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International Journal of Public Health and Clinical Sciences
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An overview of osteoporosis and heath promotional strategies for
community based osteoporosis prevention in Malaysia
Samia A1, Hejar A. R.2*, Suriani I2, Emilia Z.A.3
1
Student, PhD in Epidemiology & Biostatics, Faculty of Medicine and Health Sciences,
Universiti Putra Malaysia.
2
Department of Community Health, Faculty of Medicine and Health Sciences, Universiti
Putra Malaysia.
3
Department of Environmental and Occupational Health, Faculty of Medicine and Health
Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia.
*Corresponding author: Hejar Abdul Rahman, arhejar@yahoo.com
ABSTRACT
Osteoporosis is a global health problem which affects financial resources for prevention and
treatment. It is generally a silent disease, undiagnosed until what would otherwise be a minor
trauma from a fall causing a fracture, most commonly occurs at the hip, spine or wrist. It not
only causes increase economic burden but also leads to social, physical and psychological
consequences which expected to affect more people worldwide by 2050. It is no longer
confined to the growing older population but has implications for all age groups. But with the
progression of age, bone break down slowly over takes bone formation, resulting in gradual
bone loss and more porous, osteoporosis is likely to occur. Such gradual change inevitably
contribute progressively to morbidity. An inactive lifestyle, insufficient calcium intake, heavy
smoking, excessive alcohol consumption, poor diet, menopausal woman, aged over 50, or
have a family history of osteoporosis increase the risk of osteoporotic fractures. Osteoporosis
is preventable with proper nutrition and lifestyle habits at the community level through health
promotion & education which is effective in improving knowledge and awareness. So
educating people on predisposing factors and symptoms of osteoporosis would be one of the
best choice for increasing knowledge of osteoporosis inducing behavioural change in the
period of peak bone density which is beneficial. Public awareness of osteoporosis remains
low, especially in developing countries. So, heath promotional strategies for community
based osteoporosis prevention in Malaysia is essential and recommended.
Keywords: Osteoporosis, prevention, health promotional strategies, Malaysia
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1.0 Introduction
Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and
susceptibility to fracture (NIH Consensus, 2001). World health organization (WHO) defines
osteoporosis as a bone mineral density value more than 2.5 SD below the mean for normal,
young, white women (WHO, 2003). Osteoporosis may be invisible and painless, but this
‘silent’ disease results in fractures which cause pain, disability, and ultimately loss of
independence or premature death. So, people with osteoporosis to protect themselves against
fractures by adopting a bone-healthy lifestyle in tandem with appropriate medical treatment.
2.0 Global Osteoporosis burden
Osteoporosis is a global epidemic. The prevalence of osteoporosis is increasing and affects
the economic status of the world (Barzanji AT, 2013). Osteoporosis is estimated to affect
200 million women worldwide - approximately one-tenth of women aged 60, one-fifth of
women aged 70, two-fifths of women aged 80 and two-thirds of women aged 90 (Kanis JA,
2007). Worldwide, 1 in 3 women over age 50 will experience osteoporotic fractures and 1 in
5 men aged over 50 (Kanis et al, 2000). Globally, osteoporosis causes more than 8.9 million
fractures annually, resulting in an osteoporotic fracture every 3 seconds (Johnell O & Kanis
JA, 2006). By 2050, the worldwide incidence of hip fracture in men is projected to increase
by 310% and 240% in women, compared to rates in 1990 (Gullberg B, Johnell O, Kanis JA,
1997).
In the European Union (EU), in 2010, out of 21.3 million people considered to be at a high
risk for osteoporotic fractures, 12.3 million were left untreated. Fracture risk in the Asian
population is lower compared to the Western population (Kanis et al, 2012). However, with
the rapid expansion of the elderly population in Asia, the incidence of osteoporosis is
projected to increase significantly, so that by 2050, 50% of all hip fractures would occur in
this region (Cooper et al, 1992). It is projected that 45% of the osteoporotic hip fractures will
occur in Asia by 2050, an increase from 26% in 1990 (Gullberg B, Johnell O, Kanis JA,
1997).
