1. No category

Research Updates in Medical Sciences (RUMeS)
2015, Volume 3; Issue 1 page 77– 82
Mini Review
Review of the Risk Factor of Osteoporosis in the Malaysian
Population
Mohd Sharkawi Ahmad1 , Isa Naina Mohamed1, Sabarul Afian Mokhtar2, Ahmad Nazrun Shuid1
1
Department of Pharmacology, Faculty of Medicine, University Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz 50300
Kuala Lumpur, Malaysia
2
Department of Orthopaedics and Traumatology, UKM Medical Centre, Jalan Yaakob Latiff, 56000 Cheras, Kuala Lumpur
Correspondence should be addressed to Mohd Sharkawi Ahmad , [email protected]
Received 28-12-2014; Accepted 23-01-2015
Copyright © 2015 Mohd Sharkawi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite:
Mohd Sharkawi Ahmad, Isa Naina Mohamed, Sabarul Afian Mokhtar & Ahmad Nazrun Shuid, 2015, Review of the Risk Factor
of Osteoporosis in the Malaysian Population 3(1) : 77– 82
ABSTRACT
Osteoporosis is a threat to our population especially to the elderly and postmenopausal women. The number of osteoporosis cases was
reported to be increasing year by year worldwide, including Malaysia. There are several risk factors of osteoporosis, which can be divided into modifiable and non-modifiable risk factor. These factors include low body mass index, sedentary lifestyle, smoking, alcohol
consumption, low calcium and vitamin D intake, old age, race and ethnicity, gender and genetic/family history. This mini-review highlighted the risk factors of osteoporosis in the Malaysian population.
Keywords: Osteoporosis; Risk factor; Malaysian population
.
1. Introduction
Osteoporosis is defined as low bone mass with microarchitectural deteriorations, leading to increased risk of
fracture (WHO). It is a silent disease which poses a major threat to elderly population by causing disability, morbidity and morbidity. The incidence of osteoporosis is on
the increase every year worldwide. It was estimated that
around 25 to 28 million Americans were affected by osteoporosis [1]. Caucasian and Asians can be classified as
those who are at high risk of getting osteoporosis [2]. In
the Malaysian context, the Chinese community is at the
highest risk of getting osteoporosis, followed by the Malays and Indians.
The main age group affected is those more than 50
years old, especially female who are already menopause. There are many risk factors of osteoporosis,
which include age, gender, race, Body Mass Index (BMI),
genetics, diet, lifestyle and family history. All of these risk
factors must be taken seriously by the Malaysian population for the prevention of osteoporosis [3].
The majority of people do not really understand or
have any knowledge about osteoporosis. Most of the
osteoporotic sufferers were unaware of the risk factors of
the disease and were not diagnosed early for osteoporosis. Therefore, they failed to get an early treatment and
were not really concern about the complications of osteoporosis. A study has shown that, osteoporotic patients
who did not get an early treatment were at greater risk of
getting fractures [4]. This paper aimed to give a brief review on the risk factors of osteoporosis for the Malaysian
population by referring to published studies on osteoporosis.
77
2. Risk Factor of Osteoporosis
The risk factors of osteoporosis are divided into modifiable and non-modifiable risk factor.
Modifiable Risk Factor:
i) Low BMI
Low BMI or low body weight is associated with osteoporosis as it was found to be associated with low bone
mass. Low BMI, especially if less than 19, was associated with low bone mass with an increased risk of osteoporosis [5]. BMI values were closely related with BMD
scores and serum 25-hydroxy vitamin D levels in the trabecular and cortical bone [6]. Based on previous studies,
it was reported that low BMI is one of the risk factor for
osteoporosis and low body weight is one of the many
factors that may influence the incidence of osteoporotic
fracture [7, 8]. Asian population was found to have lower
BMI and shorter height when compared to the western
population. Therefore, Asian population which includes
Malaysian, are at higher risk of getting osteoporosis. In
order to lower the risks of osteoporosis, Malaysian would
have to be more concerned about ideal range of BMI [9].
