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Extended report
The global burden attributable to low bone mineral density
  1. L Sànchez-Riera1,2,
  2. E Carnahan3,
  3. T Vos3,
  4. L Veerman4,
  5. R Norman4,5,
  6. S S Lim3,
  7. D Hoy4,
  8. E Smith1,
  9. N Wilson1,
  10. J M Nolla2,
  11. J S Chen1,
  12. M Macara1,
  13. N Kamalaraj6,
  14. Y Li7,
  15. C Kok1,
  16. C Santos-Hernández8,
  17. L March1
  1. 1Northern Clinical School, Institute of Bone and Joint Research, University of Sydney, St Leonards, New South Wales, Australia
  2. 2Institut d'Investigació Biomèdica de Bellvitge, Hospital Universitari de Bellvitge, Departament de Reumatologia, L'Hospitalet de Llobregat, Barcelona, Spain
  3. 3Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
  4. 4School of Population Health, University of Queensland, Herston, Queensland, Australia
  5. 5Queensland Children's Medical Research Institute, University of Queensland, Herston, Queensland, Australia
  6. 6University of New South Wales, New South Wales, Australia
  7. 7The George Institute for Global Health, University of Sydney, Sydney, New South Wales, Australia
  8. 8Centro Universitario del Sur, CUSUR, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
  1. Correspondence to Dr Lídia Sànchez-Riera, Institut d'Investigació Biomèdica de Bellvitge, Hospital Universitari de Bellvitge, Department Reumatologia, Feixa Llarga s/n, L'Hospitalet de Llobregat, Barcelona 08907, Spain; 37416lsr{at}


Introduction The Global Burden of Disease Study 2010 estimated the worldwide health burden of 291 diseases and injuries and 67 risk factors by calculating disability-adjusted life years (DALYs). Osteoporosis was not considered as a disease, and bone mineral density (BMD) was analysed as a risk factor for fractures, which formed part of the health burden due to falls.

Objectives To calculate (1) the global distribution of BMD, (2) its population attributable fraction (PAF) for fractures and subsequently for falls, and (3) the number of DALYs due to BMD.

Methods A systematic review was performed seeking population-based studies in which BMD was measured by dual-energy X-ray absorptiometry at the femoral neck in people aged 50 years and over. Age- and sex-specific mean ± SD BMD values (g/cm2) were extracted from eligible studies. Comparative risk assessment methodology was used to calculate PAFs of BMD for fractures. The theoretical minimum risk exposure distribution was estimated as the age- and sex-specific 90th centile from the Third National Health and Nutrition Examination Survey (NHANES III). Relative risks of fractures were obtained from a previous meta-analysis. Hospital data were used to calculate the fraction of the health burden of falls that was due to fractures.

Results Global deaths and DALYs attributable to low BMD increased from 103 000 and 3 125 000 in 1990 to 188 000 and 5 216 000 in 2010, respectively. The percentage of low BMD in the total global burden almost doubled from 1990 (0.12%) to 2010 (0.21%). Around one-third of falls-related deaths were attributable to low BMD.

Conclusions Low BMD is responsible for a growing global health burden, only partially representative of the real burden of osteoporosis.

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