三、主要发现和建议

（一）主要发现

1.骨质疏松症已经成为我国40岁及以上人群的重要健康问题，中老年女性尤为突出

我国40岁及以上人群骨质疏松症患病率为12.6%，女性高于男性，分别为20.9%和4.4%。骨质疏松症患病率随年龄的增长而快速增加。我国男性骨质疏松症患病率水平与各国差异不大，女性患病率水平显著高于欧美国家，与日韩等亚洲国家相近。

2.我国低骨量人群庞大，男、女性并重

我国40岁及以上人群骨量低下流行率为40.9%，男性为41.7%，女性为40.0%。总体水平与韩国接近，男性相较于欧美国家处于较高水平。低骨量人群作为骨质疏松症的高危人群，数量庞大，随着我国城市化、人口老龄化进程的不断加快和不健康生活方式的广泛流行，骨质疏松症的防控形势日益严峻。

3.骨质疏松症相关危险因素不容忽视

低体重、身体活动缺乏、奶制品摄入不足、吸烟等不良生活方式是中国人群骨质疏松症患病的重要危险因素，不良生活方式亟待改善。无论男性还是女性，低体重和从不锻炼都是骨质疏松症的危险因素。现在或曾经吸烟是影响男性患骨质疏松症的重要危险因素；40岁后身高减少超过3cm以上、过去一年从未摄入奶制品是女性骨质疏松症患病的重要危险因素。同时与骨质疏松症相关的生殖系统健康以及相关慢性病患病史亟待关注。

4.骨质疏松症治疗率有待提高

基础措施中，钙剂在中国骨质疏松症人群中广泛使用，维生素D使用率有待提升。确诊的骨质疏松症人群中有25.1%使用药物治疗，男性和女性近似，城市和农村相近。药物治疗中，中成药、维生素D类似物、双膦酸盐、降钙素、维生素K2、雌激素类（女性）、甲状旁腺激素类似物、选择性雌激素受体调节剂（女性）的使用率由高到低，其中降钙素、维生素K2、雌激素类、甲状旁腺激素类似物和选择性雌激素受体调节剂的使用率均低于20%。在药物治疗中，中成药和甲状旁腺素类似物使用高于主要发达国家，维生素D、双膦酸盐、选择性雌激素受体调节剂的使用明显低于大多数欧美国家。

5.居民对骨质疏松症认知普遍不足

我国40岁及以上人群骨质疏松症相关知识知晓率仅为7.4%，城市（12.5%）高于农村（4.7%）。超过一半的人群甚至从未听说过骨质疏松症。知识知晓率低反映整个社会对骨质疏松症的认知不足，也反映我国医疗卫生机构开展骨质疏松症防控的意识、能力和措施严重不足。

（二）主要建议

1．坚持政府主导和部门协作，坚持将健康融入所有政策等基本防控策略，创造健康骨骼和骨质疏松症防控的支持性环境。

2．加强健康教育与科普宣传，提高居民骨质疏松症相关知识知晓率、治疗率等，提升全民骨骼健康意识。

3．实施早诊早治，从贯穿生命全周期的角度，针对重点人群开展骨质疏松症综合防控。

4．推广和宣传骨质疏松症防控指南和规范，强化规范诊疗，加强筛查、诊疗等新技术的推广，提高防治效果。

5．加强骨质疏松症防控能力建设。促进医防协同和分级诊疗，开展全流程健康管理；开展专业人员队伍建设；开展监测和评估；增强科学研究。

Abstract

1．Overview of the study

The China Osteoporosis Prevalence Study（COPS）2018 is the first nationwide crosssectional study in China conducted by the National Center for Chronic and Noncommunicable Disease Control and Prevention（NCNCD），China CDC and Chinese Society of Osteoporosis and Bone Mineral Research of Chinese Medical Association，under the leadership of Disease Prevention and Control Bureau of the National Health Commission. The goals of the study were to determine the distribution characteristics of bone mineral density and the prevalence of osteoporosis and related risk factors in urban and rural areas and residents of different genders in China，and to develope prevention and control strategies for osteoporosis scientifically as well.

