Bone loss and the risk of non-vertebral fractures in women and men: the Tromsø study

Association of follicle-stimulating hormone with bone turnover markers and bone mineral density in Chinese women across the menopausal transition

BACKGROUND

Elevated follicle-stimulating hormone (FSH) is associated with an increased risk of postmenopausal osteoporosis. This study investigated the association of serum FSH with bone turnover markers (BTMs) and bone mineral density (BMD) in healthy women undergoing menopausal transition.

METHODS

A total of 487 healthy women (age 35-65 years, 50 ± 8.5 years) were enrolled in this study. Serum FSH, BTMs, and BMD at lumbar spine and total hip were measured in these subjects.

RESULTS

Follicle-stimulating hormone was positively correlated with various BTMs (r = 0.339-0.583, all p < 0.001) and negatively correlated with lumbar spine and total hip BMD (r = -0.629 and -0.514, all p < 0.001). After adjusting for age and body mass index, the partial correlation coefficients of FSH with BTMs and BMD remained significant. Estimating from the regression equation, for every 10 IU/L increase in serum FSH, BTMs increased by 0.38-3.6 units, and BMD decreased by 0.03-0.05 g/cm2 , respectively. Multiple linear regression analysis showed that FSH was a positive factor for serum bone-specific alkaline phosphatase, osteocalcin, and N-telopeptide of collagen type 1 (β = 0.188-0.403, all p < 0.001), and a negative factor for lumbar spine BMD and serum C-telopeptide of collagen type 1 (β = -0.629 and -0.183, all p < 0.001).

CONCLUSIONS

This study suggests that serum FSH levels are an independent risk factor for BTMs and BMD in menopause-transitioning women, particularly for serum BAP and lumbar spine BMD.

Anti-Mullerian Hormone as Predictor of Future and Ongoing Bone Loss During the Menopause Transition

The menopause transition in women is a period of significant bone loss, with rapid declines in bone mineral density (BMD) commencing a year before the final menstrual period (FMP). Changes in menstrual bleeding patterns cannot reliably tell us if this rapid bone loss has begun or is imminent. We hypothesized that low circulating levels of anti-Mullerian hormone (AMH), which decline as women approach the FMP, would be associated with future and ongoing rapid bone loss. We used data from The Study of Women's Health Across the Nation, a multisite, multi-ethnic, prospective cohort study of the menopause transition to test this hypothesis. Adjusted for age, body mass index, race/ethnicity, and study site, every 50% decrement in AMH level in premenopause and early perimenopause was associated with 0.14% per year faster decline over the following 3 to 4 years in lumbar spine BMD and 0.11% per year faster decline in femoral neck BMD (p < 0.001 for both). AMH in late perimenopause was not associated with the rate of future BMD decline. AMH was also associated with the magnitude of ongoing bone loss, measured as percent of peak BMD lost by the end of the next 2 to 3 years. Every 50% decrement in AMH level was associated with 0.22% additional loss in spine BMD in premenopause, 0.43% additional loss in early perimenopause, and 0.50% additional loss in late perimenopause (p < 0.001 for all three). If a woman will lose more of her peak BMD than the site-specific least significant change (LSC) at either the lumbar spine or femoral neck by the next 2 to 3 years, then AMH below 100 pg/mL will detect it with sensitivity of 50% in premenopause, 80% in early perimenopause, and 98% in late perimenopause. These findings suggest that AMH measurement can help flag women at the brink of significant bone loss for early intervention. © 2022 American Society for Bone and Mineral Research (ASBMR).

Follicle-stimulating hormone and blood lead levels with bone mineral density and the risk of fractures in pre- and postmenopausal women

BACKGROUND

The conclusions on the associations of serum follicle-stimulating hormone (FSH) and blood lead levels with bone mineral density (BMD) were controversial. Furthermore, little was known on the impacts of co-existence of serum FSH and blood lead levels on BMD and the risk of fractures in premenopausal and postmenopausal women. Therefore, the present study aimed to examine the associations of serum FSH and blood lead levels with BMD and the risk of fractures in premenopausal and postmenopausal women.

METHODS

Data were derived from the National Health and Nutrition Examination Survey. FSH is assayed using the Microparticle Enzyme Immunoassay technology. Blood lead levels were measured using atomic absorption spectrometry. BMD was measured using dual energy X-ray absorptiometry. Fractures were defined as subjects with fractures in any site of hip, wrist, and spine.

RESULTS

This study included 3798 participants. Elevated blood lead levels were associated with increased serum FSH levels (β= 48.22, 95% CI: 40.21~ 56.22). Serum FSH levels were negatively associated with total femur BMD in pre- and postmenopausal women. However, elevated serum FSH levels were associated with a lower lumbar spine BMD and a higher risk of fractures only in postmenopausal women (β= -0.0010, 95% CI: -0.0015~ -0.0006; OR: 1.007, 95% CI: 1.000~1.014, respectively).