Table 1 showed the recommended BMI cut-off points for
body weight classification and public health action for
Malaysia [10].
ii) Sedentary Lifestyle
Practicing healthy lifestyle and doing regular exercise
were proven to enhance the quality of life. More than
60% of adults worldwide were not practicing healthy lifestyle [11]. Physical exercise, simple exercise and activities such as weight-bearing and resistance training improved bone strength, encouraged bone growth and preserved bone mass. Regular exercise may also increase
bone mineral density (BMD) [12]. Lack of exercise or
sedentary lifestyle is a risk factor for osteoporosis. Women who remain sedentary for more than nine hours per
days have greater chance of getting hip fracture com-
pared to women who remain sedentary less than six
hours a day [13]. Women who exercise regularly had
higher bone mineral density compared to sedentary
women [14]. Chandrashekhar et al., (2012) reported that
the physical activity of young adults in Malaysia has not
reached a satisfactory level [15]. The majority of Malaysian was not active and did not exercise adequately for
healthy lifestyle. Thus, most of them did not meet the
recommended physical activity level [16]. Malaysians
was recommended to be more active everyday by doing
at least 30 minutes of moderate physical activity for at
least five days a week. They must avoid sedentary lifestyle to lower the risk of getting osteoporosis [10].
iii) Smoking Behavior
Smoking has been identified to be one of the risk factor
for osteoporosis since 20 years ago. Some studies have
shown that there is a strong relationship between tobacco use and low bone density [17]. Smoking is also an
established risk factor for osteoporotic fracture. Current
and former smokers have higher risk of low BMD [18].
Therefore, smoking has been recognized to cause poor
bone health [19]. Female smokers lost around 5 to 10 %
of bone tissue more than female non-smokers when they
reach menopause [20]. Tawima et al. (2011) have conducted a study on the smoking behavior of Malaysian
adolescent and reported that around 5% of adolescent in
Malaysia were current smokers and around 8.1 % of Malaysian adolescent were beginning to smoke [21]. It was
estimated that around 46.4% of Malaysian adult male
were smokers, which wass among the highest in the region [22]. Global Adult Tobacco Survey (2011) reported
that in Malaysia, 43.9% of men, 1.0% of women, and
23.1% overall (4.7 million adults) were smokers [23].
Based on these reports, it could be concluded that the
number of smokers in Malaysian was high, especially
among men. This unhealthy behavior needs to be controlled as it is one of risk factor for osteoporosis.
Table 1 Recommended BMI cut-off points for body weight classification and public health action for Malaysia
Body Weight
Classification
Underweight
BMI cut-off points for definition
(kg/m2)
< 18.5
BMI cut-off points for public health
action (kg/m2)
< 18.5
Normal range
18.5 to 24.9
18.5 to 22.9
Overweight
≥ 25.0
23.0 to 27.4
Pre-obese
25.0 to 29.9
27.5 to 32.4
Obese class 1
30.0 to 34.9
32.5 to 37.4
Obese class 2
35.0 to 39.9
≥ 35.0
Obese class 3
≥ 40.0
78
iv) Alcohol Consumption
Alcohol consumption is another unhealthy lifestyle which
is identified as the modifiable risk factor of osteoporosis.
The risk of osteoporosis is dependent on the amount of
alcohol consumption, frequency and duration of intake.
Chronic alcohol consumption could be destructive to
bone development and bone mass maintenance. Alcohol
intake was found to reduce peak bone mass and weaken
bone until it is prone to fracture [24]. It was reported that
women aged around 67 to 90 years who took six drinks
per day had greater bone loss compared to women who
took minimal amount of alcohol. Alcohol consumption
seemed to cause more harm on bone formation rather
than promoting bone breakdown [25]. Alcohol intake of
more than 207 mL per week was found to be a risk factor
for bone loss which could lead to osteoporosis [26].
Based on the survey by World Health Organization
(2004), the prevalence of alcohol drinking was estimated
to be around 23% of non-Muslim adults in Malaysia.
About 32.5% of them were categorized with high alcohol
intake. Teenagers in Malaysia, under the age of 18 were
reported to start taking alcohol regularly, which accounted for 45% of the Malaysian youth [27]. Since alcohol
intake is one of the modifiable risk factor of osteoporosis,
it is best to avoid this unhealthy lifestyle.
v) Low Calcium and Vitamin D Intake
Insufficient intake of supplement and nutrition is another
modifiable risk factor for osteoporosis. Calcium, vitamin
D, phosphorus, magnesium, protein and other nutrients
are essential for bone development and prevention of
osteoporosis. Therefore, adequate intake of these supplements and nutrients is essential to prevent osteoporosis [28]. Studies have shown that calcium and vitamin D
are important nutrients for bone health and its maintenance. Sufficient intake of calcium and Vitamin D is important for healthy bone and prevention of osteoporosis.
