Validity of self-reported osteoporosis in mid-age and older women

Geographic Variation in Osteoporosis Treatment in Postmenopausal Women: A 15-Year Longitudinal Analysis

Context

Osteoporosis affects more than half of older women, but many are not treated. Whether treatment differs between rural and urban areas is unknown.

Objective

To examine differences in osteoporosis treatment among postmenopausal women living in urban and rural areas of Australia.

Methods

Women participating in the Australian Longitudinal Study on Women's Health, a prospective longitudinal cohort study, born between 1946-1951, and with osteoporosis or fractures, were included. Surveys from 2004 to 2019 were linked to the Pharmaceutical Benefits Scheme (government-subsidized medications) to assess osteoporosis treatment and adherence, comparing geographical areas.

Results

Of the 4259 women included (mean age, 55.6 years), 1703 lived in major cities, 1629 inner regional, 794 outer regional, and 133 remote areas. Over the 15-year follow-up, 1401 (32.9%) women received treatment, including 47.4% of women with osteoporosis and 29.9% with fractures. Women in outer regional and remote areas were less likely to use antiosteoporosis treatment than those in major cities on univariable analysis (outer regional odds ratio, 0.83; 95% CI, 0.72-0.95; remote, 0.65; 0.49-0.86), but this did not remain significant on multivariable analysis. Median duration of use was 10 to 36 months, adherence varied by treatment type (34%-100%) but was not related to incident fractures, and of the women who stopped denosumab, 85% did not receive another consolidating treatment.

Conclusions

One-third of women with osteoporosis/fractures received treatment, and adherence was low. There was no difference in treatment use between urban and rural areas after adjusting for risk factors, although the specific treatment used, and adherence, differed.

Social relationship satisfaction and accumulation of chronic conditions and multimorbidity: a national cohort of Australian women

Background

Social relationships are associated with mortality and chronic conditions. However, little is known about the effects of social relationship satisfaction on multiple chronic conditions (multimorbidity).

Aims

To examine whether social relationship satisfaction is associated with the accumulation of multimorbidity.

Methods

Data from 7 694 Australian women who were free from 11 chronic conditions at 45-50 years of age in 1996 were analysed. Five types of social relationship satisfaction (partner, family members, friends, work and social activities) were measured approximately every 3 years and scored from 0 (very dissatisfied) to 3 (very satisfied). Scores from each relationship type were summed to provide an overall satisfaction score (range: ≤5-15). The outcome of interest was the accumulation of multimorbidity in 11 chronic conditions.

Results

Over a 20-year period, 4 484 (58.3%) women reported multimorbidities. Overall, the level of social relationship satisfaction had a dose-response relationship with the accumulation of multimorbidities. Compared with women reporting the highest satisfaction (score 15), women with the lowest satisfaction (score ≤5) had the highest odds of accumulating multimorbidity (odds ratio (OR)= 2.35, 95% confidence interval (CI): 1.94 to 2.83) in the adjusted model. Similar results were observed for each social relationship type. Other risk factors, such as socioeconomic, behavioural and menopausal status, together explained 22.72% of the association.

Conclusions

Social relationship satisfaction is associated with the accumulation of multimorbidity, and the relationship is only partly explained by socioeconomic, behavioural and reproductive factors. Social connections (eg, satisfaction with social relationships) should be considered a public health priority in chronic disease prevention and intervention.

Adherence to Lifestyle Recommendations for Bone Health in Older Adults with and without Osteoporosis: Cross-Sectional Results of the OUTDOOR ACTIVE Study

Sustaining good bone health into older age is key for preventing osteoporosis. Bone health is associated with several lifestyle factors. This study investigates older adults’ adherence to bone health-promoting lifestyle recommendations dependent on osteoporosis status. Cross-sectional data of 1610 community-dwelling older adults (65–75 years) residing in Bremen, Germany (53.4% female) were included. The Osteoporosis Self-Assessment Tool and self-reported osteoporosis diagnosis were used to classify participants by osteoporosis status (low risk, high risk, diagnosis). Adherence to bone health recommendations regarding calcium and vitamin D intake, sun exposure, alcohol consumption, resistance/weight-bearing exercise, and physical activity were assessed. Descriptive statistics were applied, stratified by sex and osteoporosis status. A total of 91 women (10.6%) and 15 men (2.0%) reported an osteoporosis diagnosis, 457 women (43.2%) and 311 men (41.4%) were classified as having a high risk, and 311 women (36.2%) and 425 men (56.6%) as having a low risk. Adherence to bone health recommendations was high for calcium intake (93.3–100.0%), vitamin D intake (77.8–93.3%), and sun exposure (86.7–97.7%). Lower adherence was observed regarding resistance/weight-bearing exercise (36.3–54.4%), physical activity (14.3–57.7%), and alcohol consumption (40.0–72.4%). In conclusion, tailored prevention strategies are needed that focus on older adults with an osteoporosis diagnosis or who are at high risk.

