Osteoporosis and Sarcopenia Prevention in Middle-Aged Population (FORTIFY)

This initiative is designed to yield substantial and multi-level benefits for the Hong Kong community by pioneering a transformative model of preventive healthcare. It represents the largest randomized controlled trial for osteoporosis and sarcopenia prevention in the region, adopting a comprehensive approach to fracture prevention through innovative fitness, lifestyle, and digital strategies.

The study's primary objective is to evaluate the efficacy of preventing fractures, osteoporosis, and sarcopenia through an incentivized program of fitness and lifestyle modifications in adults aged 40-60. The secondary objectives include: (1) to validate the use of simple, low-cost measures (grip strength and InBody body composition analysis) as reliable proxy indicators for osteoporosis and sarcopenia risk relative to the gold-standard DEXA scan; (2) to develop a formal, standardized clinical protocol for early detection and prevention, including specified DEXA anatomical measurement sites, for use by healthcare professionals in primary and community care settings; (3) to assess changes in exercise behavior, musculoskeletal health, physical function, health literacy, and participant engagement with the digital (AI chatbot) support system; (4) to analyze the cost-effectiveness of the intervention compared to standard care or pharmacological treatment, including an assessment of healthcare utilization and Quality-Adjusted Life Years (QALYs).

After baseline screening and consent, participants are randomly assigned to one of two groups (1:1 ratio) with intention-to-treat principles. The Control Group will receive passive, static support. This involves participating in one initial FUN Day, receiving standard exercise videos, using a passive chatbot for data reporting, undergoing start and end DEXA scans (which require a co-payment), completing a 3-month assessment, and receiving souvenirs at the study start and end. Meanwhile, the Intervention Group will receive active, dynamic support designed to build and reinforce healthy habits. This involves participating in the initial FUN Day, a reinforcement FUN Day at 2 months, nine mandatory structured exercise touchpoints, using an active chatbot with reminders, feedback, and gamification, undergoing start and end DEXA scans (which require a co-payment), completing a 3-month assessment, and receiving ongoing incentives and souvenirs at multiple points. Therefore, researchers will compare between the control and intervention groups to see if intervention can prevent osteoporosis and sarcopenia at a population level.

All participants will undergo a series of assessments at specific timepoints. This includes two DEXA scans (at the study start and in the fourth year, requiring a participant co-payment), InBody composition analysis, and physical health assessments (e.g., grip strength, balance, cardiovascular fitness). These assessments will be performed at baseline (during the first FUN Day), 3 months, 12 months, 24 months, and 36 months. A long-term follow-up will continue for up to 10 years to monitor adverse health events such as falls and fractures. Participants will also complete questionnaires via an AI chatbot at baseline, 3 months, and annually during follow-up. The collected data will encompass health literacy (e.g., osteoporosis/sarcopenia knowledge scores), digital engagement (e.g., chatbot responsiveness), and economic outcomes (e.g., incremental cost per Quality-Adjusted Life Year [QALY] gained). Data analysis will employ appropriate statistical methods to compare outcomes between the control and intervention groups across all assessments and timepoints.

Study Overview

• Status: Not yet recruiting
• Conditions: Sarcopenia; Osteoporosis
• Intervention / Treatment: Behavioral: Intervention Group; Behavioral: Control Group

Detailed Description

The proposed FORTIFY project is a prospective, multi-centre, randomized, controlled trial designed with patient-centred objectives. This pilot project aims to significantly prevent fracture and reduce the prevalence of osteoporosis within the study cohort, thereby shifting the participants at-risk age to a lower risk category over a multi-year follow-up period. Targeted participants are adults aged 40-60 years old identified as being low-to-moderate risk for osteoporosis. After baseline screening and consent, the participants will be randomly assigned to one of two groups for a 12-month intervention period, with subsequent three years follow-up. In brief, the control group will receive passive and static support, while intervention group will receive more active, dynamic, and sustained support designed to build and reinforce healthy habits. All participants will undergo dual-energy X-ray absorptiometry (DEXA) scanning, in-body measurements, and health assessments (e.g., grip strength, endurance, balance, cardiovascular fitness, etc.) at the start and end of the project. All participants will also be continuously assessed during the three years follow-up and long-term follow-up beyond the study period including any fall and fracture event.

