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Speaking up for the ‘silent disease’ in the Asia Pacific

October 27, 2020/
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APCO round-up of World Osteoporosis Day 2020 activities

 

Last Tuesday, October 20, 2020, members of the Asia Pacific Consortium on Osteoporosis (APCO) celebrated with gusto, World Osteoporosis Day (WOD) – an annual International Osteoporosis Foundation (IOF) campaign designed to promote public awareness of osteoporosis, and to support local bone health-related activities in its more than 260 national societies worldwide. We were thrilled to see so many of our APCO members proactively raising awareness of the need for optimal diagnosis, treatment, and prevention of osteoporosis in Asia Pacific (APAC), the world’s most densely populated region. To learn how Australia, New Zealand, Pakistan, Singapore, Thailand, Vietnam and the IOF celebrated this important occasion on the annual public health calendar, read on.

Australia

To commemorate WOD this year, Osteoporosis Australia (OA) called for Australians to take action to protect their bone health by learning to identify the risk factors for osteoporosis. OA shared multiple patient stories on their website and social media channels, and promoted the IOF Risk Check infographic, an invaluable international bone health resource, tailored to the Australian market.

Federal Health Minister, The Hon. Greg Hunt MP, provided a personal video message to mark WOD, during which he thanked OA CEO and APCO Executive Committee Member, Dr Greg Lyubomirsky, Sydney and the Garvan Institute of Medical Research, for their invaluable contribution to protecting the nation’s bone health.

“This is an immensely important topic. Together with OA and the osteoporosis community, we have developed the National Strategic Action Plan for Osteoporosis. We contributed a total of AUD 4 million towards the cause, including AUD 3 million for research into prevention, treatment and ultimately finding a cure. In addition to that, AUD 500,000 was contributed to OA and AUD 500,000 to the work of the Garvan Institute. Now, all of that leads us to where we want to go from here,” said Minister Hunt.

New Zealand

Fracture Liaison Service (FLS) teams in hospitals New Zealand-wide manned stands in their foyers to reinforce the importance of maintaining healthy bones, and ways to proactively prevent osteoporosis. Hospital visitors and staff alike were encouraged to perform a Know Your BonesTM online self-assessment to determine their risk of osteoporotic fracture at bones.org.nz, and were armed with language-specific osteoporosis resources. Waitematā District Health Board (DHB) provided three iPads for visitors to complete the online bone health assessment at their stand.

To further complement these activities, Osteoporosis New Zealand issued regular posts on their Facebook and LinkedIn channels on WOD, encouraging New Zealanders to take the Know Your BonesTM health assessment.

 

Pakistan

The Bone and Mineral Diseases Research Group, Aga Khan University (AKU), Karachi, Pakistan coordinated a virtual webinar to mark WOD. Chaired by APCO Executive Committee member, Prof Aysha Habib Khan, and moderated by AKU Chemical Pathology Senior Instructor, Dr Sibtain Ahmed, the webinar featured APCO Chair, Senior Consultant and Director, Osteoporosis and Bone Metabolism Unit, Singapore General Hospital (SGH), Dr Manju Chandran, Singapore, canvassing her experience of developing the APCO FRAMEWORK on osteoporosis diagnosis and management in the Asia Pacific region, and proposing optimal osteoporosis care solutions for low and middle income countries (LMIC).

Dr Chandran discussed the burden of osteoporosis in Asia Pacific, APCO’s pivotal role in addressing care gaps in osteoporosis management in the region, and the way forward for secondary fracture prevention (SFP) in resource-constrained LMICs, including Pakistan. Prof Khan concluded the webinar by calling for a multi-disciplinary approach to help bridge the osteoporosis care gap, and the delivery of enhanced quality of care to those with bone and mineral diseases, through improved education and research.

The webinar attracted more than 170 health care professionals and policy makers from Pakistan, China, Hong Kong, Afghanistan, Portugal, United Arab Emirates, and the United Kingdom.

Post-webinar queries and comments included the role of goal directed therapy (GDT) for osteoporosis, application of Artificial Intelligence (AI) tools for osteoporosis screening and secondary fracture prevention (SFP) services, and the fact that men too, are at risk of osteoporosis, and therefore require appropriate evaluation and intervention.