Osteoporotic fractures incur significant healthcare and economic burdens. A recent study in
the South Korean population indicated that the societal cost of osteoporotic fractures,
inclusive of direct and indirect medical costs, increased from USD $8.8 million in 2007 to
$149.3 million in 2011(Kim J et al, 2015). Another study in the Eastern Saudi Arabian
population showed that the treatment cost of osteoporotic fractures of the femur for the first
year was USD $628.95 million, with a projected lifetime cost of $9.34 billion in 2025(SadatAli et al, 2015).
Samia A, Hejar A. R., Suriani I, Emilia Z.A.
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3.0 Epidemiology of Osteoporosis in Malaysia
The prevalence of osteoporosis in Malaysia was reported as 24.1% in 2005, predominantly
affecting the hip among the elderly (Lim et al, 2005). Osteoporosis research in Malaysia is
very limited. The most comprehensive survey in hip fracture incidence was performed in
1996–1997 which was a retrospective study, whereby it was demonstrated that the rate was
218/100,000 for women and 88/100,000 for men (Lee JK & Khir ASM, 2007). The direct
hospitalization cost for hip fracture in 1997 was estimated conservatively at RM 22 million
(Lee JK & Khir ASM, 2007).
In Malaysia, significant ethnic differences in hip fracture incidence were found, 63% of
patients presenting with hip fractures were Chinese. This was followed by Malays at 20% and
Indians, 13%. Race-specific incidence data showed that the fracture rates are highest among
the Chinese (160 per 100 000) followed by Indians (150 per 100 000) and Malays (30 per 100
000) (Damodaran et al, 2000). Race and sex-specific incidence data showed that the
incidence was highest among Chinese females (220 per 100 000), followed by Indian females
(200 per 100 000) (Damodaran et al, 2000).
The age-specific incidence was 500 per 100 000 for patients above 75 years, compared to 10
per 100 000 in those between 50 and 54 years and individuals above 50 years of age was 90
per 100,000 populations (Lee & Khir, 2007). These figures translate to a 5.2% lifetime risk
for a woman living to an average female life expectancy of 74 years. Hence a fracture
induced by osteoporosis is likely to be a primary cause of mortality for at least 2.6% of the
female population of Malaysia (Lau et al, 2001).
Females were twice as commonly affected compared to males. The percentage of females in
the population of Malaysia of 70 years and over was 54.2% in 1990 and has estimated that it
will increase to 56.7% by 2020 (Karim, 1997). All these considerations suggest that while
few adequately detailed clinical studies have been undertaken in Malaysia to make accurate
predictions, the next decade will see a strong increase in osteoporosis-related trauma and
resulting morbidity.
4.0 Pathogenesis and Risk factors
In osteoporosis, bone mass decreases gradually and painlessly, resulting in weak, fragile,
brittle bones which are prone to fractures. There are several factors associated with
osteoporosis including age, endocrine changes, lifestyles, general health condition, and
certain medications (Dontas, 2007).
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Table 1: Secondary causes of osteoporosis
Endocrine
Hyperthyroidism,
Hyperparathyroidism,
Cushing
disorder
disease
Gastrointestinal Postgastrectomy, Chronic liver disease, Malabsorption
disorder
syndrome
Bone disease
Osteogenesis imperfect, Malignancy
Drugs
Steroid, Heparin, Furosemide, Thyroxin, progesterone,
cytotoxic drugs.
Others
Hypercalciuria,
Vitamin
D
deficiency,
Hemochromatosis, Hypophosphatasia.
Source: U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A
Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human
Services, Office of the Surgeon General, 2004
Primary osteoporosis is characterized by reduction of bone mass due to the aging process.
Secondary osteoporosis is caused by exogenous drugs or systemic disease affecting bone
metabolism. These causes which list out above in Table 1 must be excluded before primary
osteoporosis is diagnosed as some of these are treatable medical conditions.
