Ethnic and racial disparities exist in the screening, diagnosis, and treatment of osteoporosis.

Conclusions: Across ethnic and racial groups, more women experience fractures than the combined number of women who experience breast cancer, myocardial infarction, and coronary death in 1 year. Prevention efforts should target all women, irrespective of their race/ethnicity, especially if they have multiple risk factors.

Fig. 1

Lifetime risk (%) of hip fracture at age 50 years in men (M) and women (W) is shown according to country [23]. The frequency of hip fractures varies greatly by race and ethnicity. Reproduced with permission and copyright 2002 of John Wiley & Sons, Inc, from Kanis JA, Johnell O, De Laet C, Jonsson B, Oden A, Ogelsby AK. International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res. 2002;17:1237–1244. Morales-Torres J, Gutierrez-Urena S; Osteoporosis Committee of Pan-American League of Associations for Rheumatology. The burden of osteoporosis in Latin America. Osteoporos Int. 2004;15:625–632.

Fig. 2

A graph shows annualized rates of fracture by race/ethnicity according to the Women’s Health Initiative Observational Study [8]. The annualized rates are greater than 2% for white and Native American women and lower for African American, Hispanic, and Asian women. Reproduced with permission and copyright 2007 of John Wiley & Sons, Inc, from Cauley JA, Wu L, Wampler NS, Barnhart JM, Allison M, Chen Z, Jackson R, Robbins J. Clinical risk factors for fractures in multi-ethnic women: The Women’s Health Initiative. J Bone Miner Res. 2007;22:1816–1826.

Fig. 3

Fractures are more common in minority women than MI/CHD death, stroke, and breast cancer combined in 1 year [7]. Data are expressed as number of cases per year per 10,000 women. Reproduced with kind permission and copyright 2008 of Springer Science + Business Media BV from Cauley JA, Wampler NS, Barnhart JM, Wu L, Allison M, Chen Z, Hendrix S, Robbins J, Jackson RD; Women’s Health Initiative Observational Study. Incidence of fractures compared to cardiovascular disease and breast cancer: The Women’s Health Initiative Observational Study. Osteoporos Int. 2008;19:1717–1723. MI/CHD = myocardial infarction/coronary heart disease.

Fig. 4A–B

(A) The graph shows the prevalence of osteoporosis in NHANES III (1988–1994) and NHANES (2005–2006) for women regarding femoral neck BMD. The overall prevalence of osteoporosis by BMD was about 18% in white women from 1988 to 1994 and declined to about 10% from 2005 to 2006. (B) The graph shows the prevalence of low BMD in NHANES III (1988–1994) and NHANES (2005–2006) for women regarding femoral neck BMD [24]. The prevalence of low bone mass (T score of −1 to < −2.5) did not change over time. Reproduced with permission and copyright 2010 of John Wiley & Sons, Inc, from Looker AC, Melton LJ 3rd, Harris TB, Borrud LG, Shepherd JA. Prevalence and trends in low femur bone density among older US adults: NHANES 2005–2006 compared with NHANES III. J Bone Miner Res. 2010;25:64–71.

Fig. 5

A graph shows fracture rates per 100 person-years by age among women of different ethnic origin [1]. The fracture rates increased with age in all ethnic and racial groups. Reproduced with permission and copyright 2005 of John Wiley & Sons, Inc, from Barrett-Connor E, Siris ES, Wehren LE, Miller PD, Abbott TA, Berger ML, Santora AC, Sherwood LM. Osteoporosis and fracture risk in women of different ethnic groups. J Bone Miner Res. 2005;20:185–194.

Fig. 6

A graph shows fracture rates per 100 person-years by ethnicity and T-score according to the National Osteoporosis Risk Assessment Study [1]. Across all ethnicities, low BMD is a consistent risk factor for fractures. Reproduced with permission and copyright 2005 of John Wiley & Sons, Inc, from Barrett-Connor E, Siris ES, Wehren LE, Miller PD, Abbott TA, Berger ML, Santora AC, Sherwood LM. Osteoporosis and fracture risk in women of different ethnic groups. J Bone Miner Res. 2005;20:185–194.

Fig. 7

Graph shows annualized incidence rate of fracture by the total number of risk factors across ethnic group [8]. Women with eight or more risk factors had twice the rate of fracture compared to women with four or fewer risk factors. Reproduced with permission and copyright 2007 of John Wiley & Sons, Inc, from Cauley JA, Wu L, Wampler NS, Barnhart JM, Allison M, Chen Z, Jackson R, Robbins J. Clinical risk factors for fractures in multi-ethnic women: The Women’s Health Initiative. J Bone Miner Res. 2007;22:1816–1826.

Fig. 8A–B

Graphs show (A) female and (B) male Medicare beneficiaries with fracture claims (hip, distal forearm, or spine) and the proportion with osteoporosis diagnosis by age [9]. The proportion of African American women who, despite their fracture, are diagnosed with osteoporosis is less than 40%, even after age 80 years. Reproduced with kind permission and copyright 2009 of Springer Science + Business Media BV from Cheng H, Gary LC, Curtis JR, Saag KG, Kilgore ML, Morrisey MA, Matthews R, Smith W, Yun H, Delzell E. Estimated prevalence and patterns of presumed osteoporosis among older Americans based on Medicare data. Osteoporos Int. 2009;20:1507–1515.