 

Singapore

Singapore’s first Virtual public forum on bone health and osteoporosis- ‘Healthy Bones Healthy Families’was held on October 17, to commemorate WOD. A joint endeavour by the Osteoporosis and Bone Metabolism Unit and WISHBONE (Women (and Men) In Support of Healthy Bones) Osteoporosis Support Group at Singapore General Hospital (SGH), the Osteoporosis Society Singapore (OSS) and Women’s Integration Network (WIN) Council of the People’s Association, the event was conducted via Zoom and simultaneously streamed live on Facebook, and has attracted a substantial 10,000 views to date!

The event featured an ‘Investing in your bone bank to have a fail proof retirement’ presentation by APCO Chair, and founder of WISH BONE, Dr Manju Chandran. In addition, Senior Principal Physiotherapist, Department of Physiotherapy, SGH, Dr Cindy Ng, provided an exercise demonstration titled ‘Move it or lose it’, along with a foot-stomping Bollywood Zumba dance demonstration by Owner and Founder of Dancing Feet Dancing Studio, Ms Sneha Yadav, Singapore.

The event concluded with a lively Q&A session with audience-posted questions answered by Drs Chandran and Ng. The event attracted positive feedback and laid the foundations for further potential virtual bone health forums.

 

Thailand

Thai APCO representative and Chief of the Osteoporosis and Geriatric Excellent Center, Police General Hospital, Dr Tanawat Amphansap, Bangkok, participated in a Thai Osteoporosis Foundation (TOPF) hosted Facebook live osteoporosis seminar prior to WOD on October 7, 2020.

To further extend the WOD celebration, the Thai Osteoporosis Foundation plans to stage a ‘Fit Your Bone Run’ to promote the importance of healthy bones on December 20, 2020. The event will involve a 10.5km mini-marathon and a 3km fun run. The winner of the mini-marathon will be awarded a Royal Trophy from Her Royal Highness Princess Maha Chakri Sirindhorn.

 

Vietnam

APCO member and Deputy Head of the Department of Internal Medicine, Pham Ngoc Thach University of Medicine, Dr Lan Ho-Pham, Ho Chih Minh City, staged a local event to mark WOD, offering 100 people at risk of osteoporosis a complimentary DXA BMD scan at the Vietnam Osteoporosis Study (VOS) lab. DXA scans remain the gold standard for measuring BMD in Vietnam and play an important role in evaluating those at risk of osteoporosis.

The IOF

To mark WOD 2020, the IOF uploaded new resources to its dedicated website – www.worldosteoporosisday.org. Under the banner ‘THAT’S OSTEOPOROSIS’, 15 patient stories and portraits in poster format highlighted the role of post-fracture care by family carers, the need to be aware of personal risk factors for osteoporosis (including parental hip fracture), and the importance of bone-healthy nutrition for the entire family. Due to this year’s pandemic restrictions, the IOF chose to focus on digital campaigns to reach consumers and healthcare professionals, via webinars and video messages. The IOF’s 105 social media posts using the hashtag #WorldOsteoporosisDay have reached more than 200,000 people to date.

The IOF was particularly honoured to host a WOD video message from Her Royal Highness the Duchess of Cornwall, President of the Royal Osteoporosis Society, on its website. The organisation also issued a media release via an international news agency with a potential outreach of 1.25 billion people, and an additional release announcing the impact of the COVID-19 pandemic on FRAX risk assessments and osteoporosis management.

 

Dr Chandran congratulated APCO members for their fabulous contribution to WOD 2020, and for championing this seriously neglected disease, stating: “As the region’s largest and only consortium of independent osteoporosis experts, we look forward to continuing to co-create more innovative and elaborate initiatives designed to address the current critical gap in osteoporosis care throughout Asia Pacific.”

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Low Calcium Intake

Reference 1: This review examined calcium intake among adults around the world and found that many populations do not consume enough calcium to support good bone health. The authors highlight that low calcium intake is particularly common in many Asian countries, where average intakes are often well below recommended levels. Because calcium is essential for building and maintaining strong bones, inadequate intake may increase the risk of osteoporosis and fractures. The study emphasises the importance of promoting calcium rich foods and other practical ways to help people meet their daily calcium needs.

