Fracture Incidence and the Relevance of Dietary and Lifestyle Factors Differ in the United Kingdom and Hong Kong: An International Comparison of Longitudinal Cohort Study Data

Fewer spine degenerations among Southeast Asians than among Southern Chinese suggests populations from a warmer climate have inherently better spine health

Background

Compared with older Caucasians, older Chinese have remarkably lower prevalence and lower severity of spine degenerative changes. There have been few studies on Southeast East populations. This study aims to compare radiographic spine degeneration features among older Hong Kong (HK) Chinese, older Thais, and older Indonesians.

Methods

This study included 195 Thai women (mean: 73.6 years), 202 Thai men (mean: 73.7 years), 227 Indonesian women (mean: 70.5 years), and 174 Indonesian men (mean: 70.2 years), as well as same number of gender- and age-matched HK Chinese. The recruitment plan was that the participants would represent the general older population of their respective communities. With spine radiograph, spine hyper-kyphosis, osteoarthritic wedging (OAw), acquired short vertebrae (SVa), general osteophyte formation, lumbar disc space narrowing, and lumbar spondylolisthesis were assessed.

Results

Compared with Southeast Asians (Thais and Indonesian data together), Chinese women and men had a higher prevalence of hyper-kyphosis (24.9% vs. 16.4%), OAw (2.4% vs. 0.9%), general osteophyte formation (15.3% vs. 10.5%), lumber disc space narrowing (27.6% vs. 20.3%), and lumbar spondylolisthesis (20.7% vs. 15.3%). The trends were also consistent for sub-group data analyses. An even lower prevalence was noted among Indonesian women and men than among Thais in general osteophyte formation (5.9% vs. 14.1%), lumbar disc space narrowing (18.3% vs. 24.1%), and lumbar spondylolisthesis (11.4% vs. 19.3%).

Conclusions

This study showed a lower prevalence of spine degeneration changes among older Thais and older Indonesians than among older Chinese. Indonesians, who inhabit an even warmer climate, show even fewer spine degeneration changes than Thais.

For older women, the majority of hip fragility fractures and radiographic vertebral fragility fractures occur among the densitometrically osteoporotic population: a literature analysis

It has been frequently cited that 'the majority of fragility fractures (FF) occur at non-osteoporotic bone mineral density (BMD)'. For the reports with T-score measured around the time of a hip fracture, we conducted a systematic literature search in December 2022, and resulted in 10 studies with five for Caucasian women and five for East Asian women. Femoral neck (FN) T-score was reported in five Caucasian studies and three East Asian studies, three of five Caucasian studies had a mean T-score ≤-2.5, and one study had the majority of their patients measuring a mean T-score ≤-2.5. All three East Asian studies reported a mean FN T-score ≤-2.7. Total hip T-score was reported in two Caucasian studies and three East Asian studies, the two Caucasian studies both had a mean T-score ≤-2.5, and all three East Asian studies had a mean T-score ≤-2.6. A new literature search conducted in April 2024 results in additional three studies, with results being consistent with the data described above. A trend was noted that 'younger' patients suffer from hip fractures at a 'higher' T-score. For the highly cited articles where the notion the majority of FF occur at non-osteoporotic BMD was derived from, authors reported prospective epidemiological studies where BMD was not measured at the timepoint of hip fracture, instead, BMD was measured at the study baseline. These epidemiological studies suggest that >50% of hip fractures likely occur in women with an osteoporotic FN or hip T-score. However, a pattern was seen that older men suffer from hip fracture at a notably higher T-score than older women. For the cases of radiographic vertebral FF, despite varying criteria being used to classify these FFs, the majority of female patients had spine densitometric osteoporosis. Literature shows, compared with the cases of hip fracture, distal forearm fracture occurs at a 'younger' age and 'higher' BMD, suggesting distal forearm fracture is more likely associated with a 'higher' trauma energy level.

Revision of the 1994 World Health Organization T-score definition of osteoporosis for use in older East Asian women and men to reconcile it with their lifetime risk of fragility fracture

