In an exclusive exchange, BioPharma APAC engaged in a conversation with Serene Chang, General Manager of Amgen Singapore and Malaysia, delving into the significant issue of osteoporosis and bone health in the Asia-Pacific region. During our discussion, she provided invaluable insights into the prevalence of osteoporotic fractures among women aged 50 and above in Singapore and Malaysia, emphasized the importance of a bone-healthy lifestyle, and shed light on the challenges and gaps in early identification and intervention for at-risk individuals. Furthermore, Ms. Chang shared details of Amgen's endeavors in establishing country bone health alliances and introduced specific programs aimed at combatting osteoporosis in these nations. This dialogue offers a deeper understanding of the ongoing efforts to combat osteoporosis and underscores the pivotal role of public-private partnerships in advancing bone health.

Can you provide more insights into the prevalence of osteoporotic fractures among women over the age of 50 in Singapore and Malaysia? What factors contribute to these high rates, and why is this a growing concern?

Osteoporosis is a bone disease that occurs when the body loses too much bone, makes too little bone, or both¹. This can lead to a decrease in bone strength that can increase the risk of fractures (broken bones). While osteoporosis affects men and women of all races, white and Asian women, especially older women who are past menopause, are at highest risk².

A study by the Asian Federation of Osteoporosis Societies estimated that the number of hip fractures in Malaysia would increase from 5,880 in 2018 to 20,893 in 2050³, and the direct medical cost of hip fractures is estimated to increase from US$ 35.3 million to US$ 125.4 million correspondingly⁴. Additionally, according to Galen Centre, 77 per cent of Malaysian women living with post-menopausal osteoporosis (PMO) are undiagnosed⁵.

Meanwhile, one in three Singaporean women over 50 years old has osteoporosis⁶. Studies in Singapore project that the total number of osteoporotic fractures will increase from 15,267 in 2017 to 24,104 in 2035, which represents a 57.9% increase in less than 20 years⁷.

Urbanization and sedentary lifestyles have contributed to a significant rise in osteoporosis and related fractures^8,9. However, osteoporosis is also inherently an age-related disease and much of the increase in incidence rates can also be attributed to the growing proportion of the population over the age of 60 worldwide.

In Malaysia, it is anticipated that by 2050, more than 15% of its population will be aged above 65 by 2050, qualifying the nation as an aged society’¹⁰ and by 2056, it is expected to become a ‘super-aged nation’, with this age group exceeding 20% of its total population.

Similarly, Singapore’s population is aging rapidly – around one in four citizens will be aged 65 and above by 2030¹¹. The seriousness of this issue has been formally recognized with the government’s launch of Healthier SG, a transformative initiative that shifts its health system towards preventative care in response to its aging problem.

World Osteoporosis Day's theme this year is "Build Better Bones." Could you elaborate on the significance of a bone-healthy lifestyle as a foundation for strong bones and its impact on preventing fractures in the future?

This year’s theme for World Osteoporosis Day focuses on educating the public on good bone health and increasing awareness of personal risk, particular on post fracture care and fall prevention tips12. With that in mind, it is important for us to take proactive and holistic steps to maintain good bone health, which is vital to our quality of life, and the foundation for a mobile, independent future as we age.

According to the International Osteoporosis Foundation, osteoporosis is greatly underdiagnosed and undertreated in Asia, even among the most high-risk patients who have already suffered a fracture¹³. As such, it is important to be aware of one’s osteoporosis risk factors, and to go for regular bone screening and consultation, if needed, to enable early detection of the disease. Lifestyle measures such as diet, exercise, adequate vitamin D levels, maintaining a healthy body weight and adequate sunlight, play a key role in maintaining good bone health, along with the right treatments and medications, if needed.

Prevention of secondary fractures is also important. Those who have experienced a hip fracture are at an increased risk of mortality compared to people who have not had a hip fracture^14,15. Maintaining bone health and ensuring that this group of patients receive the necessary treatment and follow-up care through programs like fracture liaison services is important to prevent recurrent fractures.

In the context of bone health, what are some of the challenges and gaps in early identification and timely intervention for high-risk patients that you've observed in Singapore and Malaysia? 

In general, lack of screening and awareness are two key obstacles in reaching at-risk groups at the appropriate junctures and provide interventions.

In Malaysia, osteoporosis remains underdiagnosed and undertreated, with little data documented on its prevalence¹⁶. In addition, a key contributing factor is that awareness on the importance of bone health is extremely low, coupled with the lack of recognition for osteoporosis as a health priority. Some may have misperceptions that the condition is a part of the natural aging process and does not warrant further evaluation or treatment.

Similarly, awareness of osteoporosis among Singaporeans has not yet reached an ideal level. A recent study in 2021 found that 88% of participants had low osteoporosis awareness and prevention knowledge¹⁷. This was also strikingly lower than the local study performed 20 years ago that showed 42.7% of participants had low osteoporosis awareness¹⁸.

Other studies have cited a lack of understanding of the screening process¹⁹. Similar concerns have been linked to poor adherence to osteoporosis treatment, such as time-consuming follow-up appointments, medication costs and side effects, and the perceived lack of importance of osteoporosis treatment²⁰.

You mentioned the importance of industry and public-private partnerships in better managing bone health in these regions. Could you provide specific examples of such partnerships and how they have contributed to improved outcomes for patients?

Partnerships play a crucial role in managing bone health by bringing together various stakeholders,multifaceted aspects of bone health and osteoporosis prevention.

Despite the fact that one broken bone is likely to lead to another, most patients only receive care to mend a current fracture but no comprehensive care for underlying osteoporosis. As a result, it is also important to incorporate programs and initiatives that focus not just on primary prevention but also secondary prevention within the community. This is where fracture liaison services (FLS) play a role.