This was supported by findings that adequate calcium
intake was associated with lower risk of osteoporotic
fracture [29, 30]. This is especially important for postmenopausal women who are prone to bone loss. High
intake of vitamin D was found to lower the risk of hip fracture in postmenopausal women. Similarly, sufficient intake of calcium was proven to reduce the risk of osteoporosis in postmenopausal women [31]. Arfah et al. (2010)
conducted a nutrition study among 70 healthy male and
female students of a public university in Malaysia and
reported that only 1.4% of the subjects met the daily requirement of calcium intake. The authors recommended
that consumption of high skim milk is effective in reducing bone loss [32]. It is a fact is that calcium intake into
the body is dependent on vitamin D as it is required for
normal calcium absorption and metabolism. Maintaining
an adequate vitamin D level in a tropical country like Malaysia should not be a problem as exposure to sunlight is
a major source of vitamin D [9]. Although vitamin D deficiency is uncommon in Malaysian men, a significant proportion of them are suffering from vitamin D insufficiency
[33]. It is recommended for those living in tropical coun-
tries such as Malaysian to expose their skin to sunlight
for 30 minutes per day. This would provide the daily requirement of vitamin D for the body. There are also foods
with high vitamin D content such as butter, cream, egg,
yolk and fish liver oils. There are many other sources of
calcium in the Malaysian food besides milk and dairy
product such as tofu, shrimp paste, tempeh, cincaluk,
budu, and others. It is hope that the health authority
would take proactive steps in making sure that Malaysians would have sufficient calcium and vitamin D intake to
prevent osteoporosis [34].
Non-Modifiable Risk Factor
Although these risks are not modifiable, it is important for
Malaysians to be aware of them so that necessary steps
and lifestyle changes could be taken to prevent osteoporosis.
i) Age
Age is one of the non-modifiable risk factors of osteoporosis. Elderly are at high risk of getting osteoporosis and
osteoporotic fracture. Age was reported to be the main
factor that contributes to osteoporosis, especially with the
age of 70 years and above [39]. The BMD reduces with
age, resulting in thinning of the bone. Low BMD was associated with higher incidence of osteoporotic fracture in
elderly more than 50 years old. Around 90% of patients
suffering from hip fracture were above 50 years old. The
high incidence was believed to be related to deterioration
of the bone mineral density with advancing age [13]. Elderly people at these ages also have higher risk of falls,
which may lead to osteoporotic fracture [37]. In a study
by Manish & Chad (2002), it was reported that osteoporosis is a threat to elderly women and men around the
age of 50 years and above [40]. Prevalence of osteoporosis in United States showed that 15% of women
around the age 50 to 59 years old and 70% of women at
age 80 years old were diagnosed with osteoporosis. It is
estimated that around 900 million men and women
above 65 years of age in Asia, will suffer from osteoporosis by the year 2050 [41]. Based on the study by Joon
and Amir (2007), the mean age of Malaysia population
with hip fracture in 1997 was 74.5 years. In terms of gender, the mean age of getting a hip fracture for female and
male was 75.5 and 72.3 years old, respectively [42]. It is
very important to make sure that our elderly population
are screened for osteoporosis and necessary actions
taken if they are diagnosed with osteoporosis.
ii) Race and Ethnicity
Demographic factors such as race and ethnicity are the
non-modifiable risk factors of osteoporosis. It is reported
that Asian and Caucasian women are at higher risk of
getting osteoporosis compared to African and Hispanic
women [43]. The prevalence of osteoporosis or low bone
mass in United States differed according to race, age
and ethnicity. The prevalence of male osteoporosis in
Mexican American was 6%, non-Hispanic white 4% and
79
other races was 9%. Meanwhile, the prevalence of osteoporosis among women of Mexican American was the
highest, at 24%, followed by other races at 19%, nonHispanic white at 15% and non-Hispanic black at 9% [44].
Malaysia is a multiracial country which consisted of Malay, Chinese, Indian and others ethnic groups. Malay is
the major race followed by Chinese, Indians and others.
There are differences in the incidence of hip fracture between the different races [45]. In Malaysia, the Chinese
has the highest incidence of osteoporosis, followed by the
Malay and Indians. The total hip fracture cases reported
in 1996 were 1353 cases in Chinese, 424 cases in Malay,
294 cases in Indians and 95 cases in other races. Meanwhile, in 1997, the hip fracture cases for Chinese, Malay,
Indians and other races were reported to be 1442, 478,
280 and 94 cases, respectively [42].
factors, especially the modifiable risk factors.