Studies had postulated a few mechanisms in the pathogenesis of primary osteoporosis. One
theory is related to chronic inflammatory process influence on the bone turnover. Proinflammatory cytokines have been implicated in the regulation of osteoblasts and osteoclasts
and activation of immune system in the ageing process (Ginaldi et al, 2005; De Martinis et al,
2006). Pelvic bone marrow adipose tissue (BMAT) is another factor postulated in the
pathogenesis. MRI-measured BMAT is strongly inversely correlated with dual-energy x-ray
absorptiometry (DXA) measured Bone marrow density (BMD) independent of other
predictor variables (Lorentzon M, 2006). More research in this area is currently being carried
out.
Table 2: Risk factors
Non-modifiable
1.Advancing age
2.Ethnic group (Oriental & Caucasian)
3.Female gender
4.Premature menopause (<45 years)
including surgical menopause
5.Family history of osteoporosis or
fracture in first degree relative
6.Personal history of fracture as an adult
Modifiable
1.Low calcium and/or vitamin D intake
2.Sedentary lifestyle
3.Cigarette smoking
4.Alcohol intake of more than 3 units daily
5.Caffeine intake of more than 330 mg daily
(more than 3 cups daily)
6.Low body weight (BMI < 19 kg/m2)
7.Estrogen deficiency
8.Frequent falls
Source: U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A
Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human
Services, Office of the Surgeon General, 2004
The risk factors for osteoporosis are well established in many epidemiological studies. They
are classified into modifiable and non-modifiable risk factors which are pointed in Table 2
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above. Intervention on the modifiable risk factors forms the basis for counseling and primary
prevention of osteoporosis in the community.
5.0 Behavioral risks for osteoporosis and fracture
Five factors that are related to behavior or lifestyle have been evaluated for their relationship
to osteoporosis and osteoporosis related fragility fractures: nutrition, cigarette smoking,
alcohol consumption, physical activity and falls.
5.1 Nutrition
Calcium is effective for preventing osteoporotic fractures in postmenopausal women. A metaanalysis reviewed the literature from 1966 to 1997 assessing the effectiveness of calcium
supplementation for the prevention of osteoporotic fractures in postmenopausal women. The
main finding of the review was that increased calcium intake among postmenopausal women
appears to be associated with a small reduction in risk of fracture. Most of these trials found
about a 30% reduction in fracture risk among those taking around 1 gram of calcium
supplement/day. The meta-analysis suggests that 1g/day of dietary calcium is associated with
a 24% reduction in risk of hip fracture. The rate of bone loss in untreated women aged 60 to
80 years is about 0.75% per year and that a 1000 mg calcium supplement halves the rate of
bone loss, 10 years of calcium supplementation would lead to about a 4% higher bone mass
in treated than untreated women. The study also stated that a 4% difference in proximal
femur bone mass is equivalent to 0.25 SD, and the relative risk of hip fracture per 0.25 SD
increase in bone mass is 0.78 (a 22% reduction in risk of hip fracture) (Cummings & Nevitt
1997).
Vitamin D has been extensively studied regarding its impact on osteoporotic fracture risk
reduction. In fact, vitamin D deficiency has been associated with greater incidence of hip
fracture even in developed country, including postmenopausal women (Chapuy et al, 1992).
Women with osteoporosis in United States, who were hospitalized due to hip fractures, 50%
were found to have signs of vitamin D deficiency (LeBoff et al, 1999).
A meta-analysis of 29 studies, with over 63,000 individuals analyzed, looked at calcium and
calcium in combination with vitamin D trials for use in prevention of fracture and bone loss
was recently reported in Australia. The authors concluded that treatment was associated with
a 12% risk reduction in fractures of all types. Trials with higher compliance revealed
significant risk reduction compared to studies with lower compliance. In the 8 studies with
greater than 80% compliance, a 24% risk reduction for all fractures was identified. The
author’s conclusions were that calcium, or calcium in combination with vitamin D
supplementation, was effective in the preventive treatment of osteoporosis in people aged 50
years or older. It appeared that the best effect was seen with minimum doses of 1200 mg of
calcium and 800 units of vitamin D daily (Tang et al, 2007).