FLSs are the most widely utilized and supported multidisciplinary care programs for bone health. Leveraging an approach that involves multi-sectoral collaboration, these services aim to improve secondary prevention of osteoporosis with services such as counselling for patients about their treatment options and follow-up arrangements, as well as falls risk assessment, education and exercise programs.

Singapore boasts the oldest FLS in Asia, dating to 2008, and is one of only three scorecard economies where FLS population coverage goes beyond minimal. Studies have showed a 2.3% 30-day mortality and 5.9% 1-year mortality rate in hip fracture patients after implementing FLS in Singapore²¹, representing a low complication and mortality rate, and significant functional improvement post-operatively.

On the other hand, as FLS services remain concentrated in certain areas in Malaysia, continued collaboration between stakeholders is needed to increase coverage within FLS and across the country²².

In Malaysia, Amgen has been in close partnership with the Fragility Fracture Network Malaysia (FFNM) since 2020, to map and expand the FLS network nationwide through targeted FLS workshops for aspiring FLS champions and teams. Amgen also supported the development of FFNM FLS National Framework, which was launched in December 2022, to provide guidance to the setup of new FLS or to improve existing FLS in practice.

Additionally, the bone health alliances established in Malaysia and Singapore are good examples of how private and public institutions are collaborating to better bone health in the region. Bone health alliances bring public and private stakeholders to collectively promote bone health and prevent disease, improve bone disease diagnosis and treatment and enhance bone research, surveillance and evaluation.

Can you share details about Amgen's efforts and progress in establishing country bone health alliances in Singapore and Malaysia? What initiatives or programs have been put in place to address the osteoporosis issue in these countries?

Amgen is a leader in bone health with more than 20 years of osteoporosis research experience and is committed to combatting this disease to help patients at high risk of fracture reduce their risk of a first and subsequent fracture.

Amgen supports several bone health initiatives that organizations are leading in Malaysia and Singapore to improve local fracture care and prevention. This is achieved through active efforts in partnering and supporting various healthcare institutions to provide medical education to community partners, healthcare professionals and the public to increase awareness on bone health, fractures and osteoporosis.

In Malaysia, Amgen supports the Bone Health Alliance Malaysia (BHAM), a collaborative partnership between Osteoporosis Awareness Society of Kuala Lumpur and Selangor (OASKLS), Fragility Fracture Network Malaysia (FFNM), and Malaysian Osteoporosis Society (MOS). BHAM has been actively driving the awareness, management, and prevention of osteoporosis in Malaysia through regular community-health and the prevention of osteoporosis in the local community²³.

As part of BHAM's WOD 2023 campaign, the alliance has organized an inaugural 'Step Up for Bone Health Fun Walk' on 22 October 2022 in Kuala Lumpur aimed at driving education and awareness on the importance of regular bone health screening, consultations and treatment. In addition, BHAM has also teamed up with celebrity chef Sherson Lian to showcase bone-nourishing recipes, emphasizing the need for a comprehensive approach that incorporates lifestyle changes like diet, exercise and adequate sunlight, to promote good bone health and prevent osteoporotic fractures.

Amgen is also a founding member of the Bone Health Alliance Singapore, which aims to improve Singapore’s osteoporosis fracture care system by accelerating collaboration across sectors to promote a holistic approach to bone health. Priorities include early identification of those at risk of fractures and improving patient experiences and outcomes. In addition, the Bone Health Ambassador Program²⁴, a program between the Health Promotion Board of Singapore and Osteoporosis Society Singapore (OSS), has trained 300 bone health ambassadors to educate Singaporeans on the importance of a healthy lifestyle and diet.

We also work closely together with healthcare professionals in Singapore to support meaningful initiatives that help to advance osteoporosis detection and management. For example, a recent mobile clinic initiative with Dr Carol Tan, who is a Geriatrician at The Good Life Medical Centre, has been remarkably effective in identifying the very high-risk population for further diagnosis and management. Separately, in another initiative with Frontier Healthcare, a primary care network, we co-created an approach to facilitate the management of osteoporotic patients with high fracture risks at the primary care level.

Could you discuss the role of Amgen in helping women at high risk for fracture reduce their risk of a first and subsequent fracture? What specific strategies or treatments is Amgen using to combat osteoporosis in the region?

Beyond the work around bone health alliances, Amgen is helping health systems shift from a traditional reactive acute care (“break and fix” model) to proactive and preventive care (“predict and prevent” model) that can help stabilize healthcare and societal costs and improve patient access for ageing populations.

In 2018, Amgen catalyzed the creation of the Asia Pacific Fragility Fracture Alliance (APFFA), providing funding for a secretariat function, event management and communication activities leading up to the formation of a ground-breaking multi-stakeholder alliance charged with countering fragility fractures threatening the world’s most populated, and fastest aging region.

In addition, Amgen supported the development of the Asia Pacific Consortium on Osteoporosis (APCO) framework, which provides practical, clear and feasible recommendations for osteoporosis care within the Asia Pacific region. In 2022, leading bone experts from 19 Asia Pacific countries and regions convened in Singapore for the Scientific Summit to further their vision of reducing the burden of osteoporosis and fragility fractures for 2023 and beyond.

Through these partnerships and efforts, Amgen is committed to working closely with relevant stakeholders, including healthcare providers, policymakers and the public to reduce the burden of osteoporosis and fragility fractures in the region through supporting programs for the prevention and treatment of osteoporosis.

arcilla.fran@biopharmaapac.com

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21 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10521283/#bibr20-21514593231204783

22 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10425002/#ref34

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