Racial/ethnic and socioeconomic differences in bone loss among men

Socioeconomic status influences on bone mineral density in American men: findings from NHANES 2011-2020

The association between socioeconomic status (SES) and bone mineral density (BMD) in men remains controversial. We showed that SES was positively associated with BMD in American men. Confounding factors like race/ethnicity and age could affect the association.

INTRODUCTION

Based on the data from the National Health and Nutrition Examination Survey (NHANES), 2011-2020, this article aims to investigate the association of SES (poverty income ratio (PIR) and education level) with the BMD in American men.

METHODS

We evaluated the association of SES with BMD in 4446 men aged ≥ 20 years (mean age, 41.0 ± 13.4 years) from the NHANES 2011-2020. BMD was measured by dual-energy X-ray absorptiometry (DXA) at the lumbar spine. We used multivariate linear regression models to examine the relationship between SES and total spine BMD, adjusted for a large range of confounding factors.

RESULTS

Compared with other PIR quarters, individuals in the highest quarter of PIR were more likely to be older and white and had fewer smoking or drinking behaviors. After adjusting for race/ethnicity, age, drinking and smoking behavior, body mass index (BMI), total protein, serum calcium, serum uric acid, cholesterol, serum phosphorus, and blood urea nitrogen, PIR was positively correlated with total spine BMD (β = 0.004 95% CI: 0.001-0.007, P = 0.006). Individuals with the highest degree (college degree or above) had a 0.057 g/cm² greater BMD than that of the lowest degree (less than 9th grade) (β = 0.057 95% CI: 0.037-0.077, P < 0.001).

CONCLUSIONS

Our study indicates that SES was positively associated with the lumbar BMD among American men. Clinicians, healthcare providers, and policymakers should consider the unequal SES of men when implementing osteoporosis prevention and treatment strategies.

Effects of Dietary Protein Quantity on Bone Quantity following Weight Loss: A Systematic Review and Meta-analysis

Research supports the hypothesis that higher total protein intake during weight loss promotes retention of lean soft tissue, but the effect of dietary protein quantity on bone mass, a lean hard tissue, is inconsistent. The purpose of this systematic review and meta-analysis was to assess the effect of dietary protein quantity [higher protein (HP): ≥25% of energy from protein or ≥1.0 g · kg body wt-1 · d-1; normal protein (NP): <25% of energy from protein or <1.0 g · kg body wt-1 · d-1] on changes in bone mineral density (BMD) and content (BMC; total body, lumbar spine, total hip, femoral neck) following a prescribed energy restriction. We hypothesized that an HP diet would attenuate the loss of BMD/BMC following weight loss in comparison to an NP diet. Two researchers systematically and independently screened 2366 publications from PubMed, Cochrane, Scopus, CINAHL, and Web of Science Core Collection and extracted data from 34 qualified publications. Inclusion criteria included the following: 1) healthy subjects ≥19 y; 2) a prescribed energy restriction; 3) measurements of total protein intake, BMD, and BMC; and 4) an intervention duration of ≥3 mo. Data from 10 of the 34 publications with 2 groups of different total protein intakes were extracted and used to conduct a random-effects model meta-analysis. A majority of publications (59%) showed a decrease in bone quantity following active weight loss, regardless of total protein intake. Statistically, the loss of total BMD (P = 0.016; weighted mean difference: +0.006 g/cm2; 95% CI: 0, 0.011 g/cm2) and lumbar spine BMD (P = 0.019; weighted mean difference: +0.017 g/cm2; 95% CI: 0.001, 0.033 g/cm2) was attenuated with an HP versus an NP weight-loss diet. However, the clinical significance is questionable given the modest weighted mean difference and study duration. Higher total protein intake does not exacerbate but may attenuate the loss of bone quantity following weight loss.

Long-term Patterns of Age-Related Facial Bone Loss in Black Individuals

Importance

Facial skeletal changes that occur with aging have critical importance to the aesthetics of the aging face and the field of facial rejuvenation. Patterns of bony change may differ based on race, but existing research is limited primarily to white or unspecified racial populations.

Objective

To longitudinally document patterns of facial skeletal change among black individuals.

Design, Setting, and Participants

This retrospective case series study evaluated the medical records of patients treated at an urban tertiary medical center and with at least 2 facial computed tomographic (CT) images obtained at least 6 years apart between 1973 and 2017. All patients were self-identified black adults initially aged 40 to 55 years with no history of facial surgery who required repeated facial CT imaging that included the entire midface and cranium. All data analysis took place between August 1, 2018, and October 31, 2018.

Main Outcomes and Measures

Facial CT scans were analyzed for 2-dimensional measurements to document changes in glabellar angle, bilateral maxillary angles, frontozygomatic junction width, orbital width, and piriform width.

