Epidemiology, costs and burden of osteoporosis in Mexico

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1 DOI /s REVIEW Epidemiology, costs and burden of osteoporosis in Mexico Patricia Clark Fernando Carlos José Luis Vázquez Martínez Received: 16 April 2010 /Accepted: 28 June 2010 # International Osteoporosis Foundation and National Osteoporosis Foundation 2010 Abstract Summary Osteoporosis is a serious health condition internationally recognized in developed countries where its impact has been compared with other chronic diseases. Osteoporosis and its related fragility fractures have been reported to have a greater impact on patient quality of life and social costs than breast and prostate cancers. Introduction Consistent with trends in other regions of the world, Mexico is facing an epidemiological transition with a growing number of elderly people and an increase in life expectancy. Although this ageing process took almost two centuries to occur in industrialized and developed countries, it is taking place very rapidly in Mexico. Life expectancy at birth has increased almost 39 years on average over the last seven decades (from 36.2 to 75 years old). The population of 50 years and over is currently 19 million, and it will increase to 55 million by By then, the average life expectancy in Mexico will be 82 years of age [1]. Because osteoporosis is a disease associated with ageing, the number of osteoporotic fractures is expected to rise accordingly. P. Clark (*) Clinical Epidemiology Unit, Hospital Infantil Federico Gómez SS, Mexico City, Mexico patriciaclark@prodigy.net.mx P. Clark Faculty of Medicine, UNAM, Mexico City, Mexico F. Carlos RAC Salud, Mexico City, Mexico J. L. Vázquez Martínez Division of Informatics, Instituto Mexicano del Seguro Social, Mexico City, Mexico Discussion Hip fractures worldwide are projected to increase from 1.2 million in the 1990s to 2.6 million by 2025 and to 4.5 million by 2050, assuming no change in age- and sex-specific incidence. The vast majority of hip fractures in the twenty-first century will occur in developing countries; Asia and Latin America are estimated to be the two regions that will have the highest increases [2]. Osteoporosis and fragility fracture have become a focus of research in Mexico, and the National Institutes of Health in Mexico have recently recognized osteoporosis as a public health problem. However, osteoporosis still remains a greatly undetected and untreated national health priority disease because of the lack of awareness at all levels. Keywords Osteoporosis. Burden. Epidemiology. Mexico. Costs Key findings in Mexico in 2009 In 2009, 17% of the total population is aged 50 and over, and it is expected to reach 37% by Seventeen per cent of Mexican women and 9% of Mexican men 50 years and over present with osteoporosis of the lumbar spine; 16% of Mexican women and 6% of Mexican men have osteoporosis at the hip. One in 12 Mexican women and one in 20 Mexican men over 50 years of age will sustain a hip fracture. The total number of hip fracture cases was approximately 21,000 in 2005, and it is projected to reach 110,055 in 2050, a 431% increase. Vertebral fractures are largely underestimated. Statistics show this fracture to be the least frequently clinically diagnosed.