Citation: Balk EM, Adam GP, Langberg VN, et al. “Global dietary calcium intake among adults: a systematic review.” Osteoporos Int. 2017 Dec;28(12):3315-3324. doi: 10.1007/s00198-017-4230-x. Epub 2017 Oct 12. Erratum in: Osteoporos Int. 2018 May;29(5):1223. doi: 10.1007/s00198-018-4447-3. PMID: 29026938; PMCID: PMC5684325.

Reference 2: This review explores the important role of calcium in maintaining healthy bones throughout life. The authors explain that adequate calcium intake helps build and maintain bone strength, while long term low intake may contribute to bone loss and increase the risk of fractures. The paper also discusses the importance of obtaining calcium from a balanced diet, with supplements considered when dietary intake is insufficient. Overall, the review reinforces that meeting daily calcium needs is an important part of supporting lifelong bone health.

Citation: Cormick G, Belizan JM. “Calcium Intake and Health.” Nutrients. 2019 Jul 15;11(7):1606. doi: 10.3390/nu11071606. PMID: 31311164; PMCID: PMC6683260.

Reference 3: This review explores how common calcium deficiency is around the world and the impact it can have on health. The authors explain that many people do not consume enough calcium, particularly in low and middle income countries, increasing the risk of poor bone health and fractures. The paper highlights the importance of consuming enough calcium throughout life to help build and maintain strong bones. It also emphasises the need for practical strategies, such as improving access to calcium rich foods, fortified foods, and nutrition education, to help people meet their daily calcium needs.

Citation: Shlisky J, Mandlik R, Askari S, et al. “Calcium deficiency worldwide: prevalence of inadequate intakes and associated health outcomes.” Ann N Y Acad Sci. 2022 Jun;1512(1):10-28. doi: 10.1111/nyas.14758. Epub 2022 Mar 5. PMID: 35247225; PMCID: PMC9311836.

High Sodium Intake

Reference 1: This review explored whether eating too much salt affects bone health in postmenopausal women. The authors found that while high salt intake may increase calcium loss from the body, there is currently not enough high quality evidence to clearly determine its long term effects on bone mineral density or fracture risk. The paper highlights the need for more research to better understand this relationship. In the meantime, following general recommendations to limit excessive salt intake remains an important part of maintaining overall health.

Citation: Imash D, Gusmanov A, Chan MY. “High salt intake and bone health in postmenopausal women: exposing the lack of studies – a systematic review and meta-analysis.” Front Endocrinol (Lausanne). 2025 Nov 19;16:1694539. doi: 10.3389/fendo.2025.1694539. PMID: 41347127; PMCID: PMC12672310.

Reference 2: This study explored whether salt intake was linked to bone health in postmenopausal women in southern India. The authors found that women who consumed more salt were more likely to have weaker bones, poorer bone structure, osteoporosis, and vertebral fractures. These findings suggest that excessive salt intake may be associated with poorer bone health in this population. The study adds to growing evidence that a balanced diet, including limiting excess salt, may help support healthy bones.

Citation: John R, Cherian KE, Kapoor N, et al. “Excess dietary salt is associated with an altered bone strain index, degraded bone microarchitecture, vertebral fractures, and increased prevalence of osteoporosis in postmenopausal women – A study from a teaching hospital in southern India.” Aging Med (Milton). 2024 Oct 10;7(5):606-613. doi: 10.1002/agm2.12360. PMID: 39507226; PMCID: PMC11535168.

Lower Protein Intake Among Older Adults

Reference 1: This review explored how protein intake and regular exercise can help slow the progression of age-related muscle loss in older adults living in the community. The authors found that combining adequate protein with strength or resistance exercise was more effective than either approach alone in helping to maintain muscle strength and physical function. The paper highlights that preserving muscle health is important for reducing the risk of falls, fractures, and loss of independence. It also reinforces the value of healthy lifestyle habits in supporting active and healthy ageing.