CONCLUSIONS

Serum lead levels were associated with serum FSH levels. Serum FSH levels were associated with a lower BMD and a higher risk of fractures.

Faster Lumbar Spine Bone Loss in Midlife Predicts Subsequent Fracture Independent of Starting Bone Mineral Density

CONTEXT

Bone mineral density (BMD) decreases rapidly during menopause transition (MT), and continues to decline in postmenopause.

OBJECTIVE

This work aims to examine whether faster BMD loss during the combined MT and early postmenopause is associated with incident fracture, independent of starting BMD, before the MT.

METHODS

The Study of Women's Health Across the Nation, a longitudinal cohort study, included 451 women, initially premenopausal or early perimenopausal, and those transitioned to postmenopause. Main outcome measures included time to first fracture after early postmenopause.

RESULTS

In Cox proportional hazards regression, adjusted for age, body mass index, race/ethnicity, study site, use of vitamin D and calcium supplements, and use of bone-detrimental or -beneficial medications, each SD decrement in lumbar spine (LS) BMD before MT was associated with a 78% increment in fracture hazard (P = .007). Each 1% per year faster decline in LS BMD was related to a 56% greater fracture hazard (P = .04). Rate of LS BMD decline predicted future fracture, independent of starting BMD. Women with a starting LS BMD below the sample median, and an LS BMD decline rate faster than the sample median had a 2.7-fold greater fracture hazard (P = .03). At the femoral neck, neither starting BMD nor rate of BMD decline was associated with fracture.

CONCLUSION

At the LS, starting BMD before the MT and rate of decline during the combined MT and early postmenopause are independent risk factors for fracture. Women with a below-median starting LS BMD and a faster-than-median LS BMD decline have the greatest fracture risk.

Peak trabecular bone microstructure predicts rate of estrogen-deficiency-induced bone loss in rats

Postmenopausal osteoporosis affects a large number of women worldwide. Reduced estrogen levels during menopause lead to accelerated bone remodeling, resulting in low bone mass and increased fracture risk. Both peak bone mass and the rate of bone loss are important predictors of postmenopausal osteoporosis risk. However, whether peak bone mass and/or bone microstructure directly influence the rate of bone loss following menopause remains unclear. Our study aimed to establish the relationship between peak bone mass/microstructure and the rate of bone loss in response to estrogen deficiency following ovariectomy (OVX) surgery in rats of homogeneous background by tracking the skeletal changes using in vivo micro-computed tomography (μCT) and three-dimensional (3D) image registrations. Linear regression analyses demonstrated that the peak bone microstructure, but not peak bone mass, was highly predictive of the rate of OVX-induced bone loss. In particular, the baseline trabecular thickness was found to have the highest correlation with the degree of OVX-induced bone loss and trabecular stiffness reduction. Given the same bone mass, the rats with thicker baseline trabeculae had a lower rate of trabecular microstructure and stiffness deterioration after OVX. Moreover, further evaluation to track the changes within each individual trabecula via our novel individual trabecular dynamics (ITD) analysis suggested that a trabecular network with thicker trabeculae is less likely to disconnect or perforate in response to estrogen deficiency, resulting a lower degree of bone loss. Taken together, these findings indicate that the rate of estrogen-deficiency-induced bone loss could be predicted by peak bone microstructure, most notably the trabecular thickness. Given the same bone mass, a trabecular bone phenotype with thin trabeculae may be a risk factor toward accelerated postmenopausal bone loss.

Association between a literature-based genetic risk score and bone mineral density of African American women in Women Health Initiative Study

Genetic risk of low BMD in African American women remains unclear. Based on SNPs discovered from a predominantly Caucasian sample, genetic profile was summarized and was found to be significantly associated with BMD variation in African American women.

INTRODUCTION

Osteoporosis is largely under-recognized and undertreated in African-American women, the post-fracture morbidity and mortality rates in this racial group is rather high. Since BMD was proved to be highly heritable, based on a comprehensive genome-wide meta-analysis that reported 63 BMD-related single nucleotide polymorphisms (SNPs), we aim to unravel the overall genetic risk for decreased BMD and osteoporosis in African-American women.

METHODS

Genotype data of 842 African American women in a Women's Health Initiative cohort were analyzed. Comprehensive genotype imputation was conducted at the Sanger Imputation Server. Multi-locus genetic risk scores (GRSs) based on 62 BMD-related single-nucleotide polymorphisms (SNPs) were calculated. The association between GRS and BMD was assessed by regression analysis. Longitudinal data was further analyzed using a generalized estimating equation, which helps achieve more efficient and unbiased regression parameters by accounting for the within-subject correlation of responses on dependent variables.