• Study Type: Interventional
• Enrollment (Estimated): 8336
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Christian FANG; Phone Number: +852 22554581; Email: cfang@hku.hk

Study Locations

• Hong Kong
  • Hong Kong, Hong Kong
    • Queen Mary Hospital, The University of Hong Kong, Hong Kong,
    • Principal Investigator: Christian FANG
    • Contact: Christian FANG; Phone Number: +852 22554581; Email: cfang@hku.hk

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• General Population: Women and men aged 40-60 years, defined as age groups where the rate of injuries were still relatively lower, thus considered as a low to moderate risk cohort for osteoporosis.
• Risk profile: Targets a low to moderate risk cohort for osteoporosis (e.g., as defined by no prior fragility fracture and questionnaire). This aligns with the study's primary prevention objective.
• Individuals with well-controlled comorbidities like hypertension, diabetes, or pre-diabetes can be included in the study program. Exercise and healthy nutritional diets can also help treat their existing health conditions.

Exclusion Criteria:

• Significant comorbidities: Individuals with existing (e.g., severe or uncontrolled) medical illness, due to risk to aerobic exercise. This includes, but is not limited to, active ischemic heart disease, unstable angina, uncontrolled hypertension, or other conditions as determined by study physicians.
• High baseline activity: Individuals who have engaged in >4 hours intensive sports per week will be excluded. This population is deemed to be at very low risk, thus would likely derive minimal additional benefit from the intervention, and their inclusion could represent inefficient use of finite resources (e.g., DEXA scanning services).

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention Group; The intervention group will receive active, dynamic, and sustained support designed to build habits and maintain long-term healthy habits.	Behavioral: Intervention Group; The interventions include FUN Day, reinforcement FUN Day (2 months), nine mandatory structured exercise touchpoints, active chatbot with reminders/feedback/gamification, start and end DEXA scans (co-payment), 3-month assessment, ongoing incentives, and souvenirs at multiple points.
Active Comparator: Control Group; The control group will receive passive and static support.	Behavioral: Control Group; The control group serves to establish baseline comparison with the intervention group to determine whether this new and intensive program is significantly better than the current standard of advice and basic tools. These include FUN Day, exercise videos, passive chatbot for data reporting, start and end DEXA scans (co-payment), 3-month assessment, and souvenirs at study start and end.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Fracture risk	It measures the incidence of fracture or adverse events, which is the ultimate clinical endpoint for osteoporosis prevention. Unit of measure: Count of fractures (per participant) Source: Electronic report/questionnaire and medical records for verification	To be reported monthly throughout study period (years 0-3) and annually after the study ends with long-term follow up (years 4-10).