The China Osteoporosis Prevalence Study 2018 covered 44 counties or districts in 11 provinces，（municipalities）including Beijing，Shanxi，Jilin，Jiangsu，Zhejiang，Hubei，Hunan，Guangdong，Sichuan，Chongqing and Shaanxi. Residents aged 20 and over were investigated，including 20 to 39 years old for establishing reference of peak bone mass in Chinese and aged 40 and over for estimation of osteoporosis prevalence in China. Participants were recruited using multi-stage stratified cluster random sampling methods to obtain a nationally representative sample. For the first stage of sampling（provincial level），11 provinces（municipalities）were randomly selected. Within each province（municipality），4 counties /districts were selected according to the overall population size；In each county（district），4 townships（streets）were then randomly selected；2 villages or communities were randomly selected from each township（street）；1 neighborhood or group was randomly selected from each village（community）；8 residents aged 20 to 39 years were selected in each neighborhood or group，stratified by age（20-29，30-39）and gender，and 50 households were randomly selected from each neighborhood or group；one resident aged 40 and over was randomly selected from each household.

Data and information were collected through a combination of centralized face-to-face interviews and household face-to-face interviews. The survey consisted of questionnaires，bone mineral density measurements and physical measurements，etc. The questionnaires included demographic characteristics，osteoporosis-related symptoms，risk factors，history of diseases and medication，and osteoporosis awareness. Bone mineral density were measured using the internationally recognized “gold standard” dual-energy X-ray absorptiometry（DXA），which measured the bone density of the lumbar spine，femoral neck and total hip separately.Physical measurements included height and weight. A nationally representative sample of 20 416 individuals was obtained，of which 20 281 were investigated.

2．Main results

2.1　General information of the participants

A total of 20 281 individuals were surveyed in the China Osteoporosis Prevalence Study 2018，of which 8 776（43.3%）were males and 11 505 were females（56.7%）．There were 11 039 urban residents（54.4%）and 9 242（45.6%）rural residents. Among the 17 489 valid samples aged 40 and over，there were 7 393（42.3%）males and 10 096（57.7%）females.

2.2　Distribution of bone mineral density

In 2018，the bone mineral density（BMD）of Lumber 1-Lumber 4 was the highest and that of femoral neck was the lowest in all age groups in China. Overall，the BMD was higher in urban areas than that in rural areas among all age groups，reflecting the urban-rural difference in bone mineral density. In men，peak BMD of lumbar spine，femoral neck and total hip occurred in the 20 to 29-year age group，which were 0.998g/cm2，0.868g/cm2 and 0.923g/cm2，respectively. In women，peak BMD of femoral neck and total hip occurred in the 20 to 29-year age group，which were 0.827g/cm2 and 0.885g/cm2　respectively，and the peak BMD of lumbar occurred in the 30 to 39-year age group，which was 1.042g/cm2.

2.3　Prevalence of osteoporosis

In 2018，the prevalence of osteoporosis among residents aged 40 and over in China was 12.6%，of which 4.4% for males and 20.9% for females. The prevalence was higher in females than that in males. The prevalence was 10.9% in urban areas and 13.6% in rural areas，which was higher in rural areas than in urban areas. The prevalence of osteoporosis among those aged 60 and over reached 27.4%（8.0% for men and 45.9% for women）．

2.4　Low bone mass

In 2018，the prevalence of low bone mass among residents aged 40 and over in China was 40.9%， 41.7% among males and 40.0% among females. The prevalence of males was slightly higher than that in females. The prevalence was 39.5% in urban areas and 41.6% in rural areas and that in the rural areas is higher than in the urban areas. The prevalence of low bone mass among people aged 60 and over reached 47.5%，51.2% among men and 44.1% among women.