Citation: Li L, He Y, Jin N, Li H, Liu X. “Effects of protein supplementation and exercise on delaying sarcopenia progression in Asian community-dwelling older adults.” Food Chem X. 2022 Jan 20;13:100210. doi: 10.1016/j.fochx.2022.100210. PMID: 35128383; PMCID: PMC8808080.

Reference 2: This consensus paper encourages a broader focus on maintaining muscle health throughout life rather than only identifying or treating sarcopenia after it develops. The authors explain that healthy muscles are essential for mobility, balance, independence, and overall wellbeing, especially as people age. The paper highlights the importance of regular physical activity, good nutrition, and early action to help preserve muscle strength and function. It also encourages healthcare professionals and the public to view muscle health as an important part of healthy ageing alongside bone health.

Citation: Chen LK, Hsiao FY, Akishita M, et al. “A focus shift from sarcopenia to muscle health in the Asian Working Group for Sarcopenia 2025 Consensus Update.” Nat Aging. 2025 Nov;5(11):2164-2175. doi: 10.1038/s43587-025-01004-y. Epub 2025 Nov 4. PMID: 41188603.

High Prevalence of Lactose Intolerance

Reference 1: This review explores how lactose intolerance may affect bone health. The authors explain that people who avoid dairy because of lactose intolerance may miss out on important nutrients, particularly calcium, if these nutrients are not replaced from other foods. The paper highlights that getting enough calcium is important for maintaining strong bones and reducing the risk of fractures. It also emphasises that there are many ways to meet calcium needs, including lactose free dairy products and other calcium rich foods.

Citation: Hodges JK, Cao S, Cladis DP, Weaver CM. “Lactose Intolerance and Bone Health: The Challenge of Ensuring Adequate Calcium Intake.” Nutrients. 2019 Mar 28;11(4):718. doi: 10.3390/nu11040718. PMID: 30925689; PMCID: PMC6521087.

Reference 2: This review explores whether drinking milk can help support bone health in Asian populations, particularly those at higher risk of osteoporosis. The authors highlight that many people in Asia consume less milk than recommended, which may contribute to lower calcium intake and poorer bone health. The paper explains that milk provides important nutrients for strong bones and discusses practical options for people who cannot tolerate regular milk, such as lactose free milk and yoghurt. Overall, the review suggests that finding suitable ways to include dairy or alternative calcium rich foods in the diet may help support lifelong bone health.

Citation: Jiao H, Xu Y, Zhang Y, et al. “Is it advisable for Asians to drink milk, especially those at risk of osteoporosis?” Front Nutr. 2025 Jun 25;12:1586623. doi: 10.3389/fnut.2025.1586623. PMID: 40635901; PMCID: PMC12239142.

Reference 3: This review explores ways to protect bone health in populations where calcium and vitamin D intake is often too low. The authors explain that getting enough of these nutrients is essential for building and maintaining strong bones, yet deficiencies remain common in many parts of the world. The paper highlights that healthy eating, safe sun exposure, regular physical activity, and, where needed, fortified foods or supplements can all help support bone health. It also emphasises the importance of public health efforts to improve awareness and make nutritious foods more accessible, particularly for people at greater risk of osteoporosis.

Citation: Yeum KJ, Ju S, Choe U. “Strategies for preventing bone loss in populations with inadequate calcium and vitamin D intake.” Nutr Res Pract. 2025 Apr;19(2):155-169. doi: 10.4162/nrp.2025.19.2.155. Epub 2025 Mar 13. PMID: 40226767; PMCID: PMC11982687.

Vitamin D Deficiency Despite Sunshine

Reference 1: This review examined how common vitamin D deficiency is around the world and found that it remains a widespread public health concern. The authors explain that many people do not get enough vitamin D because of factors such as limited sun exposure, diet, and lifestyle. As vitamin D plays an important role in maintaining strong bones and muscles, low levels may increase the risk of poor bone health. The study highlights the importance of improving awareness and ensuring people have adequate vitamin D through safe sun exposure, diet, fortified foods, or supplements when needed.