The diabetes-fracture association in women with type 1 and type 2 diabetes is partially mediated by falls: a 15-year longitudinal study

This study evaluated mediators of fracture risk in postmenopausal women with type 1 (T1D) and type 2 diabetes (T2D), over a 15-year follow-up period. This study provides evidence that the increased fracture risk in women with T1D or T2D is partially explained by falls. Furthermore, a shorter reproductive lifespan in women with T1D contributes modestly to fracture risk in this cohort.

PURPOSE

Skeletal fragility is associated with diabetes mellitus, while limited estrogen exposure during the reproductive years also predisposes to lower bone mass and higher fracture risk. We aimed to determine osteoporosis diagnosis, fall and fracture rates in women with type 1 (T1D) and type 2 (T2D) diabetes mellitus, and explore mediators of the diabetes-fracture relationship.

METHODS

Prospective observational data drawn from the Australian Longitudinal Study in Women's Health (ALSWH) from 1996 to 2010. Women were randomly selected from the national health insurance database. Standardized data collection occurred at six survey time points, with main outcome measures being self-reported osteoporosis, incident fracture, falls, and reproductive lifespan. Mediation analyses were performed to elucidate relevant intermediaries in the diabetes-fracture relationship.

RESULTS

Exactly 11,313 women were included at baseline (T1D, n = 107; T2D, n = 333; controls, n = 10,873). A total of 885 new cases of osteoporosis and 1099 incident fractures were reported over 15 years. Women with T1D or T2D reported more falls and fall-related injuries; additionally, women with T1D had a shorter reproductive lifespan. While fracture risk was increased in women with diabetes (T1D: OR 2.28, 95% CI 1.53-3.40; T2D: OR 2.40, 95% CI 1.90-3.03), compared with controls, adjustment for falls attenuated the risk of fracture by 10% and 6% in T1D and T2D, respectively. In women with T1D, reproductive lifespan modestly attenuated fracture risk by 4%.

CONCLUSION

Women with T1D and T2D have an increased risk of fracture, which may be partially explained by increased falls, and to a lesser extent by shorter reproductive lifespan, in T1D.

Age at natural menopause and development of chronic conditions and multimorbidity: results from an Australian prospective cohort

STUDY QUESTION

Is age at natural menopause (ANM) associated with the development of multiple chronic conditions (multimorbidity) in postmenopausal life?

SUMMARY ANSWER

Women with premature menopause experience increased odds of developing individual chronic conditions and multimorbidity.

WHAT IS KNOWN ALREADY

ANM is considered as a marker of age-related morbidity and mortality in postmenopausal life. Multimorbidity affects more than 60% of older women and has been recognized as the most common 'chronic condition'. Few studies have examined the association between ANM and the development of multimorbidity.

STUDY DESIGN, SIZE, DURATION

A prospective national cohort study of 11 258 Australian women, aged 45-50 years in 1996. Women were followed from 1996 to 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Information about ANM and 11 chronic conditions (diabetes, hypertension, heart disease, stroke, arthritis, osteoporosis, asthma, chronic obstructive pulmonary disease, depression, anxiety and breast cancer) were estimated approximately every 3 years. Multimorbidity is defined as 2 or more of these 11 conditions. Generalized estimating equations were used to link the categorical ANM with individual chronic conditions and multimorbidity.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 5107 women reporting ANM, 2.3% experienced premature menopause (≤40 years) and 55.1% developed multimorbidity. Compared with women who experienced menopause at age 50-51 years, women with premature menopause had twice the odds of experiencing multimorbidity by age 60 (OR = 1.98, 95% CI 1.31 to 2.98) and three times the odds of developing multimorbidity in their 60s (OR = 3.03, 95% CI 1.62 to 5.64). Women with premature menopause also experienced higher incidence of most individual chronic conditions.

LIMITATIONS, REASONS FOR CAUTION

The main limitation of this study was the use of self-reported data, but with repeated assessments from prospective study design and the validity of most of the chronic conditions from hospital data, the potential for non-differential misclassification is minimized.