2.5　Osteoporosis related risk factors

The relationship between osteoporosis and related risk factors including family history，low body weight，lifestyles（alcohol intake，smoking，diary products intake，physical activity，outdoor activity），reproductive health，chronic diseases（hyperthyroidism，hyperparathyroidism，diabetes，chronic gastrointestinal diseases and rheumatoid arthritis），medication history（steroid drugs，antiepileptics，anticoagulants，thyroid hormones，sedative hypnotics，and acid suppressants）and other related risk factors was analyzed.

In men，low body weight，current or previous smoking，never exercising，and suffered from impotence or loss of libido were found to increase the risk of osteoporosis，with OR values of 5.825（95%CI：3.893-8.716），1.320（95%CI：1.014-1.718），1.577（95%CI：1.128-2.205）and 1.412（95%CI：1.057-1.886）respectively.

In women，parents diagnosed with osteoporosis or hip fracture，losing more than 3cm of height after the age of 40，low body weight，never consuming dairy products in the past year，menopause occurring before 45 and chronic gastrointestinal disease were found to increase the risk of osteoporosis，with OR values of 1.287（95%CI：1.052-1.574），1.380（95%CI：1.198-1.590），4.205（95%CI：3.061-5.777），1.240（95%CI：1.104-1.392），1.231（95%CI：1.073-1.413），1.717（95%CI：1.469-2.007）and 1.354（95%CI：1.111-1.648）respectively.

2.6　Diagnosis of osteoporosis

The awareness rate of osteoporosis（proportion of people who were aware of their diagnosis with osteoporosis in the total number of osteoporosis determined in current survey）was 6.4%among people aged 40 and over in China in 2018. It was lower in males than that in females（3.7%vs. 7.0%），and higher in urban areas than that in rural areas（10.5% vs .4.6%）．

2.7　Treatment of osteoporosis

In 2018，16.1% of residents with diagnosed osteoporosis aged 40 and over in China were treated with calcium and vitamin D at the same time. The proportion in men was lower than that in women（9.8% vs. 19.4%）and was higher in urban areas than that in rural areas（18.3% vs. 13.8%）．

In 2018，25.1% of residents with diagnosed osteoporosis aged 40 and over took medication，and the proportions in men and women were about the same（25.0% and 25.2%，respectively）．The proportions were similar in urban areas and rural areas（25.9% and 24.3%，respectively）．Among those who took medication，28.1% used bisphosphonates，17.3% used calcitonin，7.2%used estrogen（females），5.8% used parathyroid hormone analogues，3.9% used female selective estrogen receptor modulators（females），33.7% used Vitamin D analogs，11.1% used vitamin K2 and 40.2% used Chinese patent medicine.

2.8　Knowledge of osteoporosis and measurement of bone mineral density

2.8.1　Awareness of osteoporosis disease name：In 2018，48.8% of residents aged 40 years old and over had heard about a condition called osteoporosis. The proportion was 48.6% in males and 49.0% in females and it was higher in urban areas（61.9%）than in rural areas（41.7%）．

2.8.2　Knowledge of osteoporosis：In 2018，knowledge awareness rate of osteoporosis was 7.4% in residents aged 40 years old and over，with 7.0% in males，and 7.9% in females. The rate in females was slightly higher than in males. Knowledge awareness rate of osteoporosis was significantly higher in urban areas than in rural areas，which were 12.5% and 4.7% respectively.

2.8.3　Bone mineral density measurement：In 2018，only 3.3% of residents aged 40 years and over in China ever measured bone mineral density and the proportion in females was slightly higher than in males，which were 2.8% and 3.8% respectively. 6.6% of residents in urban areas ever measured bone mineral density and only 1.6% in rural areas.

