Bone health comparison in seven Asian countries
using calcaneal ultrasound
Marlena C Kruger1*
* Corresponding author
Joanne M Todd2
Linda M Schollum2,3
Drew W McLean2
1 Institute of Food, Nutrition and Human Health, Massey University, Private Bag
11222, Palmerston North 4442, Palmerston North, New Zealand
2 Fonterra Co-operative Ltd, Private Bag 92032, Auckland, New Zealand
3 Fonterra Research and Development Centre, Private Bag 11029, Palmerston
North 4442, New Zealand
Bone density measurements by DXA are not feasible for large population studies, whereas
portable ultrasound heel scanners can provide a practical way of assessing bone health status.
The purpose of this study was to assess bone health in seven Asian countries using heel
Stiffness index (SI) was measured and T-scores generated against an Asian database were
recorded for 598,757 women and 173,326 men aged over 21 years old using Lunar Achilles
(GE Healthcare) heel scanners. The scanners were made available in public centres in
Singapore, Vietnam, Malaysia, Taiwan, Thailand, Indonesia and the Philippines.
The mean SI was higher for men than women. In women SI as well as T-scores declined
slowly until approximately 45 years of age, then declined rapidly to reach a mean T-score of
< −2.5 at about 71–75 years of age. For men, SI as well as the T-score showed a slow steady
decline to reach a mean of −2.0 to −2.5 at about 81–85 years. The results for females indicate
that there are differences in the rate of decline between countries (significant differences
between the slopes at P < 0.05). Vietnam had the fastest decrease for both T-Score and SI,
resulting in this population having the poorest bone health of all countries at older ages. The
results for males aged 46–85 years indicate that there are no significant differences in the rate
of decline between countries for SI and T-Score. In both men and women aged 46–85 years,
Vietnam and Indonesia have the lowest SI as well as T-Score for all age groups while the rate
of decline for SI in men is greatest in Indonesia and the Philippines. For Vietnam and
Indonesia, more than 50% of the women could be at risk of having osteoporosis and related
fractures after the age of 70, while in Thailand and the Philippines this was >80 years.
The heel scan data shows a high degree of poor bone health in both men and women in Asian
countries, raising concern about the possible increase in fractures with ageing and the
expected burden on the public health system.
Heel ultrasound, Asia, Risk for osteoporosis
According to the International Osteoporosis Foundation’s Asian Audit, published in 2009, the
incidence of hip fracture has risen 2- to 3-fold in most Asian countries over the past 30 years
[1-4]. Hip fracture rates in Hong Kong and Singapore are approaching those observed in US
Caucasians . The increased prevalence of osteoporosis- associated peripheral and vertebral
fractures will also lead to an increase in socioeconomic burdens due to related costs for the
public health system in the Asian region [2,5,6].
Bone mineral density using DXA is the standard diagnostic technique for osteoporosis but the
cost is relatively high, and there is a shortage of DXA machines through most of the
developing Asian countries . Most of these machines are also located in the urban areas
and therefore not accessible by the rural population. DXA is not ideal for community based
studies, as DXA machines cannot be transported to rural areas and the cost of a scan is
The general recommendation in Europe for DXA machines is 0.11 per 10,000 population
(www.iofbonehealth.org) . Most of the Asian countries are well below this ratio, with the
ratio for Indonesia at 0.001 per 10,000 population for example, more than 70-fold lower .
As a result of this lack of available DXA technology, other clinical prediction tools have been
developed, such as the Osteoporosis Self-assessment tool (OSTA)  and the Kohn Kaen
Osteoporosis Study Score (KKOS) [10,11] in order to attempt to identify people at risk of
osteoporosis and therefore who should receive a DXA scan. The FRAX® tool has been
developed by the World Health Organisation (WHO) to evaluate fracture risk of patients .
It is based on individual patient models that integrate the risks associated with clinical risk
factors as well as bone mineral density (BMD) at the femoral neck. But the FRAX® has not
been validated for Asian populations with the exception of China, Hong Kong, the
Philippines, Sri Lanka, Singapore and Taiwan .
Quantitative ultrasound (QUS) may offer an alternative tool for screening or assessment of
risk of poor bone health in large populations. QUS measures the peripheral skeleton, and may
give some assessment of bone microarchitecture in addition to bone mass . It is relatively
inexpensive, and is portable, and therefore could be used as a tool to screen for poor bone
health at the community level . QUS has also been shown to be as good as bone mineral
density (BMD) assessed by DXA in predicting fracture risk . Previous studies have
shown that broad band attenuation (BUA) of QUS correlates moderately well with bone
density by DXA . The Achilles has been US FDA-approved for three clinical uses: It can
predict the risk of hip fracture comparable to DXA at hip/spine; 2) it has valid T-scores for
use in the same way as DXA at hip/spine, and 3) it has precision for monitoring bone changes
in older populations (PMA number P970040).