WIDE IMPLICATIONS OF THE FINDINGS

To our knowledge, this is the first study to assess the association of premature menopause and development of multimorbidity in a larger national cohort of mid-aged women. Health professionals should consider comprehensive screening and assessment of risk factors for multimorbidity when treating women who experienced premature menopause.

STUDY FUNDING/COMPETING INTEREST(S)

The Australian Longitudinal Study on Women's Health was supported by the Australian Government Department of Health. X.X. is funded by an International Postgraduate Research Scholarship from the Australian government and a UQ Centennial Scholarship from The University of Queensland. G.D.M. is supported by the National Health and Medical Research Council Principal Research Fellowship (APP1121844). None of the authors has any conflicts of interest to declare.

Validity of Self-Reported Diagnosis of Osteoporosis in Japan Nurses' Health Study

Purpose

Although the validity of self-reported osteoporosis is often questioned, validation studies are lacking. This study was performed to investigate how well self-reported diagnoses of osteoporosis agreed with validated clinical information in young and middle-aged women in the Japan Nurses’ Health Study (JNHS), a nationwide prospective cohort study of nursing professionals.

Patients and Methods

Data were reviewed for 15,717 subjects from the combined cohorts of the JNHS and a preceding pilot study (Gunma Nurses’ Health Study). The subjects’ mean age at the baseline (BL) survey was 41.6 ± 8.3 years, and the mean follow-up period was 11.5 ± 4.4 years. Participating nurses were mailed a follow-up questionnaire every 2 years. Respondents who self-reported a positive osteoporosis diagnosis during the study period were sent an additional confirmation questionnaire to corroborate the details.

Results

The number (proportion) of women with osteoporosis was 884 (5.6%) [primary osteoporosis, 812 (5.2%); secondary osteoporosis, 72 (0.5%)]. The cumulative incidence of osteoporosis at the age of 40, 50, 60, 70, and 80 years was estimated to be 0.1% (95% confidence interval, 0.1–0.2), 1.1% (0.9–1.3), 7.7% (7.0–8.4), 23.6% (21.6–25.7), and 54.2% (40.2–68.1), respectively. For BL and regular follow-up + expert review versus BL and regular follow-up + confirmation questionnaire + expert review, the positive predictive value (PPV) was 61.3% versus 85.6% and the negative predictive value (NPV) was 98.9% versus 98.2%, respectively.

Conclusion

Self-reporting was associated with a high NPV for the incidence of osteoporosis. Although the PPV was slightly lower, additional corroborations by confirmation questionnaire might improve the PPV.

Clinical Characteristics of an Internet-Based Cohort of Patient-Reported Diagnosis of Granulomatosis With Polyangiitis and Microscopic Polyangiitis: Observational Study

Background

Utilizing the traditional centers of excellence approach to conduct clinical trials involving rare diseases remains challenging. Patient-based registries have been shown to be both feasible and valid in several other diseases.

Objective

This report outlines the clinical characteristics of a large internet registry cohort of participants with a self-reported diagnosis of granulomatosis with polyangiitis or microscopic polyangiitis.

Methods

Patients with a self-reported diagnosis of granulomatosis with polyangiitis or microscopic polyangiitis in an internet-based prospective longitudinal cohort (from the Vasculitis Patient-Powered Research Network) were included. Data on symptoms, diagnostic testing, and treatment were collected using standardized questionnaires.

Results

The study compared patients with granulomatosis with polyangiitis (n=762) and patients with microscopic polyangiitis (n=164). Of the cohort, 97.7% (904/925) reported the diagnosis had been confirmed by a physician. Compared to microscopic polyangiitis, patients with granulomatosis with polyangiitis reported significantly more ear, nose, and throat manifestations (granulomatosis with polyangiitis: 641/723, 88.7%; microscopic polyangiitis: 89/164, 54.3%; z=10.42, P<.001), fevers (granulomatosis with polyangiitis: 325/588, 55.3%; microscopic polyangiitis: 64/139, 46.0%; z=1.96, P=.05), joint involvement (granulomatosis with polyangiitis: 549/688, 79.8%; microscopic polyangiitis: 106/154, 68.8%; z=2.96, P=.003), and pulmonary involvement (granulomatosis with polyangiitis: 523/734, 71.3%; microscopic polyangiitis: 90/154, 58.4%; z=3.13, P=.002). Compared to microscopic polyangiitis, patients with granulomatosis with polyangiitis reported significantly less renal involvement (granulomatosis with polyangiitis: 457/743, 61.5%; microscopic polyangiitis: 135/163, 82.8%; z=–5.18, P<.001) and renal transplantation (granulomatosis with polyangiitis: 10/721, 1.4%; microscopic polyangiitis: 7/164, 4.3%; z=–2.43, P=.02). Antineutrophil cytoplasmic antibody positivity was reported in 94.2% (652/692) of patients with granulomatosis with polyangiitis and 96.1% (147/153) of patients with microscopic polyangiitis. A biopsy showing vasculitis was reported in 77.0% (562/730) of patients with granulomatosis with polyangiitis and 81.9% (131/160) of patients with microscopic polyangiitis.