RESULTS

After adjusting for age, body weight, hormone use, and previous fracture, for every unit increase of GRS.FN and GRS.LS, BMD at hip and lumbar spine decreased 0.124 g/cm² and 0.086 g/cm², respectively. Collectively, the model accounted for 34.95% of the femoral neck BMD variation and 25.79% of lumbar spine BMD variation. Notably, GRS.FN and GRS.LS accounted for 2.03% and 2.39% of the total explained variance, respectively. The proportion of BMD variation can be explained by GRSs increasing as participants aged.

CONCLUSIONS

Genetic risk score was significantly associated with lower BMD in the current study, suggesting that SNPs discovered from prior meta-analysis based on primarily Caucasian population can also explain a considerable proportion of BMD variation in African Americans.

Estradiol and Follicle-Stimulating Hormone as Predictors of Onset of Menopause Transition-Related Bone Loss in Pre- and Perimenopausal Women

The menopause transition (MT) may be an opportunity for early intervention to prevent rapid bone loss. To intervene early, we need to be able to prospectively identify pre- and perimenopausal women who are beginning to lose bone. This study examined whether estradiol (E2), or follicle-stimulating hormone (FSH), measured in pre- and perimenopausal women, can predict significant bone loss by the next year. Bone loss was considered significant if bone mineral density (BMD) decline at the lumbar spine (LS) or femoral neck (FN) from a pre- or early perimenopausal baseline to 1 year after the E2 or FSH measurement was greater than the least detectable change. We used data from 1559 participants in the Study of Women's Health Across the Nation and tested E2 and FSH as separate predictors using repeated measures modified Poisson regression. Adjusted for MT stage, age, race/ethnicity, and body mass index, women with lower E2 (and higher FSH) were more likely to lose BMD: At the LS, each halving of E2 and each doubling of FSH were associated with 10% and 39% greater risk of significant bone loss, respectively (p < 0.0001 for each). At the FN, each halving of E2 and each doubling of FSH were associated with 12% (p = 0.01) and 27% (p < 0.001) greater risk of significant bone loss. FSH was more informative than E2 (assessed by the area under the receiver-operator curve) at identifying women who were more versus less likely to begin losing bone, especially at the LS. Prediction was better when hormones were measured in pre- or early perimenopause than in late perimenopause. Tracking within-individual change in either hormone did not predict onset of bone loss better than a single measure. We conclude that measuring FSH in the MT can help prospectively identify women with imminent or ongoing bone loss at the LS. © 2019 American Society for Bone and Mineral Research.

Lower Bone Density, Impaired Microarchitecture, and Strength Predict Future Fragility Fracture in Postmenopausal Women: 5-Year Follow-up of the Calgary CaMos Cohort

The aim of this prospective study was to use high-resolution peripheral quantitative computed tomography (HR-pQCT) to determine if baseline skeletal parameters can predict incident fragility fracture in women and, secondly, to establish if women that fracture lose bone at a faster rate than those who do not fracture. Women older than 60 years who experienced a fragility fracture during the 5-year follow-up period (incident fracture group, n = 22) were compared with those who did not experience a fragility fracture during the study (n = 127). After image registration between baseline and follow-up measures, standard and cortical morphological analyses were conducted. Odds ratios were calculated for baseline values and annualized percent change of HR-pQCT and finite element variables. At the radius, baseline HR-pQCT results show women who fractured had lower total bone mineral density (Tt.BMD; 19%), trabecular bone mineral density (Tb.BMD; 25%), and trabecular number (Tb.N; 14%), with higher trabecular separation (Tb.Sp; 19%) than women who did not fracture. At the tibia, women with incident fracture had lower Tt.BMD (15%), Tb.BMD (12%), cortical thickness (Ct.Th; 14%), cortical area (Ct.Ar; 12%), and failure load (10%) with higher total area (Tt.Ar; 7%) and trabecular area (Tb.Ar; 10%) than women who did not fracture. Odds ratios (ORs) at the radius revealed every SD decrease of Tt.BMD (OR = 2.1), Tb.BMD (OR = 2.0), and Tb.N (OR = 1.7) was associated with a significantly increased likelihood of fragility fracture. At the tibia, every SD decrease in Tt.BMD (OR = 2.1), Tb.BMD (OR = 1.7), Ct.Th (OR = 2.2), Ct.Ar (OR = 1.9), and failure load (OR = 1.7) were associated with a significantly increased likelihood of fragility fracture. Irrespective of scanning modality, the annualized percent rate of bone loss was not different between fracture groups. The results suggest baseline bone density, microarchitecture, and strength rather than change in these variables are associated with incident fragility fractures in women older than 60 years. Furthermore, irrespective of fragility fracture status, women experienced changes in skeletal health at a similar rate. © 2017 American Society for Bone and Mineral Research.