Results

A total of 20 patients were included in our analysis (6 men, 14 women). The patients' mean (SD) initial age was 46.8 (5.8) years, with a mean (SD) follow-up of 10.7 (2.9) years. There was a significant increase in mean (SD) piriform aperture width from 3.24 (0.37) cm to 3.31 (0.32) cm (P = .002) and mean (SD) female orbital width from 3.77 (0.25) cm to 3.84 (0.19) cm (P = .04). There was a significant decrease in mean (SD) frontozygomatic junction width from 5.46 (1.38) mm to 5.24 (1.42) mm (P < .001). No significant differences were found in glabellar angles, maxillary angles, or male orbital width between initial and final imaging time points.

Conclusions and Relevance

This study is the first to our knowledge to document longitudinal bony changes of the face among a population of black individuals. Although significant facial skeletal changes can be observed over an average 10-year period, they are minor in comparison to previously published data among whites. This study suggests that there may be significant differences in facial bony aging between races which may have an impact on the aesthetics of aging and hold implications for facial rejuvenation.

Level of Evidence

NA.

Effects of deprivation, ethnicity, gender and age on distal radius fracture incidence and surgical intervention rate

INTRODUCTION

Social deprivation has been shown to be associated with increased incidence of many types of fracture but the causes for this have not been established. The aim of this study was to establish if distal radius fracture was associated with deprivation and investigate reasons for this.

METHOD

Data was reviewed of 4463 adult patients who attended our Emergency Department over a four year period. The Index of Multiple Deprivation was used to measure deprivation for each patient. Modelling techniques were used to investigate the relationship between fracture rate and deprivation, gender, ethnicity and age.

RESULTS

Distal radius fracture rate was higher for patients in more deprived quintiles. Mean age in the most deprived two quintiles was 54.4 years compared to 60.1 years in the least deprived three quintiles. Modelling showed important differences between ethnic groups. Deprivation was an independent risk factor for distal radius fracture only in white patients. Deprived white women had a lower second metacarpal cortical index than women of other ethnicities suggesting increased bone fragility. Being male is a risk factor for fracture when deprivation, ethnicity and age are taken into account. Incidence rate ratio of the least deprived quintile compared to the most deprived was 0.33 (95% CI: 0.30-0.37) for white men and 0.47 (95% CI: 0.44-0.49) for white women.

CONCLUSION

Effective interventions exist to prevent further fragility fracture and this work allows geographical areas at risk to be identified. Presentation with a distal radius fracture provides an opportunity to implement interventions. In the current economic climate resources are scarce and must be used prudently. Resources should be targeted to those at risk patients from deprived areas and preventative strategies put in place.

Trabecular microstructure is influenced by race and sex in Black and White young adults

Lower fracture rates in Black men and women compared to their White counterparts are incompletely understood. High-resolution imaging specific to trabecular bone may provide insight. Black participants have enhanced trabecular morphology. These differences may contribute to the lower fracture risk in Black versus White individuals.

INTRODUCTION

Lower fracture rates in Black men and women compared to their White counterparts may be explained by favorable bone microstructure in Black individuals. Individual trabecular segmentation (ITS) analysis, which characterizes the alignment and plate- and rod-like nature of trabecular bone using high-resolution peripheral quantitative computed tomography (HR-pQCT), may provide insight into trabecular differences by race/ethnic origin.

PURPOSE

We determined differences in trabecular bone microarchitecture, connectivity, and alignment according to race/ethnic origin and sex in young adults.

METHODS

We analyzed HR-pQCT scans of 184 adult (24.2 ± 3.4 years) women (n = 51 Black, n = 50 White) and men (n = 34 Black, n = 49 White). We used ANCOVA to compare bone outcomes, and adjusted for age, height, and weight.

RESULTS

Overall, the effect of race on bone outcomes did not differ by sex, and the effect of sex on bone outcomes did not differ by race. After adjusting for covariates, Black participants and men of both races had greater trabecular plate volume fraction, plate thickness, plate number density, plate surface area, and greater axial alignment of trabeculae, leading to higher trabecular bone stiffness compared to White participants and women, respectively (p < 0.05 for all).

CONCLUSION

These findings demonstrate that more favorable bone microarchitecture in Black individuals compared to White individuals and in men compared to women is not unique to the cortical bone compartment. Enhanced plate-like morphology and greater trabecular axial alignment, established in young adulthood, may contribute to the improved bone strength and lower fracture risk in Black versus White individuals and in men compared to women.