4. Acknowledgements
The author would like to thank the University Kebangsaan
Malaysia (UKM) and the Pharmacology Department staff
for their technical support.
References
1.
Evolution and management of osteoporosis following hospitalization for low impact-fracture. J Gen Intern Med. 2003;
18(1): 17-22.
2.
iii) Gender
Gender can be categorized as one of the non-modifiable
risk factor for osteoporosis. Based on the gender factor,
women are at higher risk of osteoporosis compared to
men. Based on a study by Dontas & Yiannakopoulus
(2007), women have lower peak bone mass compared to
men. There is an increasing trend of bone loss in women
after menopause. The mortality rate for women is lower
than men, which mean that they live longer. Elderly women have high risk of falls which may lead to osteoporotic
fracture. Due to these reasons, women have high risk of
getting osteoporotic fracture compared to men [46]. About
40% of white women and 13% of white man above 50
year of age in the United State were at risk of fragility fracture [47]. The life expectancy for Malaysian women is also
higher than men. The percentage of female population in
Malaysia over 70 years recorded in 1990 was 54.2% and
estimated to increase up to 56.7% by 2020 [48]. According to the annual report of National Orthopaedic Registry
of Malaysia (NORM), in 2009, out of the 510 hip fracture
cases recorded, 345 patients were female [49].
Christine S, Chen YT, Julie M, Anne FL, and Thomas AA.
Lin JD, Chen MD, Chang HY, and Ho C.
Evaluation of
bone mineral density by quantitative ultrasound of bone in
16 862 subjects during routine health examination. The
British Journal of Radiology. 2001. 74: 602-606.
3.
Annie M.Q.M., Robert Q., Malik S., Jerald Z., William D.,
Yamini M., leonard S., and Krousel M.A.W. 2007. Implementation of a Mandatory Rheumatology Osteoporosis
Consultation in Patients with low-Impact Hip Fracture. Journal of Clinical Rheumatology. 13(2): 70-72.
4.
Yusra HK, Azmi S, and Amer HK. When Bones Start To
Grow Soft, It’s Time To Face The Hard Truth. Canadian
Journal of Applied Sciences. 2012. 4(2): 369-377.
5.
Stetzer E. Identifying Risk Factors for Osteoporosis in
Young Women. The Internet Journal of Allied Health Sciencesand Practise. 2011. 9(4): 1-8.
6.
Meiyanti. Epidemiology of osteoporosis in postmenopausal
women aged 47 to 60 years. Univ Med. 2010. 29(3): 16976.
iv) Genetic / Family History
Osteoporosis can be categorized as a genetic disease.
Therefore, genetic make-up can be one of the nonmodifiable risk factors for osteoporosis and osteoporotic
fracture. This is because BMD is highly correlated with
heredity [50]. Genetic factors accounted for 50% of the
variance in BMD across the populations [51]. Based on
the study on factors influencing BMD in postmenopausal
Malaysian women, it was showed that women with family
history of osteoporosis are at higher risk of developing
osteoporosis compared to women without family history of
osteoporosis [52].
3. Conclusion
7.
Neville MD, and Pierre E. Risk Factors for Osteoporosis in
Crohn’s Disease: Infliximab, Corticosteroids, Body Mass
Index, and Age of Onset. Inflamm Bowel. 2013. 1-4.
8.
Gordon MW. Putting body weight and osteoporosis into
perspective1’2. The American Journal of Clinical Nutrition.
1996. 63:433S-6S.
9.
Loh KY. Osteoporosis: Primary Prevention in the Community. Med J Malaysia. 2007. 62(4): 355-358.
10. Malaysian Dietary Guideline. Maintain body weight in a
healthy
range.
http://www.moh.gov.my/images/gallery/
Garispanduan/diet/KM2.pdf. 2010. Accessed on December
2013.
The risk factors of osteoporosis need to be given attention
and publicised to gain public awareness and increase
their knowledge on osteoporosis. It may be possible to
reduce the incidence of osteoporosis by controlling risk
11. Joanna K. Physical Activity in the Prevention of the Most
Frequent Chronic Diseases: an Analysis of the Recent Evidence. Asian Pacific J Cancer Prev. 2007. 8: 325-338.
80
12. Chan KM, Mary A, and Edith MCL. Exercise interventions:
defusing the world’s osteoporosis time bomb. Bulletin of the
World Health Organization . 2003. 81:827-830.