Investigation and management of osteoporosis in aged trauma patients: a treatment algorithm adapted to the German guidelines for osteoporosis

BACKGROUND

Osteoporosis-associated fractures are of increasing importance in trauma surgery. Systematic diagnostics and treatment of osteoporosis during a hospital stay, however, remain inadequate. Therefore, a specific algorithm for diagnosing and treating osteoporosis in trauma surgery patients was developed based on the DVO (German Osteology Society) guideline for osteoporosis from 2014.

METHODS

In a first step, the individuals' age and risk profile for osteoporosis is identified considering specific fractures indicating osteoporosis and risk factors assessed by a specific questionnaire. In addition, physical activity, risk of falls, dietary habits and the individuals' medication are considered. Basic osteoporosis laboratory tests, a bone densitometry by dual-energy X-ray absorptiometry (DXA) and, if needed, X-rays of the spine are carried out to identify prevalent vertebral body fractures.

RESULTS

Based on the treatment algorithm adapted to the new guidelines for osteoporosis in the majority of proximal femoral fractures, treatment of osteoporosis could already be indicated without prior DXA. In case of preexisting glucocorticoid therapy, a history of previous fractures or other risk factors according to the risk questionnaire, the threshold of treatment has to be adjusted given the table of T-scores.

CONCLUSIONS

The treatment algorithm for diagnosing and treating osteoporosis in in-patient trauma surgery patients can help identify high-risk patients systematically and efficiently. As a result, osteoporosis-associated fractures or failure of osteosynthesis could be reduced, yet a prospective validation of the algorithm has to be completed.

Change in Trabecular Bone Score (TBS) With Antiresorptive Therapy Does Not Predict Fracture in Women: The Manitoba BMD Cohort

Bone mineral density (BMD) and trabecular bone score (TBS), along with additional clinical risk factors, can be used to identify individuals at high fracture risk. Whether change in TBS in untreated or treated women independently affects fracture risk is unclear. Using the Manitoba (Canada) DXA Registry containing all BMD results for the population we identified 9044 women age ≥40 years with two consecutive DXA scans and who were not receiving osteoporosis treatment at baseline (baseline mean age 62 ± 10 years). We examined BMD and TBS change, osteoporosis treatment, and incident major osteoporotic fractures (MOFs) for each individual. Over a mean of 7.7 years follow-up, 770 women developed an incident MOF. During the interval between the two DXA scans (mean, 4.1 years), 5083 women initiated osteoporosis treatment (bisphosphonate use 80%) whereas 3961 women did not receive any osteoporosis treatment. Larger gains in both BMD and TBS were seen in women with greater adherence to osteoporosis medication (p for trend <0.001), and the magnitude of the increase was consistently greater for BMD than for TBS. Among treated women there was greater antifracture effect for each SD increase in total hip BMD change (fracture decrease 20%; 95% CI, 13% to 26%; p < 0.001), femoral neck BMD change (19%; 95% CI, 12% to 26%; p < 0.001), and lumbar spine BMD change (9%; 95% CI, 0% to 17%; p = 0.049). In contrast, change in TBS did not predict fractures in women who initiated osteoporosis treatment (p = 0.10). Among untreated women neither change in BMD or TBS predicted fractures. We conclude that, unlike antiresorptive treatment-related changes in BMD, change in lumbar spine TBS is not a useful indicator of fracture risk irrespective of osteoporosis treatment. © 2016 American Society for Bone and Mineral Research.

Risk of hip fracture following a wrist fracture-A meta-analysis

AIMS

This purpose of this meta analysis was to investigate and quantify the relative risk of hip fracture in patients who have sustained a wrist fracture.

METHOD

Studies were identified by searching Medline, Embase, Cochrane CENTRAL database and CINAHL from their inception to August 2015. Studies reporting confirmed hip fracture following wrist fracture were included. Data extraction was carried out using a modified Cochrane data collection form by two reviewers independently. Quality assessment was carried out using a modified Coleman score and the Newcastle Ottawa scale for cohort studies. An assessment of bias was performed for each study using a modified Cochrane Risk of Bias tool. A pooled relative risk(RR) was estimated with 95% CI from the RR/HRs and CIs reported in the studies.

RESULTS

12 studies were included in the final meta-analysis (4 male, 8 female only). Relative risk of hip fracture following wrist fracture for women was 1.43 (CI 1.27 to 1.60). In men it was not significantly increased (RR 2.11, 95% CI: 0.93-4.85). Heterogeneity was low (I squared 0%) for both groups so a fixed effects model was used.