2 Over US $97 million was reported in 2006 for hip fracture s direct costs; projection for 2025 range from US $213 to over US $466 million and from US $555 to US $4.088 million for Only 25% of the available diagnostic tools for osteoporosis (dual-energy X-ray absorptiometry (DXA) equipment) are found in government health institutions that cover the vast majority of Mexicans. Effective treatments are available and approved by the Ministry of Health; however, not all of them are reimbursed in the government health care system. National programmes are needed to educate health professionals on the importance of the early detection of patients at high risk of fragility fractures and in need of intervention and to bring awareness to primary physicians and the general public on the primary and secondary prevention strategies available for osteoporosis. Studies are needed to examine vitamin D and calcium status in the Mexican population to support the development of national recommendations for calcium and vitamin D supplementation. A group of experts has been appointed to the National Commission of the Institutes of Health and high-level specialty hospitals in Mexico to set up a specific osteoporosis plan. It will include timely diagnosis and treatment of osteoporosis, wide-scale prevention programmes and programmes oriented to increase awareness of osteoporosis in patients and health care professionals. Epidemiology of osteoporosis and fragility fractures in Mexico General demographics In Mexico, a polarized model of epidemiological transition, in which diseases with infectious aetiology coexist with chronic degenerative illnesses, has been forming over the last 25 years. Middle- and upper-income individuals have been experiencing the benefits of this transition, whilst lowincome people have been left behind. The most important factors contributing to this transition are increase in life expectancy, decrease in mortality, increase in the elderly population (65 years and over) and the economic impact of these differences [3]. In 2009, the population in Mexico is approximately 111millionpeople,witha1:1ratioofmentowomen, and is projected to increase to 125 and 148 million by 2020 and 2050, respectively [3]. When the same estimates are projected for those 50 years and older, the figures increase more steeply. Figure 1 shows that the current 2009 population for this age group is over 19 Fig. 1 Population projection for Mexico until 2050 million and will increase by 47% and 300% for the same periods, reaching 28 million people in 2020 and 55 million in The Mexican health care system The Mexican health care system is a mixture of governmental and private institutions, with varying quality of services offered at different prices. The costs and impact of osteoporosis (OP) and fragility fractures differ in these systems. The government maintains multiple parallel health care systems for different population groups. There are two main governmental systems. One is the Mexican Institute of Social Security (IMSS), which provides several benefits besides health care (pensions, life insurance, disability, etc.). It covers almost 50 million beneficiaries (employees and their families) and is financed by employees payroll taxes plus legally mandated government contributions; therefore, almost 50% of the population is covered by the IMSS. The second largest governmental health care system is offered through the Ministry of Health (Secretaria de Salud) and covers the medical needs of around 48% of indigenous people who do not have access to other health care facilities [4]. During the last decade, the Ministry of Health began a health reform programme that was expanded to offer health insurance for this population; it covers basic health needs and is called Seguro Popular [5]; around 35 million are currently covered by this form of health insurance [6]. Finally, a heterogeneous, private system covers about two million people. It is noteworthy that half of the total health care expenditures in Mexico are out-of-pocket payments [4]. Prevalence of osteoporosis and osteopenia Recent data have been reported in the literature regarding osteoporosis and osteopenia rates in Mexico diagnosed by