3．Main findings and recommendations

3.1　Main findings

3.1.1　Osteoporosis has become an important public health problem for people aged 40 and over in China，especially in middle-aged and elderly women

The prevalence of osteoporosis in people aged 40 and over in China was 12.6%，which was higher in women than in men（20.9% vs. 4.4%）and increased rapidly with age. The prevalence in men in China was not much different from that in other countries，while in women was significantly higher than that in European and American countries，and was similar to that in Asian countries such as Japan and South Korea.

3.1.2　There are a large number of people with low bone mass both in males and females in China

The proportion of low bone mass in people aged 40 and over in China was 40.9%，41.7%in males and 40.0% in females. The proportion is close to that in South Korea，while it is higher than that in European and American countries among men. We are facing more and more severe situation in the field of osteoporosis prevention and control with the large number of residents with low bone mass，as high-risk population of osteoporosis，as well as with the rapid urbanization，ageing of population in China and the widespread unhealthy lifestyles.

3.1.3　More attention should be paid to risk factors related to osteoporosis

It is important to keep healthy lifestyles for osteoporosis prevention and control. Low body weight，lack of physical activity，insufficient dairy products intake，smoking and other unhealthy lifestyles were found to be risk factors for osteoporosis in the Chinese population in this survey.Low body weight and never exercised were risk factors for osteoporosis in both men and women.Current or previous smoking was an important risk factor for osteoporosis in men. Losing more than 3cm in height after the age of 40 years and never consumed dairy products in the past year were risk factors for osteoporosis in women. Meanwhile，reproductive health was associated with osteoporosis，as well as the history of chronic diseases and medication need urgent attention.

3.1.4　The treatment rate about osteoporosis needs to be improved

As basic measures，Calcium was widely used and the proportion of using vitamin D needs to be improved in the diagnosed osteoporosis population in China. 25.1% of the patients with osteoporosis were treated with drugs. The proportions were similar in man and women，urban areas and rural areas.In drug treatment measures，the utilization rate of Chinese patent medicine is the highest，followed by vitamin D analogs，bisphosphonates，calcitonin，vitamin K2，estrogen（females），parathyroid hormone analogues，and selective estrogen receptor regulator（females）．The utilization rate of calcitonin，vitamin K2，estrogen，parathyroid hormone analogues，and selective estrogen modulators were all lower than 20%. The utilization rates of Chinese patent medicine and parathyroid hormone analogues are higher than that in major developed countries，and the utilization rates of vitamin D，bisphosphonates and selective estrogen receptor modulators are significantly lower than that in most European and American countries.

3.1.5　Awareness of osteoporosis is generally very low in Chinese residents

Only 7.4% of the residents aged 40 and over，had good or excellent knowledge of osteoporosis and it was higher in urban areas（12.5%）than in rural areas（4.7%）．More than half of the survey population had never heard of osteoporosis. The low rate and poor knowledge reflect the inadequate awareness of osteoporosis in the whole society，and also indicate that there are serious deficiencies of the health system in awareness，capacity and measures for osteoporosis prevention and control.

3.2　Main recommendations

3.2.1　Adhere to the principles of government guidance，muti-department cooperation and basic prevention and control strategies such as implementing health in all policies as well as creating supportive environment for bone health，osteoporosis prevention and control.

3.2.2　Strengthen health education and health initiative of popular science propaganda to improve the awareness rate and treatment rate of osteoporosis and to raise the awareness of bone health among residents.

3.2.3　Implement early diagnosis and early treatment，and carry out comprehensive prevention and control of osteoporosis for key populations from the perspective of the entire life cycle.

3.2.4　Promote and publicize guidelines and specifications of osteoporosis prevention.Strengthen standardized diagnosis and treatment. Strengthen the popularization of new technologies about screening，diagnosis and treatment，and improve the effects of prevention and treatment.

3.2.5　Strengthen capacity building for prevention and control of osteoporosis. Promote the collaboration of treatment and prevention，hierarchical diagnosis and treatment，and carry out whole-process health management. Carry out professional team building，strengthen surveillance and evaluation，as well as scientific research.