CONCLUSION

Risk of a subsequent hip fracture is increased for women who suffer a wrist fracture (RR 1.43). Resources and preventative measures should be targeted towards these high risk patients to prevent the catastrophic event of a hip fracture. This meta analysis confirms and quantifies the increased relative risk of hip fracture after wrist fracture in women.

Diagnosis and therapy of osteoporosis in geriatric trauma patients: an update

Demographic changes confront clinicians with an increasing number of orthogeriatric patients. These patients present with comorbidities, which force their surgeons to take into consideration their medical condition. A major risk factor for fractures in orthogeriatric patients is osteoporosis in combination with frailty. To prevent subsequent fractures in these patients, we need to pay attention to adequate osteoporosis treatment in orthogeriatric patients. There is a huge treatment gap. In Germany, 77% of patients with osteoporosis are not treated adequately. Even after fragility fractures, a low percentage of patients receive a specific osteoporosis therapy. Secondary prevention is of great importance in the treatment of these patients. Diagnostics and treatment should be already initiated with the admission to the hospital. Treatment decisions need to be made individually based on the risk profile of the patients. After discharge, it is important to involve the patients’ general practitioners and to follow up on patients regularly to improve their compliance and to ensure adequate therapy. Establishing a fracture liaison service helps coordinating osteoporosis treatment during hospitalization and after discharge. Subsequent fractures can be reduced; therefore, it is an effective service for secondary prevention. The present article provides an overview of how an efficient identification and subsequent treatment of osteoporosis can be achieved in aged trauma patients.

Value of a coordinated management of osteoporosis via Fracture Liaison Service for the treatment of orthogeriatric patients

INTRODUCTION

The prevalence of osteoporosis in female patients over 75 years of age is 59.2 %. In Germany ~6.3-7.8 million patients are affected by osteoporosis. In 77 % of german patients osteoporosis is not treated adequately. Even after fragility fractures only 16-21 % of female patients and 3 % of male patients are supplied with a specific osteoporosis therapy. Establishing a Fracture Liaison Services (FLS) is a possible addition to co-management for an efficient treatment of osteoporosis in orthogeriatric patients.

MATERIALS AND METHODS

According to a treatment algorithm adapted to the DVO guideline 2014, data of 251 (77 male, 173 female) patients were collected over 3 months. For the assessment specific and standardized questionnaires were used. There was also a basic laboratory testing for osteoporosis done.

RESULTS

The average age of female patients was 76.1 years, in male patients 76.6 years. Thirty-seven patients had vertebral fractures, 25 patients proximal humerus fractures, 18 distal radius fractures and a total of 78 proximal femur fractures were recorded. Eighteen percent of the 251 patients have already been treated with a basic and 11 % with a specific osteoporosis medication. Approximately 40 % of the orthogeriatric patients were diagnosed with osteoporosis for the first time in our clinic. Less than 1 % of the patients had a vitamin D level over 40 ng/ml and 32 % had a vitamin D level under 10 ng/ml. Sixty-five percent of the discharged patients received a basic osteoporosis therapy and 25 % an additional specific therapy.

DISCUSSION

Due to the demographic development osteoporosis-associated fractures steadily increase. In addition to the surgical treatment of fractures, osteological diagnosis and treatment are essential components of successful treatment and critical to the prevention of further fractures. A combination of orthogeriatric center and fracture liaison service allows a more efficient treatment of osteoporosis by close supervision of orthogeriatric patients by the physicians involved.

Dietary restrictions, bone density, and bone quality

Caloric restriction (CR), protein restriction (PR), and specific amino acid restriction (e.g., methionine restriction (MR)) are different dietary interventions that have been confirmed with regard to their comprehensive benefits to metabolism and health. Based on bone densitometric measurements, weight loss induced by dietary restriction is known to be accompanied by reduced areal bone mineral density, bone mass, and/or bone size, and it is considered harmful to bone health. However, because of technological advancements in bone densitometric instruments (e.g., high-resolution X-ray tomography), dietary restrictions have been found to cause a reduction in bone mass/size rather than volumetric bone mineral density. Furthermore, when considering bone quality, bone health consists of diverse indices that cannot be fully represented by densitometric measurements alone. Indeed, there is evidence that moderate dietary restrictions do not impair intrinsic bone material properties, despite the reduction in whole-bone strength because of a smaller bone size. In the present review, we integrate research evidence from traditional densitometric measurements, metabolic status assays (e.g., energy metabolism, oxidative stresses, and inflammatory responses), and biomaterial analyses to provide revised conclusions regarding the effects of CR, PR, and MR on the skeleton.