Conclusions

In this large, internet-based cohort of patients with a self-reported diagnosis of granulomatosis with polyangiitis or microscopic polyangiitis, disease manifestations were consistent with expectations for each type of vasculitis. Given the rarity of these and other vasculitides, conducting some types of research through internet-based registries may provide an efficient alternative to inperson, center-of-excellence clinical trials.

Persistence and compliance to osteoporosis therapy in a fracture liaison service: a prospective cohort study

Persistence and compliance to osteoporosis medications aiming to prevent fragility fractures are essential for fracture prevention, but are suboptimal in the population. A Fracture Liaison Service with a systematic follow-up led to ongoing therapy and optimal drug compliance for more than half of treated patients over 2 years.

PURPOSE

Fracture Liaison Services (FLS) have the potential to improve persistence and compliance to osteoporosis therapy. We aimed to assess patterns of drug use in a high-level intervention FLS.

METHODS

Women and men (> 40 years) with a fragility fracture were recruited in a FLS, where osteoporosis therapy was prescribed if appropriate. Based on claims data, patients who filled their prescription in the 3-month period following baseline were selected. The 1- and 2-year persistence rates were measured using survival analysis. In non-persistent subjects, 1-year treatment re-initiation was measured. The 1- and 2-year compliance levels were measured, using the proportion of days covered (PDC > 80% = compliant). Regression analyses were performed to identify predictors of non-persistence/compliance.

RESULTS

Out of 332 subjects with complete drug insurance coverage, 297 (89.5%) were prescribed osteoporosis therapy by the FLS, and 275 (92.6%) were dispensed. Two hundred sixty participants (86.9% female; mean age 65.6 years) were selected for having filled a prescription inside 3 months after baseline. The 1- and 2-year persistence rates were 66.4% and 55.6%, respectively. Treatment re-initiation was observed in 56% of non-persistent patients. PDC was > 80% in 64.2% for 1 year and 62.5% for 2 years. Older and younger age, smoking, higher spine bone mineral density, lower major FRAX risk, and missing follow-up visits were predictors of non-persistence and/or non-compliance.

CONCLUSIONS

After 2 years in a high-level intervention FLS, more than half the treated participants were persistent and compliant to treatment. Comparative effectiveness studies must be undertaken to determine whether this intervention is an improvement over usual care.

Screening, prevention and management of osteoporosis among Canadian adults

INTRODUCTION

This study provides a benchmark for the nationwide use of osteoporosis screening, prevention and management strategies among Canadians aged 40 years and older (40+) using data collected one year prior to the release of Osteoporosis Canada's latest (2010) clinical practice guidelines.

METHODS

Data are from the 2009 Canadian Community Health Survey-Osteoporosis Rapid Response Component. The study sample (n = 5704) was divided into four risk subgroups: (1) osteoporosis diagnosis and major fracture; (2) osteoporosis diagnosis only; (3) major fracture only; or (4) neither osteoporosis diagnosis nor major fracture. We calculated descriptive statistics and performed multinomial multivariate logistic regression analyses to examine factors independently associated with osteoporosis screening, prevention and management strategies. Estimates were weighted to represent the Canadian household population (40+) living in the 10 provinces.

RESULTS

Approximately 10.1% of the population or 1.5 million Canadians 40+ reported having been diagnosed with osteoporosis. The majority related taking vitamin D or calcium supplements and having been prescribed osteoporosis medication(s), while less than 40% reported regular physical activity. Among those without a reported osteoporosis diagnosis, an estimated 6.7% or 1 million reported having had a major fracture, of which one-third reported having had a bone density test and less than half reported taking vitamin D supplements, calcium supplements or engaging in regular physical activity. Major fracture history was not associated with bone density testing or osteoporosis medication use.