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5.2 Cigarette smoking
Smoking is widely considered a risk factor for future fracture. A meta-analysis reviewed 29
cross-sectional studies that related smoking to bone density and 19 cohort and case-control
studies that reported risks of hip fracture in smokers and non-smokers. Lower BMD was
found in postmenopausal women who smoked, and the relative risk of hip fracture rose
progressively with age (Law M.R & Hackshaw A.K, 1997). For osteoporotic fracture, the risk
ratio increased with age, but decreased with age for hip fracture. A smoking history was
associated with a significantly increased risk of fracture compared with individuals with no
smoking history, but the risk ratios were lower than for current smoking (Kanis et al, 2005).
In another meta-analysis, 59,232 men and women (74% female) from ten prospective cohorts
were followed for a total of 250,000 person-years. The effect of current or past smoking, on
the risk of any fracture, any osteoporotic fracture and hip fracture alone was examined using
a Poisson model for each sex from each cohort. Current smoking was associated with a
significantly increased risk of any fracture compared to non-smokers (RR=1.25; 95%
Confidence Interval (CI) =1.15-1.36). Risk ratios were significantly higher in men than in
women for all fractures and for osteoporotic fractures, but not for hip fracture. Low BMD
accounted for only 23% of the smoking-related risk of hip fracture (Kanis et al, 2005).
5.3 Exercise
Physical activity is movement that involves movement as housework, gardening, walking,
and climbing stairs. Exercise is a specific form of physical activity which is planned,
purposeful physical activity performed with the intention of acquiring fitness or other health
benefits. Bone marrow density depends on the level of physical activity, in particular,
immobilization induces marked loss of skeletal tissue, for example in an immobilized limb or
during prolonged bed rest (Kiratli BJ, 2001).
Forty-three RCTs with 4320 participants included in mata analysis to evaluate role of
exercise for preventing and treating osteoporosis in postmenopausal women. The most
effective type of exercise intervention on bone mineral density for the neck of femur appears
to be non-weight bearing high force exercise such as progressive resistance strength training
for the lower limbs (MD 1.03; 95% confidence interval (CI) 0.24 to 1.82). The most effective
intervention for BMD at the spine was combination exercise program (MD 3.22; 95% CI 1.80
to 4.64) compared with control groups (Howe et al, 2011).
Evidence based on per-protocol analyses of individual trials in children and adolescents
indicated that programs incorporating regular weight-bearing exercise can result in 1% to 8%
improvements in bone strength at the loaded skeletal sites. In premenopausal women with
high exercise compliance, improvements ranging from 0.5% to 2.5% have been reported. It
was found a small and significant exercise effect among pre- and early pubertal boys [SMD,
effect size, 0.17 (95% CI, 0.02-0.32)], but not among pubertal girls [-0.01 (-0.18 to 0.17)],
adolescent boys [0.10 (-0.75 to 0.95)], adolescent girls [0.21 (-0.53 to 0.97)], premenopausal
women [0.00 (-0.43 to 0.44)] or postmenopausal women [0.00 (-0.15 to 0.15)] (Riku
Nikander et al, 2010).
These considerations suggest that there is as yet no compelling evidence for the efficacy of
exercise program in fracture prevention. Notwithstanding, there is good evidence that the
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avoidance of immobilization wherever possible is a valuable adjunct to a global program for
osteoporosis. In addition, regular physical activity is associated with improved health and
reduced mortality generally (Lee et al, 1995). Thus, exercise can be encouraged but cannot be
depended upon to reduce the fracture burden in the community.