3 central DXA in accordance with the WHO classification criteria. The first study was done in three different geographic areas in Mexico. Delezé et al. [7] reported on 4,460 women between 20 and 69 years of age from urban areas where lumbar and femoral neck bone mineral densities (BMD) were performed using DXA and compared them. The authors reported significant differences between the BMD in the different regions of Mexico. Women in the North had higher BMD at the lumbar spine than women in the Center or the South, but were significantly larger and taller than women in the Center or in the South. The authors noted that regional differences in BMD were significantly different according to the region where the population was counted. The second study was based on the random sample used for the Latin American Vertebral Osteoporosis (LAVOS) Study in Mexican women 50 years and over and the vertebral fracture prevalence study in men 50 years and over: [8, 9] 807 men and women had a central DXA from spine and femur. Osteoporosis was diagnosed in 9% and 17% of men and women, respectively, and osteopenia in 30% and 43% of men and women at the lumbar spine; for the total femur, osteoporosis was found in 6% of men and 16% of women and osteopenia in 56% of men and 41% of women (Fig. 2). Hip fractures The incidence rates and lifetime risk of hip fractures in Mexican men and women over 50 years were published in 2005 [10]. In this study, hip fracture cases registered in 2000 were collected at all main tertiary care hospitals in the two major health systems in Mexico City, IMSS and SS. Diagnoses were validated by chart review in all cases. It is estimated that 169 women and 98 men per 100,000 persons have hip fractures annually. Overall rates in women are about twice those for men; these differences are more pronounced when looking at the age of 70 years and older. As shown in Fig. 3, the numbers of hip fractures increase drastically with age in both sexes. The lifetime risk probability of having a hip fracture at 50 years of age was 8.5% in Mexican women and 3.8% in Mexican men. In other words, 1 out of 12 women and 1 out of 20 men will sustain a hip fracture in their later years. When the incidence figures were standardized to the US population, the age-adjusted hip fracture incidence rate equalled 203 women and 108 men per 100,000. According to the classification done by Maggi et al. [11], Mexico has an intermediate rate of hip fractures compared with other countries, the highest rate occurringinswedenandus Caucasians and the lowest rate occurring in continental China and Turkey. Vertebral fractures Lumbar Spine BMD Women normal osteopenia osteoporosis Lumbar Spine BMD Men 30% 17% 42% 9% 41% normal osteopenia osteoporosis Femoral BMD Men 61% normal osteopenia osteoporosis 38% Femoral BMD Women normal osteopenia osteoporosis 16% 43% 6% 56% 41% Fig. 2 Osteoporosis in Mexico: the LAVOS Study The recently published LAVOS [8] reported the radiographic prevalence of vertebral fractures in women 50 years and older from five Latin American countries. The overall prevalence in Mexican women was 19.2%, which was the highest among the five countries included in the study (Argentina, Brazil, Colombia, Mexico and Puerto Rico). The prevalence of vertebral fractures in Mexican women was similar and consistent with those in

4 Fig. 3 Age- and sex-specific incidence rates of hip fracture in Mexico thesofstudyintheunitedstatesandthebeijingstudy in China (Table 1). The prevalence of vertebral radiographic fractures has been studied by digital morphometry in a random sample of Mexican men 50 years and older. In Mexican men, the prevalence of vertebral fracture is half of what is found in women, 9.7% versus 19.5% with the highest rate in older subjects over 80 years: 21.4% [9]. In both sexes, the fractures increased with age, as shown in Fig. 4. Other osteoporotic fractures Databases from the emergency room were searched for January to December 2005 at the Division of Informatics at IMSS. The ICD-10 codes were used to find out the frequency of other major osteoporotic fractures (wrist, humerus, vertebral and pelvis) in men and women over 50 years old. Figure 5 shows how wrist fractures are by far the most frequently reported fractures. The second most frequent fractures are those of the hip, followed by the humerus and pelvis. In general, a major concern is that vertebral fractures are greatly underestimated. The database consulted included the emergency rooms in all health care facilities in the country at IMSS; there were no reports of vertebral fractures in any of these facilities. A possible explanation for this bias is that vertebral fractures are not diagnosed at any level of medical attention and are probably reported as osteoarthritis of the spine or lumbago. Special attention should be given to this as timely diagnosis of vertebral fractures will allow the prevention of new vertebral fractures and of fractures in other sites. Table 1 Age-specific prevalence (%) of vertebral fracture in Mexican women aged 50 and older [8] Age (years) Prevalence% (confidence Interval 95%) ( ) ( ) ( ) ( ) Fig. 4 Age-specific prevalence (%) of vertebral fractures in Mexican population aged 50 and over Calcium and vitamin D status The status of calcium and vitamin D in our population is largely unknown. Few studies have reported on calcium intake by Mexicans over 50 years through questionnaires in epidemiologic studies [8, 12]. Mexicans on average eat far less calcium than the international recommendations for this nutrient. No information