Fracture prediction from repeat BMD measurements in clinical practice

We investigated whether repeat BMD measurements in clinical populations are useful for fracture risk assessment. We report that repeat BMD measurements are a robust predictor of fracture in clinical populations; this is not affected by preceding BMD change or recent osteoporosis therapy.

INTRODUCTION

In clinical practice, many patients selectively undergo repeat bone mineral density (BMD) measurements. We investigated whether repeat BMD measurements in clinical populations are useful for fracture risk assessment and whether this is affected by preceding change in BMD or recent osteoporosis therapy.

METHODS

We identified women and men aged ≥ 50 years who had a BMD measurement during 1990-2009 from a large clinical BMD database for Manitoba, Canada (n = 50,215). Patient subgroups aged ≥ 50 years at baseline with repeat BMD measures were identified. Data were linked to an administrative data repository, from which osteoporosis therapy, fracture outcomes, and covariates were extracted. Using Cox proportional hazards models, we assessed covariate-adjusted risk for major osteoporotic fracture (MOF) and hip fracture according to BMD (total hip, lumbar spine, femoral neck) at different time points.

RESULTS

Prevalence of osteoporosis therapy increased from 18 % at baseline to 55 % by the fourth measurement. Total hip BMD was predictive of MOF at each time point. In the patient subgroup with two repeat BMD measurements (n = 13,481), MOF prediction with the first and second measurements was similar: adjusted-hazard ratio (HR) per SD 1.45 (95 % CI 1.34-1.56) vs. 1.64 (95 % CI 1.48-1.81), respectively. No differences were seen when the second measurement results were stratified by preceding change in BMD or osteoporosis therapy (both p-interactions >0.2). Similar results were seen for hip fracture prediction and when spine and femoral neck BMD were analyzed.

CONCLUSION

Repeat BMD measurements are a robust predictor of fracture in clinical populations; this is not affected by preceding BMD change or recent osteoporosis therapy.

Bone Mineral Density as a Predictor of Subsequent Wrist Fractures: Findings From the Women's Health Initiative Study

CONTEXT

Wrist fractures are common among postmenopausal women. Associations of bone mineral density (BMD) and 10-year predicted risk of major osteoporotic fracture (MOF) with wrist fractures are poorly characterized.

OBJECTIVE

The objective was to examine associations between the Fracture Risk Assessment Tool (FRAX)-predicted risk of MOF, BMD, BMD change, and wrist fracture.

DESIGN

This was a prospective observational study with a mean follow-up of 8.5 years.

SETTING

This study included 40 US centers.

PARTICIPANTS

A total of 11 392 participants from the Women's Health Initiative BMD Cohort aged 50-79 years at baseline were included in this study.

INTERVENTIONS

None.

MAIN OUTCOME

The goal was to measure incident wrist fracture.

RESULTS

A FRAX-predicted MOF risk ≥9.3% identified 17% of the women aged <65 years who subsequently experienced wrist fracture. Each one standard deviation lower BMD was associated with higher wrist fracture risk, with adjusted hazard ratio (95% confidence interval) of 1.66 (1.42-1.93) for femoral neck (FN) BMD and 1.45 (1.28-1.64) for lumbar spine BMD. Compared with FN BMD T score ≥ -1.0, wrist fracture adjusted hazard ratios (95% confidence interval) were: 1.51 (1.06-2.16) for a T score between -1.01 and -1.49; 1.93 (1.36-2.72) for T score between -1.50 and -1.99; 2.52 (1.77-3.60) for a T score between -2.00 and -2.49; and 2.65 (1.78-3.95) for a T score ≤ -2.5. Decrease in FN BMD between baseline and year 3 was associated with increased risk of subsequent wrist fracture; however, change in lumbar spine BMD was not.

CONCLUSIONS

Lumbar spine and femoral neck BMDs were associated with incident wrist fracture, but the FRAX threshold recommended to identify screening candidates did not identify the majority of women who subsequently experienced wrist fracture. Improved understanding of determinants of wrist fractures is warranted.

Relationship between pretreatment rate of bone loss and bone density response to once-yearly ZOL: HORIZON-PFT extension study

