The osteoporosis–fracture paradox in older Taiwanese men: lower osteoporosis prevalence but comparable fragility fracture burden

Summary Despite a substantially lower prevalence of osteoporosis than age-matched women, older men experienced a relatively comparable burden of fragility fractures, demonstrating a marked dissociation between osteoporosis prevalence and fracture burden. Purpose Although osteoporosis is less common in men than in women, male fragility fractures carry substantial morbidity and post-fracture mortality. Whether the lower prevalence of osteoporosis translates into a proportionally lower fracture burden remains unclear. We compared the prevalence of osteoporosis and fragility fractures between age-matched Taiwanese men and women. Methods This retrospective cohort study evaluated 2093 men undergoing clinical dual-energy X-ray absorptiometry (DXA) between 2021 and 2023, of whom 2031 met eligibility criteria and were compared with 2031 age-matched women selected via 1:1 nearest-neighbor matching. Osteoporosis was defined as a T-score ≤−2.5 at the lumbar spine, femoral neck and/or total hip. Vertebral and hip fractures were identified from radiographs and electronic medical records. Multivariable logistic regression identified independent predictors of fracture. Results The prevalence of osteoporosis in men was approximately half that in women (32.4% vs. 51.4%; P < 0.001). Conversely, vertebral fracture prevalence was comparable between the sexes (22.7% vs. 22.8%; P = 0.940), and hip fracture prevalence did not differ significantly between the sexes (6.1% vs. 5.0%; P = 0.150). In sensitivity analyses, men had a significantly higher prevalence of moderate-to-severe (Genant grade ≥2) vertebral fractures (16.9% vs. 12.3%; P < 0.001). After adjustment for age, body mass index, and osteoporosis, male sex remained independently associated with both vertebral and hip fractures. Conclusions Older Taiwanese men exhibited a substantially lower prevalence of osteoporosis than age-matched women but experienced a relatively comparable burden of fragility fractures. These findings demonstrate a marked dissociation between osteoporosis prevalence and fragility fracture burden in older men and reinforce the importance of comprehensive fracture risk assessment integrating BMD with clinical risk factors.