on other groups is available. An international study demonstrated that the average serum level of 25-hydroxyvitamin D (25(OH)D) in osteoporotic postmenopausal Latin American women was 29.6 ng/ml. The prevalence of insufficiency in the Mexican sample in accordance with the cutoff point given in the publication (serum levels of 25(OH)D) <30 ng/ml) was 67%. [13]. In another study performed in four Mexican cities, vitamin D deficiency was found in 1.9% and insufficiency in 62.3% of the studied postmenopausal women in accordance with the accepted international levels of 25(OH)D [14]. Preliminary results of two small studies in women 50 years and over showed that 62 70% of the sample presented Number of cases Overview of fractures in Mexico Men Women Vertebra Pelvis Humerus Hip Wrist fractures sites Fig. 5 Overview of osteoporotic fracture in men and women over 50 years of age taken from the emergency room from January to December Division of informatics IMSS

5 insufficient levels (<30 ng/dl) 25-hydroxyvitamin D (personal communication, unpublished). Direct and indirect costs of hip fractures treatment Hip fractures are increasing at a rapid rate in Mexico. From 2000 to 2006, IMSS reported a 24.8% increase in hip fracture incidence. Policymakers and health authorities must become aware of the enormous impact that these fractures will have in the near future and use this information to generate primary and secondary prevention programmes. Hip fracture s direct costs paid by governmental institutions and by patients at private settings in the Mexican health care system have been published, as well as the estimated impact of these entities [15]. The information was gathered through direct questionnaires given to 218 patients with hip fractures. Additionally, a chart review was conducted and information using expert panels was obtained to get accurate protocol scenarios and micro-costing; activity-based techniques were used to yield unit costs. The total direct cost for hip fractures estimated for 2006 based on the projected annual incidence of hip fractures in Mexico was a little more than US $97 million. This estimate was based on the occurrence of about 22,000 hip fracture cases, with an individual cost per event of US $4, [15]. The average hospital stay for hip fractures is different for each institution. The IMSS has the highest average with 10.7 days per event, the SS had an average of 9.3 days, and private institutions of 5.2 days. In a previous study, the IMSS analysed the frequency hospitalizations and hospital costs related to osteoporotic fractures in a 2-year period ( ). The IMSS used hospital discharge files and data of Related Diagnostic Groups (RDG) to estimate the costs of hip, distal forearm and vertebral fractures. The average cost for each case of the aforementioned fractures was US $5, The same study reported a hospital cost for the management of hip fracture in postmenopausal women of US $36.6 million for a 2-year period [16, 17]. A review of the literature for the Latin American region presents figures similar to those published by Clark and Gutierrez-Urena [18] for hip fracture cost in the region, ranging from US $4,500 to US $7,550 [15]. The estimated direct cost for acute event (hip fracture) for the year 2006 was US $77,058,159. The two aforementioned studies use different methodologies; therefore, comparison is not possible. However, they both show that the costs for fragility fractures are high in Mexico, and prevention efforts have to be implemented as soon as possible to avoid future fragility fracture epidemics and limit their economic impact. Table 2 shows the fracture-related costs in Mexican institutions. There is no study dealing with the indirect costs of hip or other fragility fractures in Mexico. Indirect costs represent the loss of productivity of patients affected by fractures. However, a protocol on costs and quality of life has been recently approved and funded. This study is part of the International Cost and Utility Related to Osteoporosis Study and results are expected by Table 2 Average cost (in USD) of hip fracture treatment per patient [15] Resource utilization IMSS SS Medium- to low-income private High-income private Surgery 1, , ,191.9 Medical staff a 2, ,689.5 Prosthesis or fixation b Hospital stay c 1, ,190.9 Exams and radiology Total medical costs 3, , , ,681.8 Transportation Meals Total non-medical costs Total direct costs d 3, , , ,777.7 a In the private sector, this represents the honoraria of a surgeon, two assistants, an anaesthetist and an internist. These costs are included in the surgery item for IMSS and SS b In private patients, these costs are included in a surgery pack c General ward and Intensive Care Unit. For private patients, only in excess of 4 days in a general ward is taken into consideration d Adjusted by the purchasing power parity index