CONCLUSION

A large proportion of Canadians at risk for osteoporosis-those with a major fracture history-are not undergoing bone density testing nor are they engaging in lifestyle approaches known to help maintain healthy bones. This study provides the historical information required to evaluate whether the latest clinical practice guidelines have had an impact on osteoporosis care in Canada.

Socio-Economic Status and Prevalence of Self-Reported Osteoporosis in Tehran: Results from a Large Population-Based Cross-Sectional Study (Urban HEART-2)

Osteoporosis is a widespread disease among older peoples. The aim of this study is to estimate the prevalence of self-reported osteoporosis and assessing its association with socio-economic status. A population-based cross-sectional study was conducted in Tehran, Iran in 2011. Participants were 45,990 individuals aged above 20 years from 22 urban districts. Osteoporosis was measured by self-administrative questionnaire. Wealth index was constructed using principal component analysis based on household assets. Chi-square test, chi square test for trend, and crude odds ratio were used to assess associations in univariate analysis. Multiple logistic regression utilized to estimate adjusted associations between self-reported osteoporosis and socio-economic status.The overall estimated prevalence of self-reported osteoporosis was 4% (95% CI 3.88-4.13), 1.19% in men, and 6.84% in women (P < 0.001). The prevalence increased considerably as age increased (P for trend < 0.001). In multivariable analysis, education and wealth status were negative, and smoking was positively associated with the prevalence of self-reported osteoporosis. No association was found between participants' skill levels and Townsend deprivation index with the prevalence of self-reported osteoporosis.The findings of the present study have improved understanding of the association between socioeconomic status and osteoporosis in the Iranian population. It is important to consider socioeconomic status in screening and prevention programs.

The prevalence of overtreatment of osteoporosis: results from the PAADRN trial

Overtreatment of osteoporosis increases costs and puts patients at unnecessary risk of experiencing adverse drug events. In the Patient Activation After DXA Receipt Notification (PAADRN) trial, we found that 8% of individuals with no indication for therapy were recommended a new osteoporosis medication or continuation of an existing medication.

PURPOSE

There is a robust body of literature addressing undertreatment in osteoporosis, but limited data addressing overtreatment. Understanding overtreatment is important to minimize harm and decrease costs.

METHODS

One of the pre-specified post hoc analyses of the PAADRN trial, a randomized, controlled, pragmatic clinical trial, was to quantify and identify risk factors associated with osteoporosis overtreatment. PAADRN included patients ≥ 50 years of age presenting for bone density testing between February, 2012, and August, 2014, at three US healthcare systems. We assessed 20,397 patients for eligibility and randomized 7749. Intervention patients received a tailored letter containing their dual-energy X-ray absorptiometry (DXA) results and an educational osteoporosis brochure. Control patients received usual care. Using the National Osteoporosis Foundation treatment guidelines, we defined overtreatment as the receipt of osteoporosis pharmacotherapy 12 weeks after DXA when treatment was not indicated. We evaluated the relationship between the following baseline variables-sex, race/ethnicity, educational attainment, and differences across health systems-and overtreatment using a series of multivariable logistic regression models.

RESULTS

Among 3602 patients with no apparent indication for osteoporosis treatment, 292 (8.1%; 95% CI, 7.22 to 9.00%) received a new prescription for osteoporosis pharmacotherapy or were instructed to continue an existing medication (presumed overtreatment). Presumed overtreatment was more common among participants with prior DXA history, those who reported a history of osteoporosis or low bone mass, and those referred for testing by family medicine providers.

CONCLUSION

In our sample of older adults, overuse of osteoporosis pharmacotherapy was only 8.1%. Nevertheless, overtreatment exposes patients to possible risk with negligible chance of benefit and should be minimized.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01507662.

Osteoporosis in the Women's Health Initiative: Another Treatment Gap?

BACKGROUND

Osteoporotic fractures are associated with high morbidity, mortality, and cost.

METHODS

We performed a post hoc analysis of the Women's Health Initiative (WHI) clinical trials data to assess osteoporosis treatment and identify participant characteristics associated with utilization of osteoporosis medication(s) after new diagnoses of osteoporosis or fracture. Information from visits prior to and immediately subsequent to the first fracture event or osteoporosis diagnosis were evaluated for medication use. A full logistic regression model was used to identify factors predictive of osteoporosis medication use after a fracture or a diagnosis of osteoporosis.