Risk of Stress Fracture Varies by Race/Ethnic Origin in a Cohort Study of 1.3 Million US Army Soldiers

Stress fractures (SF) are common and costly injuries in military personnel. Risk for SF has been shown to vary with race/ethnicity. Previous studies report increased SF risk in white and Hispanic Soldiers compared with black Soldiers. However, these studies did not account for the large ethnic diversity in the US military. We aimed to identify differences in SF risk among racial/ethnic groups within the US Army. A retrospective cohort study was conducted using data from the Total Army Injury and Health Outcomes Database from 2001 until 2011. SF diagnoses were identified from ICD-9 codes. We used Cox-proportional hazard models to calculate time to SF by racial/ethnic group after adjusting for age, education, and body mass index. We performed a sex-stratified analysis to determine whether the ethnic variation in SF risk depends on sex. We identified 21,549 SF cases in 1,299,332 Soldiers (more than 5,228,525 person-years of risk), revealing an overall incidence rate of 4.12 per 1000 person-years (7.47 and 2.05 per 1000 person-years in women and men, respectively). Using non-Hispanic blacks as the referent group, non-Hispanic white women had the highest risk of SF, with a 92% higher risk of SF than non-Hispanic black women (1.92 [1.81-2.03]), followed by American Indian/Native Alaskan women (1.72 [1.44-1.79]), Hispanic women (1.65 [1.53-1.79]), and Asian women (1.32 [1.16-1.49]). Similarly, non-Hispanic white men had the highest risk of SF, with a 59% higher risk of SF than non-Hispanic black men (1.59 [1.50-1.68]), followed by Hispanic men (1.19 [1.10-1.29]). When examining the total US Army population, we found substantial differences in the risk of stress fracture among racial/ethnic groups, with non-Hispanic white Soldiers at greatest risk and Hispanic, American Indian/Native Alaskan, and Asian Soldiers at an intermediate risk. Additional studies are needed to determine the factors underlying these race- and ethnic-related differences in stress fracture risk. © 2017 American Society for Bone and Mineral Research.

Does socioeconomic status influence the epidemiology and outcome of distal radial fractures in adults?

PURPOSE

The aim of this study in adult patients with a distal radial fracture was to determine whether socioeconomic status influenced the epidemiology, mechanism of injury, fracture severity, or the outcome according to function, radiographic assessment, and rate of associated complications.

METHODS

We identified 3983 distal radial fractures over a 7-year period. Socioeconomic status was assigned using the Carstairs score, and the population was divided into quintiles depending on deprivation. Patient demographics, mechanism of injury, fracture severity, and radiographic assessment at time of injury were assessed for epidemiological differences according to social quintile. Functional outcome was assessed using grip strength, Moberg pickup test, return to normal use of the hand, and range of movement. Radiographs were assessed at 1 week, 6 weeks, and 1 year. Complications were defined as malunion, carpal tunnel syndrome, complex regional pain syndrome (CRPS), persistent pain, and subjective cosmetic deformity of the wrist.

RESULTS

Socioeconomically deprived patients were significantly younger (p < 0.001) and more likely to be male (p = 0.017); after adjusting for confounding factors, deprived patients were 3.1 (95% CI 1.4-4.7) years younger than the most affluent patients (p < 0.001). Deprived patients were more likely to sustain their fracture by a high-energy mechanism (p = 0.004). There were no significant differences between quintiles in outcome. There was a significantly greater prevalence of CRPS in more affluent patients (p = 0.004).

CONCLUSIONS

Socioeconomically deprived patients sustaining a distal radial fracture are more likely to be younger and male. Outcome is not influenced by socioeconomic status, but the prevalence of CRPS is greater in more affluent patients.

Relationship between socioeconomic status and mortality after femur fracture in a Korean population aged 65 years and older: Nationwide retrospective cohort study

Femur fracture is an emerging public health concern in aging societies, owing to the substantially high morbidity and mortality. Because the recent increase in femur fracture incidence in Asian populations is comparable to that in the West, it is necessary to investigate the association between socioeconomic status (SES) and mortality after femur fracture in developed Asian societies.Data were obtained from the National Health Insurance Claims Database. During 2002 to 2013, femur fractures were newly diagnosed in 5441 patients among 1025,340 enrollees. Multiple logistic regression and the Cox proportional model were used to investigate the associations between individual SES and probability of surgery and mortality after femur fracture.Of 5441 patients, 1928 (35.4%) received surgery. Patients with low (odds ratio [OR] = 0.87, 95% confidence interval [CI]: 0.75-0.99) and middle (OR = 0.85, 95% CI: 0.74-0.98) income were less likely to undergo surgery than high-income patients. Patients with low (hazard ratio [HR] = 1.12, 95% CI: 1.01-1.24) and middle (HR = 1.20, 95% CI: 1.08-1.33) income had a higher HR for mortality. This difference was more prominent in patients who underwent surgery (low income: HR = 1.07, 95% CI: 0.94-1.21; middle income: HR = 1.18, 95% CI: 1.04-1.33) than in patients with conservative treatment (low income: HR = 1.24, 95% CI: 1.04-1.49; middle income: HR = 1.30, 95% CI: 1.08-1.56).Femur-fracture patients with low SES are less likely to receive surgery for and more likely to die after femur fracture. The difference in mortality risk remained even when only the patients who received surgery were considered, suggesting that we need to consider support measures for these deprived patients.