6 Hip fracture projections and economic projections for 2020 and 2050 Projections for hip fractures up to the year 2050 has been estimated based on the Mexican population projections published by the National Council of Population (CONAPO) [1] and the prevalence rate for hip fracture per 100,000 people reported for the year 2000 [15]. By the year 2050, 110,055 hip fractures are projected to occur in Mexico; this figure represents a relative growth of 431% compared to the estimated 20,725 cases in 2005 and are probably below the reality as projections for 2005 were already underestimated. Figure 6 illustrates the increments per 5-year band for the coming years. The costs for the same period were also projected. For estimating these figures, the cost for each case in the year 2006 (US $4,365.50) was updated to the year 2009 (US $5,026) using the inflation rate from June 2006 to February Then, this amount was multiplied by the projected incidence each year. Two different scenarios were investigated, and estimates are shown in Tables 3 and 4. In the first scenario, all costs are reported in current US dollars for each year, assuming an annual inflation rate of 0%, 3% or 5%. In the second scenario, estimates were expressed in 2009 US dollars, and all future costs were discounted by 0%, 3% or 5% per year. Comparison of osteoporosis-related costs with other diseases Table 5 shows the cumulative cost of diagnosis and treatment of other chronic illnesses. The methodology in every case is different as data were gathered from databases in different institutions. In the hip fracture cases, the methodology included direct interviews, chart review and micro-costing. Because there is little information on costs of musculoskeletal diseases (especially on rheumatoid arthritis), it is difficult to prove their burden and impact on the health care system. There is a need for conducting studies that allow Fig. 6 Hip fractures projections in Mexico until 2050 comparisons with other groups of diseases and permit prioritarizations in the context of the health care system. Availability and cost of DXA for the diagnosis of osteoporosis Close to 400 central DXA scanners exist in Mexico, with 85% in private practice. The Mexican Society of Bone and Mineral Metabolism (AMMOM), which offers the certification course on bone densitometry yearly, reports that only 300 of central scanning machines are in use in medical centres and that not all of them had attained certification by the International Society of Clinical Densitometry or other exams. The cost of a DXA scan in Mexico ranges from US $18.5 to (US $1,048, average income per capita per month in Mexico) [19] in public or private services, respectively. With over 16.5 million people older than 50 years of age in Mexico in 2008, about 20 DXA equipments are available per million people older than 50 years. The imbalance in this resource is noteworthy because the majority of the Mexican population use public hospitals that possess only 15% of all DXA scanners. The rest lies in private health care facilities, which tend to only a small part of the population. There is no reimbursement policy for DXA exams in Mexico. National nutritional programmes for osteoporosis prevention There are no official national nutritional programmes for the prevention of osteoporosis or fragility fractures in Mexico at this time. However, the milk industry now has a marketing programme to increase the consumption of milk and diary products in the population, and bone health is mentioned in this context. Unfortunately in Mexico, the ingestion of milk has been displaced by ingestion of carbonated soft drinks, making it the second highest country in consumption per capita of soft drinks (160 L per person) and the highest in consumption of cola soft drinks. There are many calcium and vitamin D supplements that can be easily acquired over the counter in any pharmacy, supermarket or health and nutrition store. Several doses and types can be found. Some of them have vitamin D together with calcium, which have shown to improve the vitamin D levels of osteoporotic women [20]. By an official norm, milk and dietary products are fortified with vitamin D. Recently, new types of milk have been specially marketed for men and women over 40, and they are enriched with extra calcium. Juices and cereals of