GATS_Malaysia.pdf. 2011. Accessed on January 2014.
24. Wayne HS. Alcohol’s Harmful Effects on Bone. Alcohol
Health & Research World. 1998. 22 (3): 190-194.
13. International Osteoporosis Foundation. Know and reduce
25. Wayne HS. Alcohol and Other Factors Affecting Osteoporo-
your risk of osteoporosis. http://www.iofbonehealth.org/
sis Risk in Women. Alcohol Research & Health. 2002. 26
sites/default/files/PDFs/
(4): 292-298.
know_and_reduce_your_risk_english.pdf. 2013. Accessed
on November 2013.
26. Nancy EL. Epidemiology, etiology, and diagnosis of osteoporosis. American Journal of Obstetrics and Gynecology.
14. Agnes M, Keith S, Karen ., Caroline ., and Hugh T. Bone
mineral density in relation to medical and lifestyle risk fac-
2006. 194: 3-11.
27. World Health Organization. WHO Global Status Report on
tors for osteoporosis in premenopausal, menopausal and
Alcohol
postmenopausal women in general practice. British Journal
publications/en/malaysia.pdf . 2004. Accessed on January
of General Practice. 199545: 317-320.
20014.
15. Chandrashekhar TS, Nizar AMK,
Mohammed ARJ, and
Boo NY. Physical activity and associated factors among
young adults in Malaysia: An online exploratory survey.
BioScience Trends. 2012. 6(3):103-109.
2004.
http://www.who.int/substance_abuse/
28. Prentice A. Diet, nutrition and the prevention of osteoporosis. Public Health Nutrition: 2013. 7(1A): 227–243.
29. John AS. The use of calcium and vitamin D in the management of osteoporosis. Therapeutic and Clinical Risk Man-
16. Suraya I, Norimah AK, Oon NL, and Wan ZWN. Perceived
agement. 2008. 4(4): 827–836.
physical activity barriers related to body weight status and
30. Robert GC, Steven RC, Michael CN, Jean S, Kristine EE,
sociodemographic factors among Malaysian men in Klang
Thomas MV, and Kathleen F. Calcium Intake and Fracture
Valley. BMC Public Health. 2013. 13:275.
Risk: Results from the Study of Osteoporotic Fractures.
17. National Institute Of Health, USA. Smoking and Bone
Health.
http://www.niams.nih.gov/Health_Info/Bone/
Osteoporosis/Conditions_Behaviors/bone_smoking.pdf
.
2013. Accessed on 20 November 2013.
American journal of epidemiology. 1997. 145(10): 926-934.
31. Diane F, Walter CW, and Graham AC. Calcium, vitamin D,
milk consumption, and hip fractures: a prospective study
among postmenopausal women. The American Journal of
18. Anna J, Laurberg, Peter V, and Stig A. Clinical risk factors
clinical nutrition. 2003. 77:504–511.
for osteoporosis are common among elderly people in
32. Arfah WNW, Ezane MA, and Leng FA. Knowledge, Attitude
Nuuk, Greenland. Int J Circumpolar Health. 2013. 72:
and Dietary and Lifestyle Practices on Bone Health Status
19596.
among Undergraduate University Students in Health Cam-
19. Lion S. Smoking and bone health. http://www.ncsct.co.uk/
usr/pub/smoking_and_bone_health.pdf . 2012. Accesed on
January 2014.
Environment Journal. 2010. 1(1): 34-40.
33. Kok-Yong Chin, Soelaiman Ima-Nirwana, Suraya Ibrahim,
20. Kamila P, Halina M, and Veronika B. risk factors of osteoporosis - knowledge and practices among
pus, Universiti Sains Malaysia, Kelantan. Health and the
adolescent fe-
males. Social and Health Aspects of Health Education.
2008. 21(3): 211-220.
21. Tawima S, Buppha S, Ron B, Maizurah O, and Peter D.
Smoking behavior among adolescents in thailand and malaysia. southeast asian j trop med public health. 2011. 42
(1): 218-224.
22. Lim KH, Sumarni MG, Amal NM, Hanjeet K, Wan Rozita
WM, and Norhamimah A. Tobacco use, knowledge and
attitude among Malaysians age 18 and above. Tropical Biomedicine. 2009. 26(1): 92–99.