There are very little data on the prevalence of low bone mass in several Asian countries.
There have been population studies done in Taiwan including over 16,000 volunteers ,
Vietnam [8,17], and The Asian Osteoporosis Study (AOS) [1,5,18]. Lin et al. , reported
mild to severe osteoporosis in 54% of the volunteers aged 50 and older living in Taiwan,
while Hien et al.  and Thuy et al.  reported the prevalence of osteoporosis as 39% of
women over the age of 50 years living in Hanoi City.
To date, there has not been a comprehensive assessment of bone health across the Asian
region. The aim of the present study was to assess calcaneal stiffness index and T-scores
using QUS in seven Asian countries from a large self-selected population. We hypothesised
that the pattern of bone loss will be different between countries as well as between males and
In this descriptive study, The Lunar Achilles Insight or Express (GE Healthcare, Madison,
WI, USA) heel scanners were made available in several public centres such as shopping
centres, community gatherings and office buildings in Singapore, Vietnam, Malaysia,
Taiwan, Thailand, Indonesia and the Philippines between 2006 and 2009. Men and women
attending the locations were invited to have their heel scanned. Only age and gender were
recorded and there were no inclusion/ exclusion criteria in place, although all individuals
signed a registration form. The individuals who volunteered to be scanned would have had to
be ambulatory as they were visiting a public place. The information was gathered during
public events and each individual consented to their information being stored.
Stiffness index (SI) was generated using broadband ultrasound attenuation and speed of
sound measurements for 598,757 women and 173,326 men aged ≥ 20 years old. T-scores
were then generated against the Asian reference population database provided with the heel
scanner. The Achilles systems are non-invasive dry systems, which take 2–3 minutes to scan.
For all subjects, the scan measured the right calcaneus.
Calibration was performed on each scan day according to manufacturer’s instructions. The
Achilles systems use high frequency sound waves to evaluate bone status in the heel. They
measure speed of sound (SOS) and broadband ultrasound attenuation (BUA) and combine
them to form a clinical measure called the Stiffness Index. The manufacturers cited precision
error for the SI measurement is 2.4%. As multiple scanners were used in various countries at
the same time, they were not cross calibrated.
The SI was used to calculate a T-score based on a healthy young adult reference population.
There have been 6 clinical studies involving 10,000+ women from which the reference
population was created, and the ability to express and interpret results as T scores. This can
be used to determine an individual’s risk of poor bone health. Therefore a T-score of > −1
was classified as normal, a score of < −0.1 and > −2.5 was classified as being at risk of
having osteopenia while a T-score of < −2.5 was classified as at risk of having osteoporosis
as per the FDA approval. The latter approach was reinforced by the position statement from
the International Society for Clinical Densitometry (ISCD) . While the QUS should not
be used to diagnose osteoporosis, thresholds were defined as above to identify patients at
high or low risk of having osteoporosis and being at risk of fracture.
Multiple studies using the Lunar Achilles QUS systems [19-22] have confirmed that the
system has a 90% sensitivity for detecting osteoporosis at the spine and hip, using an Achilles
T-Score referral threshold of −0.8 to −1.2. Using an Achilles T-score of −2.5 has been shown
to provide a specificity of more than 90% for identifying only those subjects at high risk.
Individuals with an Achilles T-score above −1.0 are considered at low risk for having
osteoporosis, while those with an intermediate score of −1.0 to −2.5 may have some risk of
low bone mass, and those with a T-score of < −2.5 are considered at high risk of having
osteoporosis and a high fracture risk. These cut-offs were used to interpret the data obtained
from the Achilles units used in this project.
SI and T-scores were averaged for each 5 years age group and each country and are presented
as mean and standard deviation for each age group and country as well as separately for
males and females. Two-way Analysis of Variance (ANOVA) was used on the means to test
for the effects of age and gender and their interaction on T-score and SI. Analysis of
Covariance (ANCOVA) was used to compare the rates of decline in T-score and SI over age
during the period of linear decline (age 46–85 years). Piecewise polynomial regression was
used to test whether the rates of decline are similar in the 21 to 45 and 46–85 year age groups.