7 Table 3 Hip fracture total direct costs (USD) Projections Year Hip fracture cases Cost per case Total costs Men Women Total i=0% i=3% i=5% i=0% i=3% i=5% ,776 15,709 23,485 5,026 5,026 5, ,033, ,033, ,033, ,697 23,220 34,917 5,026 6,957 8, ,492, ,922, ,151, ,500 74, ,055 5,026 16,887 37, ,135,698 1,858,480,037 4,088,772,523 Monetary values are expressed in current US dollars per year, assuming an inflation rate of either 0%, 3% or 5% i inflation rate different brand names are also fortified with calcium and vitamin D. Treatment of osteoporosis Table 6 shows the drugs approved by the Ministry of Health in Mexico to treat postmenopausal osteoporosis, osteoporosis in men and osteoporosis induced by steroids. these programmes. We consider this governmental initiative as a positive step as osteoporosis and bone health are on the government s agenda for the first time. The authors of this publications were involved with the WHO Collaborative group in gathering the necessary epidemiological data on hip fractures nationally to enable Mexico to be part of a FRAX country model and calibrate the tool for the Mexican population that is available on the site since June. Government policy In October 2008, the Ministry of Health through the National Commission of the Institutes of Health and highlevel specialty hospitals in Mexico convened a group of osteoporosis experts composed of clinical researchers, epidemiologists, health economists, social scientists and policymakers from different institutions in Mexico. The objective of this team is to develop a national programme for prevention, treatment and education that will bring awareness to health professionals and the general public regarding osteoporosis and fragility fractures. The group meets on a regular basis each month and is currently gathering national and international data to develop national guidelines and protocols for the treatment of osteoporosis. The agenda also include setting priorities for research that will eventually evolve in nationwide prevention programmes at the population level. Education programmes for lay people and physicians will be part of Patients and health care professionals awareness of osteoporosis Many structured activities are organized through The Mexican Association of Bone and Mineral Metabolism AMMOM, the Mexican Committee for Study of Osteoporosis Prevention (COMMOP) and local societies or groups within different provinces of Mexico for the World Osteoporosis Day in October. Several courses sponsored by the pharmaceutical industry are offered for continuing education to different health care professionals, mostly clinicians. These courses are taught by leading specialists, and the programmes cover most topics related to osteoporosis and fragility fractures. Seguro Popular offers courses to qualified general physicians in several areas; osteoporosis and fragility fractures are included in this programme. AMMOM holds a yearly meeting in the first semester of the year where most attendees are physicians from Table 4 Hip fracture total direct costs (USD) Projections Year Hip fracture cases Cost per case Total costs Men Women Total r=0% r=3% r=5% r=0% r=3% r=5% ,776 15,709 23,485 5,026 5,026 5, ,033, ,033, ,033, ,697 23,220 34,917 5,026 3,631 2, ,492, ,779, ,606, ,500 74, ,055 5,026 1, ,135, ,628,672 74,829,083 r discount rate Monetary values are expressed in 2009 US dollars, assuming a discount rate of either 0%, 3% or 5%

8 Table 5 Average cost per case per year in selected chronic diseases in Mexico Diseases different specialties. It has also published a Consensus Conference on Diagnosis and Treatment of Osteoporosis in 2003 [21]. Recommendations Average cost per year (USD) Breast cancer 10, Localized cervical cancer treatment a 6, Heart disease Myocardial infarction 16, Stroke 15, Pulmonary disease COPD 9, Lung cancer 14, Inflammatory diseases Rheumatoid arthritis 2, a Cumulative cost of diagnosis and treatment Improved epidemiological data collection is required for : the number of fractures, common sites, direct and indirect costs related to fragility fractures, quality of life, disability and death rates in affected individuals. Estimate disability-adjusted life years lost due to OP and its fractures and develop economical modelling studies to estimate the burden of this entity in Mexicans in order to help the government to prioritize this health condition and be able to allocate the resources needed to treat and prevent OP. Develop absolute risk of fractures in Mexicans, make them available through the WHO FRAX site, and conduct a cost effectiveness analysis study and a case findingstrategytohelpthemexicanauthoritiessetup reasonable treatment thresholds for the Mexican population. Implement special programmes for clinicians to help them detect vertebral fractures with the objective that early diagnosis and treatment will prevent other fragility fractures in the elderly. Follow up individuals who present with a wrist fracture at the age of 50 and over as a high-risk group. Increase the number of DXA machines to cover the needs of the elderly and distribute them wisely within the governmental institutions. Facilitate better detection, treatment opportunities and education programmes for primary physicians. Encourage research on vitamin D and calcium status in Mexicans to be able to estimate to what extent these nutritional supplements are needed in older Mexicans and to develop national recommendations for