Citation: Cui A, Zhang T, Xiao P, Fan Z, Wang H, Zhuang Y. “Global and regional prevalence of vitamin D deficiency in population-based studies from 2000 to 2022: A pooled analysis of 7.9 million participants.” Front Nutr. 2023 Mar 17;10:1070808. doi: 10.3389/fnut.2023.1070808. PMID: 37006940; PMCID: PMC10064807.

Reference 2: This review examined vitamin D levels among adults living in South Asia and found that vitamin D deficiency is very common across the region. The authors explain that factors such as limited sun exposure, lifestyle, skin pigmentation, and diet may all contribute to low vitamin D levels. Because vitamin D is essential for maintaining healthy bones and muscles, addressing this deficiency is an important part of supporting lifelong bone health. The study highlights the need for greater awareness and practical strategies to help people achieve adequate vitamin D levels.

Citation: Siddiqee MH, Bhattacharjee B, Siddiqi UR, MeshbahurRahman M. “High prevalence of vitamin D deficiency among the South Asian adults: a systematic review and meta-analysis.” BMC Public Health. 2021 Oct 9;21(1):1823. doi: 10.1186/s12889-021-11888-1. PMID: 34627207; PMCID: PMC8501935.

Vegetarian and Plant-Based Diets

Reference 1: This review explores how vegetarian diets may affect bone health. The authors explain that while well planned vegetarian diets can provide many health benefits, they may also be lower in important nutrients such as calcium, vitamin D, protein, and vitamin B12 if not carefully balanced. The paper highlights that these nutrients play an important role in maintaining strong bones and reducing the risk of fractures. It also emphasises that people following vegetarian diets can support their bone health by choosing a varied, nutrient-rich diet and including fortified foods or supplements when needed.

Citation: Falchetti A, Cavati G, Valenti R, et al. “The effects of vegetarian diets on bone health: A literature review.” Front Endocrinol (Lausanne). 2022 Aug 5;13:899375. doi: 10.3389/fendo.2022.899375. PMID: 35992115; PMCID: PMC9388819.

Reference 2: This review examines how vegetarian diets may influence bone mineral density, a measure of bone strength. The authors explain that people following vegetarian diets may have lower bone mineral density if they do not consume enough nutrients that are important for healthy bones, such as calcium, vitamin D, and protein. However, the paper also highlights that a well planned vegetarian diet can support good bone health when these nutritional needs are met. The review emphasises the importance of choosing a balanced diet to help maintain strong bones throughout life.

Citation: Chuang TL, Lin CH, Wang YF. “Effects of vegetarian diet on bone mineral density.” Tzu Chi Med J. 2020 Sep 16;33(2):128-134. doi: 10.4103/tcmj.tcmj_84_20. PMID: 33912409; PMCID: PMC8059457.

Reference 3: This review examined how vegan and vegetarian diets may affect bone mineral density and fracture risk. The authors found that people following plant based diets, particularly vegan diets, may have lower bone mineral density and a higher risk of fractures if they do not get enough nutrients that support bone health. The paper highlights the importance of consuming adequate calcium, vitamin D, protein, and other key nutrients when following a plant based diet. It also emphasises that well planned vegetarian and vegan diets can support healthy bones when nutritional needs are carefully met.

Citation: Iguacel I, Miguel-Berges ML, Gomez-Bruton A, Moreno LA, Julian C. “Veganism, vegetarianism, bone mineral density, and fracture risk: a systematic review and meta-analysis.” Nutr Rev. 2019 Jan 1;77(1):1-18. doi: 10.1093/nutrit/nuy045. PMID: 30376075.

I Think I Might Be at Risk of Osteoporosis

Why should I ask?

Osteoporosis is often called the “silent disease” because there are usually no symptoms until a fracture occurs. If you have risk factors, it is important to discuss your bone health before a fracture happens. Some common risk factors include but not limited to: Family history, Smoking, Alcohol, Low Body Weight, Age and Previous Falls.

Questions to ask your Doctor

1Am I at risk of osteoporosis?
2Should I have a bone health assessment?
3Should I have a DXA scan?
4What are my personal risk factors for osteoporosis and fractures?
5Are any of my medications affecting my bone health?
6What lifestyle changes can help protect my bones?

I am experiencing Height Loss, Stooped Posture, or Bone Pain

Why should I ask?