Figure 1 summarises the age and gender distribution of the participants. In total we report
data from 598,757 heel scans for women, and 173,326 scans for men over the age of 20
years. The number of subjects per country and gender are presented in Table 1.
Figure 1 Number of males and females scanned per age group.
Table 1 Number of subjects per country and gender
Tables 2 and 3 and Figures 2a and b compare the rate of bone loss with age between men and
women. The statistical analyses indicate that there is an interaction between age group and
gender, indicating that the differences between men and women vary between age groups
(Tables 2 and 3). The rate of loss is faster in the younger men compared to women aged
between 21 and 55. Bone loss in the men is slow yet steady over time, while the rate of loss
remains slow in the women, up until the age of 50 after which it increases rapidly. Women at
age 55–60 reach a mean T-score of −1.0 which could indicate that many of these women may
have low bone mass and could be at risk of having osteopenia . The men already reach a
mean T-score of −1.0 at age 46–50 which may indicate low bone mass at a much younger age
compared to women.
Table 2 ANOVA for the effects of age and gender on stiffness index
Type III SS
Sex 1 4687.067
Age 14 22248.93
Sex*Age 14 1286.161
Pr > F
Table 3 ANOVA for the effects of age and gender on T-Score
Type III SS
Sex 1 0.001243
Age 14 178.8685
Sex*Age 14 21.42922
Pr > F
Figure 2 a and b: Comparison of SI and T-scores between males and females. Data is
presented as LS mean and 95% confidence intervals.
Data for women aged 21-90+ years old
Figure 3 shows the rate of decline in SI from the women scanned aged 46 to 85. The women
from Indonesia in general have the lowest SI measured of all countries. The results for the
females indicate that there is a significant difference in the rate of decline of SI between
countries (P < 0.05) with Vietnam having a faster decline than the Philippines (0.84 units
decline per additional year of age for Vietnam versus 0.6 units decrease per additional year of
age for the Philippines). There is no difference in the rate of decline of the measured SI
between the other countries. In the 46–50 year old age group, women from Indonesia have a
significantly lower SI than Malaysia, Singapore, Taiwan and Thailand. In the same age group
women from Taiwan have the highest SI, significantly higher than the mean SI for Indonesia,
Philippines and Vietnam. In the 76 to 80 year age group, Vietnam and Indonesia have a
significantly lower SI in comparison to all the other countries (P < 0.05); in the same age
group, women from Taiwan has the highest SI but it is only significantly higher than those
for Vietnam and Indonesia. These are no significant differences in the SI’s measured for this
age group between Malaysia, Philippines, Singapore, Taiwan and Thailand.
Figure 3 Rate of decrease in SI of women aged between 46 and 85 years.
The relevant T-scores are summarized in Table 4. The mean T-score for the young women at
20 years was low at between 0 and 0.5, and showed only a slight decline to approximately the
age of 45, and then a rapid decline reaching a mean T-score of ≤ −2.5 at about 71–75 years of
age. Women from Indonesia aged over 46 years, had significantly lower T-scores compared
to all the other countries, but the rate of decline was faster in women aged 46–85 years from
Vietnam. Women from Taiwan had the highest T-scores, significantly higher than Vietnam,
Indonesia, Malaysia and Philippines but not Singapore and Thailand (P < 0.05).
Table 4 T-Score by country and age group – females (mean and standard deviation)
21 to 25
−0.21 1.487 0.28
26 to 30
−0.34 1.438 0.14
31 to 35
−0.36 1.444 0.02
36 to 40
41 to 45
46 to 50
51 to 55
56 to 60
61 to 65
66 to 70
71 to 75
76 to 80
81 to 85
86 to 90
Data for men aged 20-90+ years old
Figure 4 shows the rate of decline in the SI in men aged between 46 and 85 years old. The
rate of decline is the fastest in Indonesia and the Philippines: 0.60 and 0.67 units decrease per
additional year of age versus 0.29 to 0.45 units decrease per additional year of age for the
remaining countries. The difference in decline between Philippines, Taiwan and Thailand is
marginally significant, but there is no difference in the decrease observed between any of the
other countries. In the 46 to 50 year age group, Vietnam has the lowest SI and the Philippines
the highest; this difference is significant (P < 0.05). All other countries are similar and none
of the other differences are significant. In the 76 to 80 year age group, Indonesia has the
lowest SI. In the same age group, Malaysia, Singapore, Taiwan, and Thailand have the
highest SI, significantly higher than Indonesia. The Philippines and Vietnam are quite low,
but not significantly differently so.