supplementation accordingly. Table 6 Drugs accepted and available for osteoporosis in Mexico Generic name and dosage Risedronate 5, 30 and 35 mg Raloxifene 60 mg Calcitonin solution 50 and 100 IU nasal spray 200 IU Alendronate 10, 70 and 70 mg with vitamin D Calcitriol 0.25 μg Alfacalcidiol Teriparatide 20 μg Strontium ranelate 2 g Ibandronate 3 mg/ml and 150 mg Zolendronic acid 5 mg/100 ml Indication Prevention and treatment of postmenopausal osteoporosis and osteoporosis induced by steroids. Treatment for Paget disease Prevention and treatment of postmenopausal osteoporosis Prevention of breast cancer in postmenopausal osteoporosis. Treatment of osteoporosis, bone pain, and osteopenia Prevention and treatment of postmenopausal osteoporosis and osteoporosis induced by steroids. Treatment for Paget disease Postmenopausal osteoporosis, hypertiroidism, kidney osteodistrophy, hypothyroidism, rickets Treatment of postmenopausal osteoporosis Prevention of falls Treatment of postmenopausal osteoporosis in women and osteoporosis in men with high risk of fractures, previous fractures, and multiple fractures. Treatment of postmenopausal osteoporosis Treatment of postmenopausal osteoporosis For prevention of osteoporosis and fragility fractures Treatment of postmenopausal osteoporosis Prevention of fractures Treatment of Paget disease

9 Increase awareness and education programmes for consumers and health professionals using media and key opinion leaders in different sectors. Make resources available to fund large-scale evidencebased studies, provide tools for early identification, recognition and post-fracture treatment, and support the management of osteoporosis both by the health care profession and in the community. Acknowledgements The group gratefully acknowledges the revision of the document by the following leaders in the field of OP in the country: Dr. Eduardo Barreira, Dr. Federico Cisneros, Dr. Fidencio Cons Molina, Dr. Margarita Delezé, Dr. José Alberto Hernandez Bueno, Dr. Eduardo Lazcano, Dr. Jorge Morales-Torres and Dr. Juan A. Tamayo and to Dr. Maria Guadalupe Mercadillo Pérez. Head of the Division de Informática en Salud (Division of Informatics in Health) from the Instituto Mexicano del Seguro Social IMSS for her help in getting all vital statistics from the IMSS that are presented in this document. This work was supported by a grant from the International Osteoporosis Foundation. References 1. Veinticinco años de transición epidemiológica en México (1999) 2. Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359(9319): Veinticinco años de transición epidemiológica en México (2000) XII_ Censo_general_de_poblacion_y_vivie 4. Barraza-Llorens M et al (2002) Addressing inequity in health and health care in Mexico. Health Aff (Millwood) 21(3): Frenk J et al (2006) Comprehensive reform to improve health system performance in Mexico. Lancet 368(9546): seguro-popular.salud.gob.mx. Gobierno Federal 2010 (cited) 7. Deleze M et al (2000) Geographic differences in bone mineral density of Mexican women. Osteoporos Int 11(7): Clark P et al (2009) The prevalence of radiographic vertebral fractures in Latin American countries: the Latin American Vertebral Osteoporosis Study (LAVOS). Osteoporos Int 20(2): Clark P et al. (2010) The prevalence of radiographic vertebral fractures in Mexican men. Osteoporos Int. doi: /s Clark P et al (2005) Incidence rates and life-time risk of hip fractures in Mexicans over 50 years of age: a population-based study. Osteoporos Int 16(12): Maggi S et al (1991) Incidence of hip fractures in the elderly: a cross-national analysis. Osteoporos Int 1: Clark P et al (1998) Risk factors for osteoporotic hip fractures in Mexicans. Arch Med Res 29(3): Lips P et al (2006) The prevalence of vitamin D inadequacy amongst women with osteoporosis: an international epidemiological investigation. J Intern Med 260(3): Elizondo-Alanis L, Espinoza-Zamora J, Za-yas-Jaime F (2006) Serum levels of vitamin D in healthy postmenopausal women at 4 cities in Mexico. Rev Metab Óseo Miner 4: Clark P et al (2008) Direct costs of osteoporosis and hip fracture: an analysis for the Mexican healthcare system. Osteoporos Int 19 (3): Cruz-Gonzalez IC-D, Salazar-Pacheco R, Tejeida-Landeros Á (2002) Costos institucionales y dificultades en la atención de los pacientes con fracturas por osteoporosis. Acta Ortop Mex 16 (6): Velasco-Murillo V et al (2003) Fracturas en mujeres postmenopáusicas en el IMSS: frecuencia y costos de su atención hospitalaria. Gac Méd Méx 139(5): Morales-Torres J, Gutierrez-Urena S (2004) The burden of osteoporosis in Latin America. Osteoporos Int 15(8): WHO Statistics (2009) Hernandez-Bueno J et al. (2008) Blood vitamin D levels in Mexican osteoporotic postmenopausal women with or without supplement administration. 12th World Congress on Menopause, Madrid, Spain 21. Consenso Mexicano de Osteoporosis (2001) Rev Invest Clin 53 (5):