Several studies have shown that high bone turnover is associated with greater rates of bone loss and greater bone mineral density (BMD) response to antiresorptive therapy in postmenopausal osteoporosis. However, it is not known whether greater rates of bone loss before therapy are associated with greater BMD response to antiresorptive therapy. In the HORIZON-PFT study and its extension, one group of women who were randomized to receive placebo for 3 years (years 1, 2, and 3) were then switched to zoledronic acid (ZOL) 5 mg annually for up to three injections (years 4, 5, and 6, P3Z3 arm) (n = 1223). We measured total hip BMD at baseline, 1, 2, and 3 years on placebo and at 4.5 and 6 years on ZOL. The procollagen type I N-terminal propeptide (PINP) was measured at 3, 4.5, and 6 years. By design, not all subjects were followed for as long as 6 years, so this analysis focused on the results at 4.5 years. Those with the largest loss in total hip BMD on placebo in years 0 to 3 had the largest gain during ZOL (years 3 to 4.5): (r = -0.39, p < 0.0001). The change in total hip BMD in years 0 to 3 on placebo was related to the serum PINP at the end of the 3-year period (r = -0.24, p < 0.0001). The change in total hip BMD on ZOL from year 3 to 4.5 was related to the serum PINP at the end of the 3-year period (r = 0.26, p < 0.0001). We conclude that BMD response to ZOL is greater in postmenopausal women who had larger loss before treatment. This association may result from higher bone turnover being associated with both greater bone loss on placebo and greater BMD response to ZOL.

Low serum concentrations of alpha-tocopherol are associated with increased risk of hip fracture. A NOREPOS study

We investigated the risk of hip fracture according to circulating alpha-tocopherol, a plant-derived substance with antioxidant properties, in community-dwelling older Norwegians. We found a linear increasing risk of hip fracture with lower serum alpha-tocopherol concentrations, with a 51% higher risk in the lowest compared to the highest quartile.

INTRODUCTION

Oxidative stress is a suggested contributing cause of osteoporosis and fractures. Vitamin E (α-tocopherol) has potent antioxidant properties in humans. The relationship between circulating α-tocopherol and fracture risk is not established. The aim of this study was to investigate the association between serum α-tocopherol concentrations and risk of hip fracture during up to 11 years of follow-up.

METHODS

We performed a case-cohort analysis among 21,774 men and women aged 65-79 years who participated in four community-based health studies in Norway 1994-2001. Serum α-tocopherol concentrations at baseline were determined in 1,168 men and women who subsequently suffered hip fractures (median follow-up 8.2 years) and in a random sample (n = 1,434) from the same cohort. Cox proportional hazard regression adapted for gender-stratified case-cohort data was performed.

RESULTS

Median (25, 75 percentile) serum α-tocopherol was 30.0 (22.6, 38.3) μmol/L, and it showed a linear inverse association with hip fracture: hazard ratio (HR) 1.11 (95% confidence interval (CI) 1.04-1.20) per 10-μmol/L decrease in serum α-tocopherol, adjusted for gender and study center. The lowest compared to the highest quartile conferred an HR of 1.51 (95% CI 1.17-1.95), adjusted for gender and study center. Adjustment for smoking, month of blood sample, BMI, education, physical inactivity, self-rated health, and serum 25-hydroxyvitamin D (25(OH)D) yielded similar results. Taking serum total cholesterol concentration into account attenuated the association somewhat: HR of hip fracture was 1.37 (95% CI 1.05-1.77) in first versus fourth quartile of serum α-tocopherol/total cholesterol ratio.

CONCLUSIONS

Low serum concentrations of α-tocopherol were associated with increased risk of hip fracture in older Norwegians.

Cohort profile: Norwegian Epidemiologic Osteoporosis Studies (NOREPOS)

AIMS

This paper describes the history, purpose, data collection and contributions in the research collaboration Norwegian Osteoporosis Epidemiologic Studies (NOREPOS).

METHODS

NOREPOS encompasses almost 85,000 bone mineral density measurements within Cohort of Norway and data on almost 140,000 hip fractures in Norway 1994-2008. Included are anthropometric measurements, blood pressure, lipids and glucose, and 50 standard questions on sociodemographic factors, diseases and risk factors. Blood samples/DNA are stored. The main research question posed in NOREPOS is why hip fracture rates in Norway are the highest in the world. Data on hip fractures 2009-2013 will be added in 2014.

RESULTS

Main findings include: Every hour a Norwegian suffers a hip fracture; hip fracture incidence rates declined after 1999; only 16% of patients used anti-osteoporosis drugs 1 year after hip fracture; 25% of patients died within 1 year after the fracture; 12% suffered a new hip fracture within 10 years; rural dwellers had lower hip and forearm fracture incidence than city dwellers; magnesium in tap water may be protective whereas bacterial contamination, cadmium and lead may be harmful to bone health; low serum vitamin D and E levels were associated with higher hip fracture risk; vitamin A was not associated with fracture risk; and abdominal obesity increased the risk of hip fracture when BMI was accounted for.

CONCLUSIONS

NOREPOS encompasses a unique source of information for aetiological research, genetic studies as well as for biomarkers of osteoporosis and fractures. Because of the increasing number of elderly people in Europe, hip fractures will continue to pose an international public health and health care challenge.