Losing height, developing a stooped posture or experiencing persistent back pain may not simply be part of ageing. These symptoms can sometimes be caused by vertebral fractures that happen without a major injury.

Questions to ask your Doctor

1Could my symptoms be caused by osteoporosis?
2Should I have spinal imaging or a VFA?
3Could I have had a spinal fracture without realising it?
4What treatments are available if I have vertebral fractures?
5How can I reduce my risk of future fractures?

I have Risk Factors but my DXA Scan was Normal

Why should I ask?

A normal bone density result does not always mean your bones are healthy. Some people may still be at increased fracture risk because of other risk factors or underlying conditions that affect bone quality.

Questions to ask your Doctor

1Does a normal DXA scan mean I cannot have osteoporosis?
2Why am I still at risk of fractures?
3Should my fracture risk be assessed using other tools?
4Are there additional tests I should have?
5How often should my bone health be reviewed?

I am worried about being on an Osteoporosis Medication

Why should I ask?

Many people are concerned about possible side effects of osteoporosis medicines. Understanding both the benefits and risks can help you make an informed decision with your doctor.

Questions to ask your Doctor

1Why are you recommending this medication?
2What are the common side effects?
3How common are the serious side effects?
4What happens if I decide not to take treatment?
5Are there other treatment options that may be suitable for me?

I am going through Menopause

Why should I ask?

Bone loss accelerates during and after menopause because of declining oestrogen levels. Acting early can help maintain bone strength and reduce future fracture risk.

Questions to ask your Doctor

1Does menopause increase my risk of osteoporosis?
2Should I have a DXA scan?
3Am I getting enough calcium and vitamin D?
4Would hormone therapy or another treatment benefit me?
5What lifestyle changes can help protect my bones?

I Have Another Medical Condition That May Affect My Bones

Why should I ask?

Some medical conditions can weaken bones, affect bone quality or interfere with the body’s ability to absorb important nutrients. Others may increase your risk of falls and thus fractures. These include diabetes, rheumatoid arthritis, thyroid disease, kidney disease, celiac disease among others.

Questions to ask your Doctor

1Does my medical condition increase my risk of osteoporosis or fractures?
2Should I have a DXA scan or other bone health tests?
3Are there treatments that can help protect my bones?
4Do I need to see a bone specialist?
5How often should my bone health be monitored?

I take Long-Term Medicines

Why should I ask?

Some medicines can reduce bone strength or increase fracture risk, particularly if they are taken over a long period. Your doctor can help determine whether you need additional monitoring or treatment.

Questions to ask your Doctor

1Could this medication affect my bones?
2Should I have a DXA scan?
3Do I need calcium or vitamin D supplements?
4Should I take medication to help protect my bones?
5How often should my bone health be reviewed while taking this medication?

I am Falling More Often and am Worried about my Balance

Why should I ask?

Most fragility fractures occur after a fall. Identifying the causes of falls and improving balance and strength can significantly reduce your fracture risk.

Questions to ask your Doctor

1Why might I be falling more often?
2Could my medications be contributing?
3Should my vision or hearing be checked?
4Would physiotherapy or balance training help?
5Can I be referred to a falls prevention programme?

I am an Older Man

Why should I ask?

Although osteoporosis is often thought of as a women’s disease, men can also develop osteoporosis and experience serious fractures. Unfortunately, osteoporosis in men is frequently under-recognised and underdiagnosed.

Questions to ask your Doctor

1Can men develop osteoporosis?
2Should I have a bone density test?
3What are my personal risk factors?
4Do I need treatment to reduce my fracture risk?
5Are there lifestyle changes I should make?

My Blood Tests show Low Vitamin D and/or Low Calcium

Why should I ask?

Vitamin D and calcium play essential roles in maintaining healthy bones. Low levels may contribute to bone loss and increase the risk of fractures if left untreated.

Questions to ask your Doctor

1What may have caused my low vitamin D and/or calcium levels?
2Do I need supplements?
3How much calcium and vitamin D should I be taking?
4Should my levels be checked again?
5Are there other tests needed to identify the underlying cause of my my low vitamin D and/or calcium levels?