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Quality-Adjusted Life Years ("QALYs")	It assesses cost-effectiveness compared to pharmacological treatment, using the EQ-5D-5L questionnaire to calculate Quality-Adjusted Life Years (QALYs), which measure both the quality and length of life. This calculation also incorporates cost data derived from both the program itself and overall healthcare utilization. Unit of measure: 0.0 to 1.0 (the higher the better), though the scale can technically go below zero. A score of 1.0 represents perfect, full, or optimal health, while a score of 0.0 is equivalent to a health state of death. Scores between 0.01 and 0.99 reflect living with varying degrees of disability. Source: participant self-administered questionnaire	Questionnaire to be taken at baseline (first FUN Day), post-intervention assessment day at 3-month, and annually during the study period (years 1-3). Long-term follow up if possible (annually after study ends, years 4-10).
Health literacy	Knowledge of osteoporosis, sarcopenia, exercise, and healthy diet tested. Unit of measure: total source (higher = better understanding) reflects the participants' capacity to manage their own risk and to reject harmful misconception. Unit of Measure: Summary score, higher indicates better knowledge (exact range to be specified). Source: Short, self-administered electronic questionnaire.	Questionnaire to be taken at baseline (during first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Long-term follow up if possible (annually after study ends, years 4-10).
Change in bone mineral density (BMD)	Participants' BMD measurements done by DEXA scans (e.g., Z-score or T-score at lumbar spine and hip). It is a gold-standard indicator of osteoporosis risk and primary prevention target. Unit of measure: T-score or Z-score (unitless). T-score compares to healthy young adult (normal ≥ -1.0; osteopenia -2.5 to -1.0; osteoporosis ≤ -2.5). Z-score compares to age-matched population (normal > -2.0; below expected ≤ -2.0). Source: DEXA scan	Scans to be done twice, once at baseline (after first FUN Day) and another scan between years 2-3 of the study.
Fall risk	Measures the participants' use of specialist and inpatient services (e.g., Accident & Emergency Department visits). Unit of Measure: Count of such events during the observation period. Source: Electronic questionnaire/report and medical record verification	To be reported monthly throughout study period (years 0-3) and annually after the study ends with long-term follow up (years 4-10).
Upper body musculoskeletal strength	Assessed based on grip strength value using digital dynamometer. The participant squeezes the device with maximum effort and force is recorded. It is a strong predictor of overall muscle strength and fracture risk. It is low cost and scalable. Unit of measure: Force in kilogram (kg). ≥24 kg target, which aligns with Asian fracture risk thresholds Source: Physical assessment with dynamometer	Assessment to be taken at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Intervention group has additional measurements during reinforcement FUN Day before the 3-month assessment day.
Lower body musculoskeletal strength	Assessed by using the 30-second chair stand test and it reflects functional mobility, including fall risk, endurance, and daily function. Participants are asked to stand up fully and sit down again as many times as possible in 30 seconds. Unit of Measure: Number of completed stands. Higher counts indicate better lower-body strength and functional mobility Source: Physical assessment	Assessment to be taken at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Intervention group has additional measurements during reinforcement FUN Day before the 3-month assessment day.
Balance	Assessed using the single leg stance test. The participant stands on one leg at a time with eyes open and arms positioned at the sides. The time they can maintain the position without the raised foot touching the ground is recorded, with a maximum of 30 seconds per trial. Each leg is tested separately. Longer standing times indicate better balance, which reflects functional mobility, fall risk, endurance, and daily function. Unit of Measure: The time in seconds from when the raised foot leaves the floor until it touches the ground, recorded as a value less than 30 seconds. If the participant maintains the position for 30 seconds or longer, the score is recorded as ">30 seconds" (maximum). Source: Physical assessment.	Assessment to be taken at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Intervention group has additional measurements during reinforcement FUN Day before the 3-month assessment day.
Cardiovascular fitness	Assessed by using the three-minute step test and it reflects functional mobility, including fall risk, endurance, and daily function. Unit of Measure: Heart rate measured for 60 seconds or 1 minute in beats per minute (bpm) Source: Physical Assessment with the heart rate monitor	Assessment to be taken at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Intervention group has additional measurements during reinforcement FUN Day before the 3-month assessment day.
Lean muscle mass distribution	Assessed by using the InBody composition analysis. It serves as a proxy for sarcopenia risk and early marker of physical decline. Unit of Measure: Estimated lean mass in kilograms (kg) Source: InBody machine	Assessment to be taken at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Intervention group has additional measurements during reinforcement FUN Day before the 3-month assessment day.
Exercise adherence	Measured by using the Exercise Adherence Rating Scale (EARS) is a self-administered questionnaire delivered by the chatbot. It contains 6 items (e.g., "I do my exercise as prescribed") rated on a 5-point Likert scale (0 = never, 4 = always). Unit of Measure: Total scores range from 0 to 24, with higher scores indicating better adherence. Source: Electronic self-reported questionnaire.	To be reported at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Long-term follow up if possible (annually after the study ends, years 4-10).
Exercise frequency	Measured as the number of exercise sessions logged by the participant via chatbot. Unit of measure: Number of sessions. Source: Electronic questionnaire and records	To be reported at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Long-term follow up if possible (annually after the study ends, years 4-10).
Physical activity level	Measured using the Physical Activity Rating Scale-3 (PARS-3). This self-report questionnaire assesses the frequency, duration, and intensity of physical activity. Each criterion is scored on a 5-point scale. Unit of Measure: Responses are converted into a continuous score. Generally to find the total score, the scores from three different categories are multiplied together, resulting in a final score between 0 and 100. Higher scores represent higher overall physical activity levels beyond the structured program sessions. This total categorizes a person's physical activity into low (lower or equivalent to 19 points), moderate (20 to 42 points), or high (higher or equivalent to 43 points) levels. Exact range to be specified) Source: Electronic self-reported questionnaire	To be reported at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Long-term follow up if possible (annually after the study ends, years 4-10).
Dietary habits (e.g. calcium and vitamin D)	Measured based on self-reported nutrition survey. It is essential for bone formation and muscle health. Unit of measure: Score, with higher score showing better adherence to dietary guidelines (exact range to be specified) Source: Chatbot questionnaire	To be reported at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Long-term follow up if possible (annually after the study ends, years 4-10).
Self-efficacy for exercise	Measured based on self-reported questionnaire using Self-Efficacy for Exercise Scale - Chinese (SEE-C). It predicts long-term maintenance of physical activity together with the PRETIE-Q questionnaire. Unit of Measure: Total score (exact range to be determined), with higher score indicates greater self-efficacy. Source: Electronic questionnaire.	To be reported at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Long-term follow up if possible (annually after the study ends, years 4-10).
Exercise tolerance	Measured by using PRETIE-Q questionnaire to measure preference for and tolerance of high-intensity exercise. It predicts long-term maintenance of physical activity together with the Self-Efficacy for Exercise Scale - Chinese (SEE-C) questionnaire. Unit of Measure: Score (exact range to be specified), with higher score means greater preference or tolerance. Source: Electronic self-reported questionnaire	To be reported at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Long-term follow up if possible (annually after the study ends, years 4-10).
Chatbot engagement	Measured based on chatbot usage data captured (with backend digital analytics) throughout the 4-year study. It is a proxy for sustained participant engagement. Unit of measure: number of interactions (count) or response rate (%), to be determined later. Continuous with range determined later and higher engagement means better outcome measure. Source: Digital usage data with backend digital analytics.	To be reported monthly throughout the 4-year study (years 0-4). Long-term follow up if possible.
Satisfaction on the program	Measured based on short, self-administered questionnaire by chatbot.	To be reported at baseline (first FUN Day), post-intervention assessment day at 3 months, and annual year assessments (years 1-3). Long-term follow up if possible (annually after the study ends, years 4-10).