23. Global Adult Tobacco Survey. Fact Sheet Malaysia 2011.
Isa Naina Mohamed, Wan Zurinah Wan Ngah. Vitamin D
Status in Malaysian Men and Its Associated Factors Nutrients 2014, 6(12), 5419-5433
34. Ministry of Health. Recommended Nutrient Intakes for Malaysia
2005.
http://www2.moh.gov.my/images/gallery/
rni/12_chat.pdf . 2005. Accessed on January 2014.
35. World Health Organization. WHO Global Report on Falls
Prevention
in
Older
Age.
http://www.who.int/ageing/
publications/Falls_prevention7March.pdf . 2007. Accessed
on January 2014.
36. David W.D. Osteoporosis and the Burden of OsteoporosisRelated Fractures. The American Journal of Manged and
Care. 2011. 17(6): 164-169.
http://www.moh.gov.my/images/gallery/Report/
81
37. World Health Organization. Assessment of osteoporosis at
the primary health care level. 2007. Geneva.
49. National Orthopaedic Registry Malaysia. annual report of
national orthopaedic registry malaysia (norm) hip fracture
38. Isnoni I, Mohamad AB, Murallitharam M, Tajuddin A, Jaya
SPP, Manmohan S, Phang H.F., Pan CH, Kamil MK, and
Anwar H. Pre-Injury Demographic Patterns of Patients Sustaining Hip Fractures in Malaysia. Malaysian Orthopaedic
Journal. 2012. 6(4): 11-15.
39. Maria LR, Cristina C, Marta C, Milagros GB, and Rafael B.
Risk Factors for Osteoporosis and Fractures in Postmenopausal Women Between 50 and 65 Years of Age in a Primary Care Setting in Spain: A Questionnaire. The Open
Rheumatology Journal. 2008. 2: 58-63.
2009. http://www.crc.gov.my/pdf/hip_norm.pdf . 2009. Accesed on January 2014.
50. Brent RJ, Hou FZ, and Tim DS. Genetics of osteoporosis
from genome-wide association studies: advances and challenges. Nature review genetics. 2012. 13: 576-588.
51. Cooper C. Epidemiology of osteoporotic fracture: looking to
the future. Rheumatology. 2005. 44(4): iv36–iv40.
52. Fatemeh M, Tengku AH, Mohd NY, Zanariah O, and Rozi
M. Lifestyle factors influencing bone mineral density in post-
40. Manish S. and Chad D. Osteoporosis in elderly: prevention
and treatment. Clin geriatr Med. 2002. 18: 529-555.
menopausal Malaysian women. Life Science Journal. 2011.
8(2): 132-139.
41. Lau EMC. Osteoporosis—A Worldwide Problem and the
Implications in Asia. Annals Academy of Medicine. 2002. 31
(1): 67-68.
42. Joon K.L., and Amir S.M.K. The incidence of hip fracture in
Malaysians above 50 years of age; variation in different
ethnic groups. APLAR Journal of Rheumatology. 2007.
10:300-305.
43. Scottie
M.
and
Vanessa
A.F.
cals.arizona.edu/pubs/health/az9712.pdf.
Osteoporosis.
2000. Accessed
on 16 November 2013.
44. Anne CL, Lori GB, Bess DH, John AS, and Nicole CW.
Osteoporosis or Low Bone Mass at the Femur Neck or
Lumbar Spine in Older Adults: United States, 2005–2008.
http://www.cdc.gov/nchs/data/databriefs/db93.pdf . 2012.
Accessed on January 2014.
45. Muslim DA., Mohd EF, Sallehudin AY, Tengku Muzaffar
TMS, and Ezane AM. Performance of Osteoporosis Selfassessment Tool for Asian (OSTA) for Primary Osteoporosis in Post-menopausal Malay Women. Malaysian Orthopaedic Journal. 2012. 6(1): 35-39.
46. Dontas IA. and Yiannakopoulos CK. Risk factors and prevention of osteoporosis-related fractures. J Musculoskelet
Neuronal Interact. 2007. 7(3):268-272.
47. Peter P. and Katharina KS. Osteoporosis: Gender-specific
aspects. Wien Med Wochenschr. 2004. 18: 411-415.
48. Peter M.B. Osteoporosis – an increasingly important issue
for both young and aging citizens of Malaysia. IeJSME.
2013. 7(1): 1-3.
49. National Orthopaedic Registry Malaysia. annual report of
national orthopaedic registry malaysia (norm) hip fracture
2009. http://www.crc.gov.my/pdf/hip_norm.pdf . 2009. Accesed on January 2014.
82