A cohort study for the impact of activity-limiting injuries based on the Canadian National Population Health Survey 1994-2006

OBJECTIVE

To examine the prevalence and factors affecting activity-limiting injuries (ALI) in individuals and in the Canadian population; to estimate the short and long term impact on health status and well-being because of ALI in Canada from 1994 to 2006 using the Canadian National Population Health Survey (NPHS).

DESIGN

The NPHS is a randomised longitudinal cohort study with biennial interviews, with information on age, sex, education, marital status, income, residence, height and weight to self-perceived health status, healthcare utilisation and medication use in addition to ALI.

SETTING

The study population was a random sample of male and female participants 20 years and older from 10 provinces and three territories in Canada.

PRIMARY AND SECONDARY OUTCOME MEASURES

Logistic regression models were used to assess the potential impact of ALI on individuals and on the Canadian population. The interviews 2 years before and 2 years after the ALI were compared to examine long-term effects, and the McNemar test option in SAS was used for the matched analysis.

RESULTS

The immediate impacts of ALI were pain, disability and disruption of regular life. Long-term effects in patients were chronic pain and increased medical doctor visits. Population impact included a considerable increase in healthcare access and cost. The odds ratios (OR) for the 20-39 age group compared with those 60+ was 2.2; 95% CI 1.8 to 2.7, while the OR associated with male participants was 1.4; 95% CI 1.1 to 1.6. Individuals consuming nine or more alcoholic drinks per week were also significantly more likely to report an ALI (OR, 1.5; 95% CI 1.3 to 1.8).

CONCLUSIONS

The findings from this study illustrated the immediate and long-term impact of individuals and population level injuries in Canada. Injury control policies should aim to prevent the number of injuries, fatalities as well as the consequences among survivors.

Diabetes and change in bone mineral density at the hip, calcaneus, spine, and radius in older women

Older women with type 2 diabetes mellitus (DM) have higher bone mineral density (BMD) but also have higher rates of fracture compared to those without DM. Limited evidence suggests that DM may also be associated with more rapid bone loss. To determine if bone loss rates differ by DM status in older women, we analyzed BMD data in the Study of Osteoporotic Fractures (SOF) between 1986 and 1998. SOF participants were women ≥65 years at baseline who were recruited from four regions in the U.S. DM was ascertained by self-report. BMD was measured with dual-energy x-ray absorptiometry (DXA) at baseline and at least one follow-up visit at the hip (N = 6624) and calcaneus (N = 6700) and, on a subset of women, at the spine (N = 396) and distal radius (N = 306). Annualized percent change in BMD was compared by DM status, using random effects models. Of 6,867 women with at least one follow-up DXA scan, 409 had DM at baseline. Mean age was 70.8 (SD 4.7) years. Baseline BMD was higher in women with DM at all measured sites. In models adjusted for age and clinic, women with prevalent DM lost bone more rapidly than those without DM at the femoral neck (-0.96 vs. -0.59%/year, p < 0.001), total hip (-0.98 vs. -0.70%/year, p < 0.001), calcaneus (-1.64 vs. -1.40%/year, p = 0.005), and spine (-0.33 vs. +0.33%/year, p = 0.033), but not at the distal radius (-0.97 vs. -0.90%/year, p = 0.91). These findings suggest that despite higher baseline BMD, older women with DM experience more rapid bone loss than those without DM at the hip, spine, and calcaneus, but not the radius. Higher rates of bone loss may partially explain higher fracture rates in older women with DM.

Official Positions for FRAX® Bone Mineral Density and FRAX® simplification from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®

Tools to predict fracture risk are useful for selecting patients for pharmacological therapy in order to reduce fracture risk and redirect limited healthcare resources to those who are most likely to benefit. FRAX® is a World Health Organization fracture risk assessment algorithm for estimating the 10-year probability of hip fracture and major osteoporotic fracture. Effective application of FRAX® in clinical practice requires a thorough understanding of its limitations as well as its utility. For some patients, FRAX® may underestimate or overestimate fracture risk. In order to address some of the common issues encountered with the use of FRAX® for individual patients, the International Society for Clinical Densitometry (ISCD) and International Osteoporosis Foundation (IOF) assigned task forces to review the medical evidence and make recommendations for optimal use of FRAX® in clinical practice. Among the issues addressed were the use of bone mineral density (BMD) measurements at skeletal sites other than the femoral neck, the use of technologies other than dual-energy X-ray absorptiometry, the use of FRAX® without BMD input, the use of FRAX® to monitor treatment, and the addition of the rate of bone loss as a clinical risk factor for FRAX®. The evidence and recommendations were presented to a panel of experts at the Joint ISCD-IOF FRAX® Position Development Conference, resulting in the development of Joint ISCD-IOF Official Positions addressing FRAX®-related issues.