RESULTS

The median length of follow-up from enrollment to the last WHI clinic visit for the study cohort was 13.9 years. Among the 13,990 women who reported new diagnoses of osteoporosis or fracture between enrollment and their final WHI visit, and also had medication data available, 21.6% reported taking an osteoporosis medication other than estrogen. Higher daily calcium intake, diagnosis of osteoporosis alone or both osteoporosis and fracture (compared with diagnosis of fracture alone), Asian or Pacific Islander race/ethnicity (compared with White/Caucasian), higher income, and hormone therapy use (past or present) were associated with significantly higher likelihood of osteoporosis pharmacotherapy. Women with Black/African American race/ethnicity (compared with White/Caucasian), body mass index ≥30 (compared with body mass index of 18.5-24.9), current tobacco use (compared with past use or lifetime nonusers), and history of arthritis were less likely to use osteoporosis treatment.

CONCLUSION

Despite well-established treatment guidelines in postmenopausal women with osteoporosis or history of fractures, pharmacotherapy use was suboptimal in this study. Initiation of osteoporosis treatment after fragility fracture may represent an opportunity to improve later outcomes in these high-risk women. Specific attention needs to be paid to increasing treatment among women with fragility fractures, obesity, current tobacco use, history of arthritis, or of Black race/ethnicity.

Trends in osteoporosis and low bone mass in older US adults, 2005-2006 through 2013-2014

This study examined trends in osteoporosis and low bone mass in older US adults between 2005 and 2014 using bone mineral density (BMD) data from the National Health and Nutrition Examination Survey (NHANES). Osteoporosis and low bone mass appear to have increased at the femur neck but not at the lumbar spine during this period.

INTRODUCTION

Recent preliminary data from Medicare suggest that the decline in hip fracture incidence among older US adults may have plateaued in 2013-2014, but comparable data on BMD trends for this time period are currently lacking. This study examined trends in the prevalence of osteoporosis and low bone mass since 2005 using BMD data from NHANES. The present study also updated prevalence estimates to 2013-2014 and included estimates for non-Hispanic Asians.

METHODS

Femur neck and lumbar spine BMD by DXA were available for 7954 adults aged 50 years and older from four NHANES survey cycles between 2005-2006 and 2013-2014.

RESULTS

Significant trends (quadratic or linear) were observed for the femur neck (mean T-score and osteoporosis in both sexes; low bone mass in women) but not for the lumbar spine. The trend in femur neck status was somewhat U-shaped, with prevalences being most consistently significantly higher (by 1.1-6.6 percentage points) in 2013-2014 than 2007-2008. Adjusting for changes in body mass index, smoking, milk intake, and physician's diagnosis of osteoporosis between surveys did not change femur neck trends. In 2013-2014, the percent of older adults with osteoporosis was 6% at the femur neck, 8% at the lumbar spine, and 11% at either site.

CONCLUSIONS

There was some evidence of a decline in femur neck BMD between 2005-2006 and 2013-2014, but not in lumbar spine BMD. Changes in the risk factors that could be examined did not explain the femur neck BMD trends.

Factors associated with the accuracy of self-reported osteoporosis in the community

We examined the agreement between self-reported osteoporosis and bone mineral density (BMD) results through dual-energy x-ray absorptiometry (DXA) using data from a national representative sample taken from the US communities. Six-year data from the continuous National Health and Nutrition Examination Survey 2005-2006, 2007-2008, and 2009-2010 were merged. Participants included adults 50 years of age or older whose data appeared in both questionnaire and medical examination data files. Self-reported osteoporosis was defined by an affirmative response to a question in the osteoporosis questionnaire then compared with BMD-defined osteoporosis, defined by BMD values taken from the examination data. Agreement between self-reported osteoporosis and DXA results were low. Kappa was only 0.24 (95 % confidence interval = 0.21-0.27), and sensitivity and positive predictive value were 28.0 and 40.8 %, respectively. When stratified by gender or age group, agreement remained poor. Self-report of osteoporosis would not be suitable for accurate prevalence estimates for osteoporosis regardless of gender or age group.

Association of Perfluoroalkyl Substances, Bone Mineral Density, and Osteoporosis in the U.S. Population in NHANES 2009-2010

BACKGROUND

Perfluoroalkyl substances (PFASs), including perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA), are detectable in the serum of 95% of the U.S.

OBJECTIVE

Considering the role of PFASs as endocrine disruptors, we examined their relationships with bone health.

METHODS

The association between serum PFAS concentration and bone mineral density at total femur (TFBMD), femoral neck (FNBMD), lumbar spine (LSBMD), and physician-diagnosed osteoporosis was assessed in 1,914 participants using data from the National Health and Nutritional Examination Survey 2009-2010.