5.4 Falls
Falls are often the cause of hip fracture, which may result in death, morbidity, and admission
to a nursing home. Muscle strength, in particular lower extremity, should be one of the
factors assessed and treated in older persons at risk for falls (Moreland et al, 2004). Some
stress upon a fragile bone is generally required to precipitate a fracture. Although fragility
fractures may be defined as resulting from minimal trauma, this is merely a convention to
make the distinction from severe trauma (e.g. road traffic accidents) capable of breaking any
bone, including an osteoporotic bone. In many cases, particularly with hip and wrist fractures,
a fall from a standing height is involved and the forces involved may be substantial
(Bouxsein ML, 2001).
A study shown, both active and inactive ambulatory elderly subjects, there was a strong
improvement in lower extremity function based on walking speed and sit-to-stand speed, in
serum 25(OH) D levels (Moreland et al, 2004). In a meta-analysis vitamin supplementation
appeared to reduce falls by 20%, and furthermore if 15 patients were treated with vitamin D,
1 fall could be prevented (Bischoff et al, 2004).
6.0 Population-based prevention
Osteoporotic patients are likely to get fragility fractures if left untreated (Stovall, 2013). A
balanced diet that contains an abundance of fruits, vegetables, protein sources but no cola
beverages has shown to support bone status. Sufficient calcium and vitamin D supplements
have shown to decrease the risk of fractures. Exercise is a safe way to prevent bone loss
(Tucker, 2009).
Bone mass and rates of bone loss are continuously distributed throughout the population, so it
is not possible to distinguish precisely an individual with disease from the normal population.
All of the previously mentioned high risk population for osteoporosis should be aware. Thus,
research should be done to identify the high risk population and assess knowledge, practice,
and attitudes about osteoporosis. But there are several problems with these approaches.
The first is that not all these risk factors are necessarily causally related to osteoporosis; in
particular, uncertainties exist with respect to smoking and moderate alcohol consumption. A
second problem relates to the ability to change a lifestyle habit, as illustrated by the limited
success of risk factor intervention in coronary heart disease (Ebrahim S, 1997). This raises a
third problem, namely that the value and feasibility of population program in osteoporosis
prevention have not been coherently evaluated. This consideration even applies to falls,
where intuition indicates that attempts to prevent falls in elderly people might be of benefit in
reducing fractures. There is, however, currently no controlled trial evidence showing that
strategies which prevent falls serve to decrease the risk of fracture in individuals (Chang et al,
2004).
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A further problem relates to the effect of remedial factors on the frequency of fractures within
a community. Despite the high prevalence of many of these factors, the increase in risk
associated with each is relatively small, as is the attributable risk. Where the attributable risk
is small, the same overall reduction in hip fracture incidence might be achieved by targeting
that segment of the population with the risk factor itself rather than the whole population. If
all the risk factors identified for hip fracture were causal and could be reversed, the impact on
fracture incidence might be as high as 50% (Marks R, 2010). In practice, it is not feasible to
modify the majority of these risk factors, so the potential effect of risk factor modification at
the population level is substantially smaller.
7.0 Recommended strategies
Population-based strategies are, therefore, the only practicable preventive measure. They can
also be advocated as a component of the adequate care of osteoporosis, even where high risk
strategies are applied. Health promotional program could be applied to national campaigns to
improve bone health and can be disseminated through social campaigns, school education
and health education by health professionals. Refer to Table 3 for an overview of
recommended health promotional strategies for specific target groups in Malaysia. One of the
most important initiatives for minimizing the burden of osteoporosis related fractures is to
identify people who have sustained a minimal trauma fracture early and initiate appropriate
treatments.
Table 3: An overview of heath promotional strategies for osteoporosis in Malaysia
Target group
Older/
elderly
people
Key message
 Vitamin D and calcium
intake
 Avoidance of smoking
and alcohol intake
 Falls prevention
 Adequate sun exposure.
Pregnant
women and
their child in
utero

Children and
adolescents

A balanced diet, high in
calcium and vitamin D,
during pregnancy can
promote healthy bone
formation for the child in
utero.
