Income-related disparities in osteoporosis and osteoporotic fractures: 15-year study in South Korea

Background

While population aging augments the burden of osteoporosis (OP) and osteoporotic fractures (OF), the pathway from OP diagnosis to effective fracture prevention varies by socioeconomic status. This study analyzed income-related disparities across sequential disease stages of diagnosis and fracture using 15-year national data.

Methods

A repeated cross-sectional study analyzed the National Health Insurance Service data (2008–2022) among adults ≥ 20 years (N=43,403,837 in 2022). Income was categorized into Medical Aid (MA) and insurance quintiles (Q1–Q5). Age- and sex-standardized rates were calculated based on the 2005 Korean standard population. Trends were assessed via Annual Percent Change (APC), and adjusted odds ratios (aOR) were derived using multivariable logistic regression controlled for age, sex, residence, and Charlson Comorbidity Index.

Results

Income-driven decoupling was observed between diagnosis and fracture trends. Over 15 years, MA alone showed decreasing OP (APC: -0.31) despite surging OF (APC: 0.69)—8.6 times steeper than Q5. Notably, the OP rise among MA recipients aged 30–39 (APC: 4.18) far exceeded that in Q5. Rural residents faced higher risks than urban dwellers (OP aOR: 1.25, 95% CI 1.24–1.25; OF aOR: 1.21, 95% CI 1.20–1.23). After adjustment, MA beneficiaries had the highest odds for both OP (aOR: 1.36, 95% CI 1.35–1.37) and OF (aOR: 1.33, 95% CI 1.31–1.35) compared to Q5.

Conclusions

Income acts as a critical filter determining if diagnosis yields actual prevention. Inequality in OP diagnosis suggests potential under-diagnosis, while the OF gap reveals a break in the trajectory where diagnosis fails to translate into prevention. Current policies fail to address the social determinants of health for vulnerable populations. Establishing a comprehensive management system integrating medication adherence, fall prevention, and nutritional and environmental support for high-risk young adults and low-income rural residents is urgent.

Key messages

• Income functions as a filter where high-income groups achieve management success while Medical Aid recipients face a decoupling of 8.6 times faster fracture growth masked by falling diagnosis.

• Health equity requires shifting from screening to “integrated care” addressing social determinants like living environments and nutrition for vulnerable populations.