The 1994 WHO criterion of a T-score ≤ -2.5 for densitometric osteoporosis was chosen because it results in a prevalence commensurate with the observed lifetime risk of fragility fractures in Caucasian women aged ≥ 50 years. Due to the much lower risk of fragility fracture among East Asians, the application of the conventional WHO criterion to East Asians leads to an over inflated prevalence of osteoporosis, particularly for spine osteoporosis. According to statistical modeling and when a local BMD reference is used, we tentatively recommend the cutpoint values for T-score of femoral neck, total hip, and spine to be approximately -2.7, -2.6, and -3.7 for Hong Kong Chinese women. Using radiographic osteoporotic vertebral fracture as a surrogate clinical endpoint, we empirically demonstrated that a femoral neck T-score of -2.77 for Chinese women was equivalent to -2.60 for Italian women, a spine T-score of -3.75 for Chinese women was equivalent to -2.44 for Italian women, and for Chinese men a femoral neck T-score of -2.77 corresponded to spine T-score of -3.37. For older Chinese men, we tentatively recommend the cutpoint values for T-score of femoral neck, total hip, and spine to be approximately -2.7, -2.6, and -3.2. With the BMD reference published by IKi et al. applied, T-score of femoral neck, total hip, and spine of -2.75, -3.0, and -3.9 for Japanese women will be more in line with the WHO osteoporosis definition. The revised definition of osteoporosis cutpoint T-scores for East Asians will allow a more meaningful international comparison of disease burden.

Fracture risk prediction in old Chinese people-a narrative review

With aging, the burden of osteoporotic fracture (OF) increases substantially, while China is expected to carry the greatest part in the future. The risk of fracture varies greatly across racial groups and geographic regions, and systematically organized evidence on the potential predictors for fracture risk is needed for Chinese. This review briefly introduces the epidemiology of OF and expands on the predictors and predictive tools for the risk of OF, as well as the challenges for their potential translation in the old Chinese population. There are regional differences of fracture incidence among China. The fracture incidences in Hong Kong and Taiwan have decreased in recent years, while it is still increasing in mainland China. Although the application of dual-energy X-ray absorptiometry (DXA) is limited among old Chinese in the mainland, bone mineral density (BMD) by DXA has a predictive value similar to that worldwide. Other non-DXA modalities, especially heel QUS, are helpful in assessing bone health. The fracture risk assessment tool (FRAX) has a good discrimination ability for OFs, especially the FRAX with BMD. And some clinical factors have added value to FRAX, which has been verified in old Chinese. In addition, although the application of the osteoporosis self-assessment tool for Asians (OSTA) in Chinese needs further validation, it may help identify high-risk populations in areas with limited resources. Moreover, the translation use of the muscle quality and genetic or serum biomarkers in fracture prediction needs further works. More applicable and targeted fracture risk predictors and tools are still needed for the old Chinese population.

A comparison of radiographic degeneration features of older Chinese women and older Italian Caucasian women with a focus on thoracic spine

BACKGROUND

Compared with Caucasians, East Asians have a lower incident of back pain, lower prevalence and severity of osteoporotic vertebral fracture and lumbar spine degeneration.

AIM

This study compares radiographic spine degeneration features of older Chinese women (as an example of East Asians) and older Italian women (as an example of Caucasians) with a focus on the thoracic spine.

METHODS

From two population-based epidemiological studies conducted in Hong Kong, China and Rome, Italy, 297 pairs (mean age: 73.6 years) age-matched older community women's lateral spine radiographs were sampled. Existence (or absence) of seven degeneration features were assessed including: (1) hyper-kyphosis, (2) disc space narrowing (T3/T4 ~ T11/T12), (3) osteoarthritic (OA) wedging (T4 ~ T12), (4) generalised osteophyte formation (T4 ~ T12); (5) acquired short vertebrae (T4 ~ T12), (6) Schmorl node (T4 - L5), (7) disc calcification (T4-L5).

RESULTS

Italian women were more likely to have hyper-kyphosis (53.4% vs 25.6%), disc space narrowing (34.4% vs. 17.2%), OA wedging (6.4% vs. 0.67%), Schmorl node (19.5% vs. 4.4%, all P < 0.001). However, there was no statistically significant difference in osteophyte formation (7.7% vs. 9.4%, P > 0.1) and acquired short vertebrae (8.0% vs. 10.4%, P > 0.1). Disc calcification was uncommon among both Chinese and Italians.

DISCUSSION AND CONCLUSION

For the first time, this study documented a lower prevalence of a number of thoracic spine degeneration features among Chinese. This study further affirms the concept of a generally healthier spine in older Chinese relative to older Caucasians. The observed differences may reflect a foundational background influence of genetic predisposition that represents an important line of future research.

A Mini Review on Osteoporosis: From Biology to Pharmacological Management of Bone Loss

Osteoporosis refers to excessive bone loss as reflected by the deterioration of bone mass and microarchitecture, which compromises bone strength. It is a complex multifactorial endocrine disease. Its pathogenesis relies on the presence of several endogenous and exogenous risk factors, which skew the physiological bone remodelling to a more catabolic process that results in net bone loss. This review aims to provide an overview of osteoporosis from its biology, epidemiology and clinical aspects (detection and pharmacological management). The review will serve as an updated reference for readers to understand the basics of osteoporosis and take action to prevent and manage this disease.