Collaborators and Investigators

• Sponsor: The University of Hong Kong
• Collaborators: The Hong Kong Jockey Club Charities Trust; The Family Planning Association of Hong Kong
• Investigators: Principal Investigator: Christian FANG, Dept of Orthopaedics and Traumatology, Queen Mary Hospital

Study record dates

Study Major Dates

• Study Start (Estimated): June 1, 2026
• Primary Completion (Estimated): May 31, 2030
• Study Completion (Estimated): May 31, 2036

Study Registration Dates

• First Submitted: May 7, 2026
• First Submitted That Met QC Criteria: May 20, 2026
• First Posted (Actual): May 28, 2026

Study Record Updates

• Last Update Posted (Actual): May 28, 2026
• Last Update Submitted That Met QC Criteria: May 20, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: Randomized Controlled Trial; AI Chatbot; Middle-Aged Population; Osteoporosis Prevention; Sarcopenia Prevention; DEXA Alternative
• Additional Relevant MeSH Terms: Neurologic Manifestations; Bone Diseases; Musculoskeletal Diseases; Nervous System Diseases; Neuromuscular Manifestations; Pathological Conditions, Anatomical; Metabolic Diseases; Bone Diseases, Metabolic; Muscular Atrophy; Atrophy; Pathological Conditions, Signs and Symptoms; Nutritional and Metabolic Diseases; Signs and Symptoms; Osteoporosis; Sarcopenia; Investigative Techniques; Epidemiologic Research Design; Epidemiologic Methods; Research Design; Methods; Control Groups
• Other Study ID Numbers: UW 26; 2026-0026-002 (Other Grant/Funding Number: The Hong Kong Jockey Club Charities Trust)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Anonymized dataset to be included as supplementary data in final publication
• IPD Sharing Time Frame: Within 1 year of study completion
• IPD Sharing Access Criteria: Additional information available upon reasonable request of principal investigator
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No