RESULTS

The mean age of the participants was 43 years. Men had higher serum PFAS concentrations than women (p < 0.001) except for PFNA. In both sexes, serum PFOS concentrations were inversely associated with FNBMD (p < 0.05). In women, significant negative associations were observed for natural log (ln)-transformed PFOS exposure with TFBMD and FNBMD, and for ln-transformed PFOA exposure with TFBMD (p < 0.05). In postmenopausal women, serum PFOS was negatively associated with TFBMD and FNBMD, and PFNA was negatively associated with TFBMD, FNBMD, and LSBMD (all p < 0.05). With one log unit increase in serum PFOA, PFHxS, and PFNA, osteoporosis prevalence in women increased as follows: [adjusted odds ratios (aORs)] 1.84 (95% CI: 1.17, 2.905), 1.64 (95% CI: 1.14, 2.38), and 1.45 (95% CI: 1.02, 2.05), respectively. In women, the prevalence of osteoporosis was significantly higher in the highest versus the lowest quartiles of PFOA, PFHxS, and PFNA, with aORs of 2.59 (95% CI: 1.01, 6.67), 13.20 (95% CI: 2.72, 64.15), and 3.23 (95% CI: 1.44, 7.21), respectively, based on 77 cases in the study sample.

CONCLUSION

In a representative sample of the U.S. adult population, serum PFAS concentrations were associated with lower bone mineral density, which varied according to the specific PFAS and bone site assessed. Most associations were limited to women. Osteoporosis in women was also associated with PFAS exposure, based on a small number of cases.

CITATION

Khalil N, Chen A, Lee M, Czerwinski SA, Ebert JR, DeWitt JC, Kannan K. 2016. Association of perfluoroalkyl substances, bone mineral density, and osteoporosis in the U.S. population in NHANES 2009-2010. Environ Health Perspect 124:81-87; http://dx.doi.org/10.1289/ehp.1307909.

The effect of dose and type of proton pump inhibitor use on risk of fractures and osteoporosis treatment in older Australian women: A prospective cohort study

OBJECTIVES

Proton pump inhibitors (PPIs) are among the most prescribed medications worldwide, however, there is growing concern regarding potential negative effects on bone health. The aim was to examine the effect of dose and type of PPI use on subsequent use of osteoporosis medication and fractures in older Australian women.

METHODS

Data were included from 4432 participants (born 1921-26) in the 2002 survey of the Australian Longitudinal Study on Women's Health. Medication data were from the national pharmaceutical administrative database (2003-2012, inclusive). Fractures were sourced from linked hospital datasets available for four major States of Australia. Competing risk regression models used PPI exposure as a time-dependent covariate and either time to first osteoporosis medication prescription or fracture as the outcome, with death as a competing risk.

RESULTS

Of the 2328 PPI users and 2104 PPI non-users, 827 (36%) and 550 (26%) became users of osteoporosis medication, respectively. PPI use was associated with an increased risk of subsequent use of osteoporosis medication (adjusted sub-hazard ratio [SHR]=1.28; 95% confidence interval [CI]=1.13-1.44) and subsequent fracture (SHR=1.29, CI=1.08-1.55). Analysis with PPI categorized according to defined daily dose (DDD), showed some evidence for a dose-response effect (osteoporosis medication: <400 DDD: SHR=1.23, CI=1.06-1.42 and ≥400 DDD: SHR=1.39, CI=1.17-1.65, compared with non-users; SHRs were in the same range for fractures). Esomeprazole was the most common PPI prescribed (22.9%). Analysis by type of PPI use showed an increased subsequent risk for: (1) use of osteoporosis medication for rabeprazole (SHR=1.51, CI=1.08-2.10) and esomeprazole (SHR=1.48, CI=1.17-1.88); and (2) fractures for rabeprazole (SHR=2.06, CI=1.37-3.10). Users of multiple types of PPI also had increased risks for use of osteoporosis medication and fractures.

CONCLUSION

An appropriate benefit/risk assessment should be made when prescribing PPIs, especially for esomeprazole and rabeprazole, as osteoporosis and fracture risks were increased in this cohort of elderly females subsequent to PPI prescription.