Figure 4 Rate of decrease in SI for men aged between 46 and 85 years.
The T-scores for men slowly decline from age 26–30 reaching a mean of ≤ −2.5 for some
countries at about 81–85 years (Table 5). There are no significant differences between the
rates of decline of the T-score between countries. The men from Indonesia and Vietnam had
the lowest T-scores and greatest risk of poor bone health compared to the other countries but
the rate of decline in the T-score (0.032 units decrease per additional year) between age 46
and 85 years was similar in all countries.
Table 5 T-Score by country and age group - males (mean and standard deviation)
21 to 25
−0.14 1.387 0.18
26 to 30
31 to 35
36 to 40
41 to 45
46 to 50
51 to 55
56 to 60
61 to 65
66 to 70
71 to 75
76 to 80
81 to 85
86 to 90
Several studies have now shown that QUS at peripheral sites can be used as a screening tool
to assess bone health [8,14,17,20,21]. Speed-of-sound measurements at the calcaneus can
identify persons at risk of osteoporotic fracture as reliably as bone mineral density
measurements [22,23] and could be an ideal tool to screen for osteoporosis at the community
level [24-26]. In the current study we aimed to assess bone health in several Asian countries
using the GE Achilles Insight or Express machine, and then to comment on the prevalence of
low bone mass in men and women aged between 20 and 90+ years in these countries. The SI
and T-scores were generated by the units, and the ISCD criteria  were used to classify
people at risk of poor bone health. Our data show a high degree of poor bone health in both
men and women in the seven Asian countries where we conducted the assessments.
The younger males in general had a higher SI compared to females aged between 21–40
while the T-scores for both men and women aged between 20 and 25 were between 0 and 0.5.
Bone loss was slow in the women up to the age of 45–50, after which it increased
significantly, with more than 50% of the women being at risk for being osteoporotic at age
70+ years. In men, bone loss was at a similar rate from age 20 to 90 years with more than
50% being classified as being osteopenic or osteoporotic at age 80+ years. Similar differences
in rates of bone loss were also reported by Lin et al.  in a Taiwanese population which
also had an increased rate of bone loss in women compared to men, after the age of 60 years.
The prevalence of low bone mass was highest in Indonesia for both women and men. In the
46–50 age group, Indonesia had a significantly lower SI than Malaysia, Singapore, Taiwan
and Thailand. In Indonesia up to 70% of women and men over 50 years could be classified as
either osteopenic or osteoporotic. Data from the Indonesian Osteoporosis society (PEROSI)
suggest that about 41.8% of men and 90% of women are osteopenic, while 28.8% of men and
32.3% of women have osteoporosis as per the WHO criteria [4,19]. These data do not define
the age groups and can therefore not be directly compared to our study. Our published data
on a small cohort of postmenopausal women in Indonesia revealed that 66.3% could be
classified as being either osteopenic or osteoporotic, according to DXA of the lumbar spine
In Taiwan the percentage of women over 50 years with low bone mass was 47.5% while the
percentage for men was 57.1%. Chie et al.  reported that the incidence of hip fracture in
Taiwanese women over 50 years was similar to those recorded for Western countries, but that
the age-specific incidence of hip fracture of elderly Taiwanese men was higher than in US
Caucasian men, at about 65% of that for women. The QUS data for the Philippines indicate a
prevalence of low bone mass in 59.3% in women over 50 years and 56.6% in older men. In a
previous study using DEXA, we found 67.2% of postmenopausal women had low bone mass
in the lumbar spine . However, this was a small study including only 58 women, and so
cannot be generalised. Miura et al.  reported a 19.8% prevalence of osteoporosis in urban
postmenopausal women in the Philippines, using QUS. Our data using QUS indicates the
percentage with osteoporosis to be 22.1%, similar to the data reported by Miura et al. .
Our data from Thailand could have underestimated the prevalence of low bone mass, as
differences in the age ranges in various publications make direct comparisons difficult.
Pongchaiyakul et al. , reported the prevalence of osteoporosis by femoral neck or lumbar
spine BMD using DXA, to be 33% in women older than 60 years, while we report that up to
17% of women over 60 years could be at risk of having osteoporosis and another study
showed the prevalence of osteoporosis to be 50% in women over 70 years old . As mixed
results have been reported for Thai women, Pongchaiyakul et al.  examined the
prognostic value of combining QUS with clinical risk factors, using a cohort of women aged
between 38 and 85 years, and found the prevalence of osteoporosis to be 12.7% in this group
of women. Age, weight and QUS outcomes were significantly associated with osteoporosis
risk. The latter study suggests that a combination of QUS with age and weight could be used
to create a normogram to be used to estimate the risk for poor bone health in Asian women.