Long-term body composition changes in antiretroviral-treated HIV-infected individuals

OBJECTIVE

Body composition impacts physical function and mortality. We compared long-term body composition changes after antiretroviral therapy (ART) initiation in HIV-infected individuals to that in HIV-uninfected controls.

DESIGN

Prospective observational study.

METHODS

We performed dual-energy x-ray absorptiometry (DXA) approximately 7.5 years after initial DXA in available HIV-infected individuals who received DXAs during the randomized treatment trial AIDS Clinical Trials Group A5202. For controls, we used DXA results from HIV-uninfected participants in the Boston Area Community Health/Bone and Women's Interagency HIV Study cohorts. Repeated measures analyses compared adjusted body composition changes between HIV-infected and HIV-uninfected individuals. Multivariable analyses evaluated factors associated with body composition change in HIV-infected individuals.

RESULTS

We obtained DXA results in 97 HIV-infected and 614 HIV-uninfected participants. Compared with controls, HIV-infected individuals had greater adjusted lean mass and total, trunk, and limb fat gain during the first 96 weeks of ART. Subsequently, HIV-infected individuals lost lean mass compared with controls. Total, trunk, and limb fat gains after 96 weeks of ART slowed in HIV-infected individuals but remained greater than in controls. Lower CD4 T-cell count was associated with lean mass and fat gain during the initial 96 weeks of ART, but subsequently no HIV-related characteristic was associated with body composition change.

CONCLUSION

Consistent with a 'return to health effect', HIV-infected individuals, especially those with lower baseline CD4 T-cell counts, gained more lean mass and fat during the first 96 weeks of ART than HIV-uninfected individuals. Continued fat gain and lean mass loss after 96 weeks may predispose HIV-infected individuals to obesity-related diseases and physical function impairment.

Long-term Bone Mineral Density Changes in Antiretroviral-Treated HIV-Infected Individuals

We compared adjusted bone mineral density (BMD) changes between human immunodeficiency virus (HIV)-infected individuals during the first approximately 7.5 years after antiretroviral therapy (ART) initiation and HIV-uninfected controls. HIV-infected individuals (n = 97) had significantly greater adjusted BMD decline than controls (n = 614) during the first 96 weeks of ART. Subsequently, the rate of BMD decline slowed in HIV-infected individuals but remained greater than the rate of decline in HIV-uninfected individuals at the lumbar spine but not at the hip. In HIV-infected individuals after 96 weeks, no HIV- or treatment-related characteristic was associated with BMD loss, but lower lean body mass was associated with greater BMD loss at both lumbar spine and hip.

Socioeconomic disparities in osteoporosis prevalence: different results in the overall Korean adult population and single-person households

OBJECTIVES

The present study was conducted in order to examine the association between socioeconomic status (SES) and osteoporosis prevalence in Korea and to assess whether different associations are found in single-person households.

METHODS

A cross-sectional population-based study was conducted using the Korea National Health and Nutrition Examination Survey, from 2008 to 2011. The study subjects were people aged ≥ 50 years with osteoporosis as defined by bone mineral density. Multivariate logistic models were used to estimate prevalence odds ratios (pORs) and 95% confidence intervals (CIs). Gender differences in the likelihood of osteoporosis were analyzed based on household income, education level, and residential area.

RESULTS

There were 8221 osteoporosis patients aged ≥ 50 years, of whom 927 lived in single-person households. There was a gender-specific association between osteoporosis prevalence and all three SES factors that we analyzed: income, education, and residential area. After adjusting for age, SES, and health behaviors, including body mass index (BMI), low household income was only significantly associated with osteoporosis in men, whereas education level had an inverse relationship with osteoporosis only in women (p = 0.01, p < 0.001, respectively). However, after controlling for age and BMI, rural residency was only associated with osteoporosis in women living in single-person households (pOR, 1.59; 95% CI, 1.05 to 2.43).

CONCLUSIONS

The Korean adult population showed a gender-specific relationship between SES and osteoporosis prevalence, with a different pattern found in single-person households.