Cohort Profile Update: Australian Longitudinal Study on Women's Health

In 1996 the Australian Longitudinal Study on Women's Health recruited a nationally representative sample of more than 40,000 women in three age cohorts, born in 1973-78, 1946-51 and 1921-26. At least six waves of 3-yearly surveys have been completed. Although the focus remains on factors affecting the health and well-being of women and their access to and use of health services across urban, rural and remote areas of Australia, the study has now been considerably expanded by linkage to other health data sets. For most women who have ever participated in the study, linked records are now available for: government-subsidized non-hospital services (e.g. all general practitioner visits); pharmaceutical prescriptions filled; national death index, including codes for multiple causes of death; aged care assessments and services; cancer registries; and, for most states and territories, hospital admissions and perinatal data. Additionally, a large cohort of women born in 1989-95 have been recruited. The data are available to approved collaborators, with more than 780 researchers using the data so far. Full details of the study materials and data access procedures are available at [http://www.alswh.org.au/].

Poor agreement between self-reported diagnosis and bone mineral density results in the identification of osteoporosis

Osteoporosis is a major health concern, estimated to affect millions worldwide. Bone mineral density (BMD) assessment is not practical for many large-scale epidemiological studies resulting in the reliance of self-report methods to ascertain diagnostic information. The aim of the study was to assess the validity of self-reported diagnosis of osteoporosis in a population-based study. This study examined data collected from 906 men and 843 women participating in the Geelong Osteoporosis Study. Osteoporosis was self-reported and compared against results of BMD scans of the hip and spine. Validity was examined by calculating sensitivity, specificity, positive predictive value, negative predictive value, and kappa statistic. Osteoporosis was self-reported by 118 (6.7%) participants and identified using BMD results for 64 (3.7%) participants. Specificity and negative predictive value were good (95.1% and 96.0%, respectively), whereas sensitivity and positive predictive value were poor (35.9% and 31.4%, respectively). The overall level of agreement (kappa) was 0.29. The results changed only slightly when we included participants with osteopenia and adult fracture as osteoporotic. Reliance on self-report methods to ascertain osteoporosis status is not recommended.

Use of calcium supplements, vitamin D supplements and specific osteoporosis drugs among French women aged 75-85 years: patterns of use and associated factors

BACKGROUND

Despite the availability of effective preventive and curative medications for osteoporosis, and guidelines for its diagnosis and management, few individuals are treated for osteoporosis, even among those who have already had a fracture.

OBJECTIVES

Our objective was to describe the patterns of use of medication for osteoporosis, i.e., calcium supplements, vitamin D supplements, and specific anti-osteoporotic drugs, such as bisphosphonates, in a large sample of French older women living at home, and to identify individual factors associated with use of these medications overall and in two specific clinical situations.

METHODS

Cross-sectional analysis of data from 4,221 women aged 75-85 years who participated in a balance and mobility examination as part of the screening procedure for the Ossébo study, a randomized controlled trial testing the effectiveness of exercise for the prevention of fall-related injuries. Electoral rolls were used to invite women in 16 towns to participate (participation rate 10.3 %). Information collected through questionnaires included current medication use and, in particular, use of osteoporosis medications (specific osteoporosis drugs, calcium and vitamin D supplementation) in the past 6 months, and history of fracture since the age of 50, including fracture locations. Fractures were categorized in three groups: no fracture, major osteoporotic fracture (hip, humerus, wrist, pelvis, and vertebra), and other fracture.

RESULTS

Nearly 48 % of the participants reported they did not take calcium or vitamin D supplements or any specific osteoporosis drugs. Of the 2,133 women who reported using osteoporosis medication, 85 % used vitamin D supplements (25 % as the sole medication against this disease), 59 % calcium supplements, and 42 % a specific anti-osteoporotic drug (75 % of them combining it with vitamin D supplementation). The use of any osteoporosis medication was significantly associated (p < 0.001) with a history of a major osteoporotic fracture, lower weight, dual-energy X-ray absorptiometry (DXA) bone-density measurement in the past 5 years, a cancer-screening examination in the past 5 years, and a positive attitude toward medication use in general. Living alone was associated with a lower likelihood of using a specific anti-osteoporotic drug, and a higher education level was associated with a higher likelihood of vitamin D supplementation. Of the 1,553 women who had already had a major osteoporotic fracture, one-third (34.8 %) were not taking any osteoporosis medication. In this subgroup, use of this medication was associated with the same factors as in the overall study population. In particular, neither older age nor a history of falls in the previous 12 months was associated with a higher likelihood of using osteoporosis medication. Among the 909 women who reported using a specific osteoporosis drug, vitamin D use was associated with a higher educational level and a more frequent preventive attitude.

CONCLUSION

In France, as in other western countries, women aged 75 years and over are not managed according to guidelines. Further studies should address the barriers encountered in improving quality of care in osteoporosis management.