The reported data raise a concern for bone health in the wider Asian region. Hip fracture rates
in Hong Kong and Singapore have been reported to be approaching those recorded for
Caucasians , and while the rates are lower for countries such as Malaysia and Thailand,
they are likely to increase. In China, at this time, more than 69 million people over the age of
50 suffer from osteoporosis, with 687,000 hip fractures each year. WHO estimated that more
than 50% of hip fractures will occur in Asia by 2050 , and the number of people with hip
fracture in Asia will be about 3.2 million per year [2,6]. A recent review by Cooper et al. 
suggested that while hip fracture rates may be reaching a plateau in the Western world, there
is an increasing age-adjusted incidence rate of hip fractures among Asian men and women.
The cost associated with hip fractures is substantial; the combined annual cost of all
osteoporotic fractures has been estimated to be $20 billion in the USA, and 30 million Euros
in the European Union .
QUS can predict the risk of wrist and osteoporosis-related fractures , the risk of vertebral
fractures [23,25,36], the risk of hip fractures [15,37,38] and can discriminate between women
with and without vertebral fractures [23,38] and hip fractures [22,35,37]. Heel QUS is also
strongly correlated with the strength of the proximal femur . Our data could therefore
indicate that the risk of osteoporotic fracture is high in women and men over the age of 70
years living in the seven countries where we collected data.
Risk factors for low bone mass in Asia include low calcium in the diet, and relative vitamin D
insufficiency. Mean daily calcium intakes in the seven countries vary between just above 200
mg in Indonesia and Thailand [27,40] to about 450 mg for Malaysia, Singapore and Taiwan
[41,42]. Suboptimal vitamin D status has also been widely reported for many Asian countries.
We reported mean 25 (OH) vitamin D3 levels for postmenopausal women in Jakarta to be
45.06 nmol/L (range 41.02 - 49.09) and for women living in Manila, Philippines to be 62
nmol/L (range 56.2 - 67.7) . Other reported values are 52 nmol/ L for Thailand , and
44 nmol/L for postmenopausal women living in Malaysia . In all of the above mentioned
studies, a significant negative correlation was reported between serum 25 (OH) vitamin D3
and Parathyroid hormone (PTH) levels [40,43,44]. There is also a strong relationship between
suboptimal vitamin D status, high PTH levels and the risk for hip fractures [44-47].
The present study had limitations: firstly, none of the QUS bone density measurements were
validated against a DXA measurement for the same person; secondly, the QUS data can only
identify people at risk of low bone mass, and is not a diagnostic tool. Thirdly, participants
were self-selected and primarily from urban areas. And lastly, measuring bone density using
QUS does not capture the Z-score which may have been more of use for the younger
populations; the SI as well as generated T-scores were used as proxy.
The results presented here provide a snapshot of the bone health status of participants from
seven regions in South East Asia. Overall results indicated that there is extensive poor bone
health in both males and females living these regions. The measured SI’s indicate low bone
mass even among young men and women, and the patterns of bone loss were very similar.
We conclude that the data presented may indicate that the risk of having low bone mass and
osteoporotic fractures is high in women and men over the age of 70 years living in these
countries with the highest risk being for people living in Indonesia and Vietnam.
There is a strong need to continue to develop detailed, robust evidence of bone health status
in communities throughout South East Asia. Osteoporosis has a severe effect on the quality
of life and independence of sufferers, and is of considerable socio-economic burden for
individuals, communities and the public health system [4,5]. Studies such as these will
contribute to an accurate assessment of bone health and its prevalence which will help to
provide valuable information for the development and implementation of tailored health
promotion campaigns, improved patient care, and reduced economic burdens.
MC Kruger, K Wylie - none.
JM Todd, LM Schollum, B Kuhn-Sherlock, DW McLean - employed by Fonterra Co-
operative Group Ltd.
The data analyses were done by B Kuhn-Sherlock.
MK was the primary author; JT and LMS edited the manuscript, BKS was responsible for the
statistical analyses and graphics; DWM and KW were responsible for data capture and entry.
All authors read and approved the final manuscript.
This study was funded by Fonterra Brands (Singapore) Ltd
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