Healthy bone habits
including
a
wellbalanced diet, calcium
intake, vitamin D and
skeletal loading are
important during growth
to reach a high peak bone
Recommended health promotional approach
 Mass media: television and radio
campaigns
 Run healthy lifestyle programs ie.
exercise, falls prevention
 It is important to be informed about
osteoporosis and discuss investigation and
treatment options with a health care
professional in primary health care clinic.
 Encourage GPs to discuss bone health
with patients who are pregnant during
antenatal visit
 Raising awareness of importance of
nutrition during pregnancy for bone health
amongst health professionals.
 Greater emphasis on bone health in health
and sport curriculum
 Provide education to parents on how to
promote their children’s bone health
 Educate physical education teachers
 Promotion of high calcium foods through
school canteens
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Middle age
and
post
menopausal
women


Men

mass.

Rapid bone loss occurs
in the years following
menopause and it is a
common time for women
to develop osteoporosis.
The Osteoporosis SelfAssessment Tool is a
simple way to assess
risk.
Men
can
develop
osteoporosis and it is
often
underdiagnosed
and undertreated, more
so than in women.






Pre
menopausal
female
athletes

People
taking
certain
medications
or treatments

People with
co-morbid
conditions

Female athletes are at
risk
of
developing
amenorrhea which can
affect the ability to
maintain bone mass.
People
undergoing
chemotherapy and long
term
users
of
glucocorticoid therapies
are at increased risk and
should
discuss
prevention/treatment
options with a health
care professional.
Certain conditions or
diseases can increase the
risk
of
developing
osteoporosis, sometimes
earlier in life.










Television,
web-based
and
radio
campaigns, Online forums – Facebook,
Twitter
Displays, presentations or information
sharing at: Women’s Gyms Beauty
Therapists, Coffee Shops, Public toilets,
Bus/train
Mass media - television and radio
campaigns or talk back radio
Encouraging GPs and Pharmacists to
discuss bone health with patients at risk of
developing osteoporosis.
Displays, presentations or information
sharing at: Gyms, sports clubs/events,
Bus/train stations, public toilets
Mass media as television and radio
campaigns or talk back radio
Encouraging GPs and Pharmacists to
discuss bone health with patients at risk of
developing osteoporosis.
Advertisements at sporting events
Mass media - television and radio
campaigns or talk back radio
Raising awareness of the risks amongst
sporting health professionals.
Education for pharmacists to highlight
risks.
Education for GPs to highlight risks.
Educate public about the risks
Education of relevant health professionals
regarding risks
Education for GPs to highlight risks.
Educate public about the risks
Education of relevant health professionals
regarding risks
8.0 Conclusion
Osteoporosis takes many years of slow and insidious imbalance between osteoblastic bone
deposition and osteoclastic bone resorbing which is the real risk of morbidity associated with
fracture. The concept of skeletal health for all age groups has been neglected. There is also
lack of driving force and support to promote bone health. There is still a lack of awareness
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among health care providers Preventive measure should be taken in Malaysia to prevent this
incipient epidemic. Efforts should be made to raise awareness about osteoporosis as a serious
and debilitating disease, increase the priority of osteoporosis at national health policy
planning, consider osteoporosis on the list of chronic & disabling diseases, define essential
care levels at a national level, define future strategies, projects and plan to fight osteoporosis,
to reduce the incidence of osteoporosis related fractures. Programs on prevention,
identification of high-risk individuals, and early diagnosis, and treatment intervention,
prevention of falls, rehabilitation program for patients with fracture should be designed for
Malaysians as well as tackling vitamin D insufficiency. Efforts to create a national
osteoporosis and osteoporosis related fracture database should be a top priority.
Declaration
The authors declare that there is no conflict of interest regarding publication of this article.
Authors declare that this paper is our original work, quotations and citations have been duly
referenced. Also, this paper has not been submitted previously or concurrently for any other
publication.
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