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Zhang F, Zhu S, Di Y, Pan M, Xie W, Li X, Zhu W. Ambient PM 2.5 components might exacerbate bone loss among middle-aged and elderly women: evidence from a population-based cross-sectional study. Int Arch Occup Environ Health 2024:10.1007/s00420-024-02090-y. [PMID: 39060505 DOI: 10.1007/s00420-024-02090-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Previous studies have primarily focused on the links between fine particulate matter (PM2.5) and bone health among the general population instead of PM2.5 components and the specific population. We aimed to investigate the associations between PM2.5 components and bone health among middle-aged and elderly women. METHODS A total of 748 middle-aged and elderly women were randomly sampled from 32 streets/villages in Hubei Province. The concentrations of ambient PM2.5 and its components were extracted across various residential areas from the Tracking Air Pollution in China (TAP) dataset. Bone mineral density measurements were obtained from dual-energy X-ray absorptiometry scans of study participants. Multivariable logistic and linear models were employed to assess the relationship between PM2.5 and its components and bone loss. RESULTS Per interquartile range (IQR) increase in nitrate (NO3-) and ammonium (NH4+) concentrations were associated with 1.65 [95% confidence intervals (CI): 1.13, 2.30] and 1.77 (95% CI: 1.26, 2.49) times higher odds of osteoporosis, respectively. Long-term exposure to sulfate (SO42-), NO3-, and NH4+ was negatively associated with T-scores and bone mineral density in L1-L4 lumbar vertebrae. In addition, the elderly, women who have experienced menarche after the age of 14, and postmenopausal women were more susceptible to the water-soluble inorganic salts of PM2.5. CONCLUSION The study emphasizes the need for comprehensive policies addressing air quality, with a specific focus on vulnerable populations such as middle-aged and elderly women. Public health interventions aimed at reducing ambient PM2.5 concentrations and minimizing exposure to its harmful components are crucial in mitigating the adverse impact on skeletal health and improving the overall well-being of communities.
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Affiliation(s)
- Faxue Zhang
- Wuhan Orthopaedics Hospital of Integrated Traditional Chinese and Western Medicine, The Affiliated Hospital of Wuhan Sports University, Wuhan, 430079, China
- Department of Occupational and Environmental Health, School of Public Health, Wuhan University, Wuhan, 430071, China
| | - Shijie Zhu
- Department of Occupational and Environmental Health, School of Public Health, Wuhan University, Wuhan, 430071, China
| | - Yanfeng Di
- Xinjiang Institute of Ecology and Geography, Chinese Academy of Sciences, Urumqi, 830011, China
| | - Minghao Pan
- Department of Occupational and Environmental Health, School of Public Health, Wuhan University, Wuhan, 430071, China
| | - Wei Xie
- Wuhan Orthopaedics Hospital of Integrated Traditional Chinese and Western Medicine, The Affiliated Hospital of Wuhan Sports University, Wuhan, 430079, China
| | - Xugui Li
- Wuhan Orthopaedics Hospital of Integrated Traditional Chinese and Western Medicine, The Affiliated Hospital of Wuhan Sports University, Wuhan, 430079, China.
| | - Wei Zhu
- Wuhan Orthopaedics Hospital of Integrated Traditional Chinese and Western Medicine, The Affiliated Hospital of Wuhan Sports University, Wuhan, 430079, China.
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Vallée A, Ceccaldi PF, Carbonnel M, Feki A, Ayoubi JM. Pollution and endometriosis: A deep dive into the environmental impacts on women's health. BJOG 2024; 131:401-414. [PMID: 37814514 DOI: 10.1111/1471-0528.17687] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/05/2023] [Accepted: 09/14/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND The interaction between pollution and endometriosis is a pressing issue that demands immediate attention. The impact of pollution, particularly air and water pollution, or occupational hazards, on hormonal disruption and the initiation of endometriosis remains a major issue. OBJECTIVES This narrative review aims to delve into the intricate connection between pollution and endometriosis, shedding light on how environmental factors contribute to the onset and severity of this disease and, thus, the possible public health policy implications. DISCUSSION Endocrine-disrupting chemicals (EDCs) in pollutants dysregulate the hormonal balance, contributing to the progression of this major gynaecological disorder. Air pollution, specifically PM2.5 and PAHs, has been associated with an increased risk of endometriosis by enhancing chronic inflammation, oxidative stress, and hormonal imbalances. Chemical contaminants in water and work exposures, including heavy metals, dioxins, and PCBs, disrupt the hormonal regulation and potentially contribute to endometriosis. Mitigating the environmental impact of pollution is required to safeguard women's reproductive health. This requires a comprehensive approach involving stringent environmental regulations, sustainable practices, responsible waste management, research and innovation, public awareness, and collaboration among stakeholders. CONCLUSION Public health policies have a major role in addressing the interaction between pollution and endometriosis in a long-term commitment.
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Affiliation(s)
- Alexandre Vallée
- Department of Epidemiology and Public Health, Foch Hospital, Suresnes, France
| | - Pierre-François Ceccaldi
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Foch Hospital, Suresnes, France
- Medical School, University of Versailles, Saint-Quentin-en-Yvelines (UVSQ), Versailles, France
| | - Marie Carbonnel
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Foch Hospital, Suresnes, France
- Medical School, University of Versailles, Saint-Quentin-en-Yvelines (UVSQ), Versailles, France
| | - Anis Feki
- Department of Gynaecology and Obstetrics, University Hospital of Fribourg, Fribourg, Switzerland
| | - Jean-Marc Ayoubi
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Foch Hospital, Suresnes, France
- Medical School, University of Versailles, Saint-Quentin-en-Yvelines (UVSQ), Versailles, France
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Zhang Y, Yu J, Pei H, Zhao X, Wang C, Wang G, Shen Z, Hua J, He B. Potential causal associations of PM2.5 and osteoporosis: a two-sample mendelian randomization study. Front Genet 2024; 15:1263916. [PMID: 38463167 PMCID: PMC10921569 DOI: 10.3389/fgene.2024.1263916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 02/12/2024] [Indexed: 03/12/2024] Open
Abstract
Background: Observational studies suggest a potential association between atmospheric particulate matter 2.5 (PM2.5) and osteoporosis, but a causal association is unclear due to the presence of confounding factors. Methods: We utilized bone mineral density indices at four specific sites to represent osteoporosis: femoral neck (FN-BMD), lumbar spine (LS-BMD), forearm (FA-BMD), and heel (HE-BMD). The PM2.5 data was obtained from the UK Biobank database, while the datasets for FN-BMD, LS-BMD, and FA-BMD were obtained from the GEFOS database, and the dataset for HE-BMD was obtained from the EBI database. A two-sample Mendelian randomization analysis was conducted using mainly the inverse variance weighted method, horizontal pleiotropy and heterogeneity were also assessed. Results: The results indicated that PM2.5 was not correlated with a decrease in FN-BMD (β: -0.305, 95%CI: -0.762, 0.153), LS-BMD (β: 0.134, 95%CI: -0.396, 0.666), FA-BMD (β: -0.056, 95%CI: -1.172,1.060), and HE-BMD (β: -0.084, 95%CI: -0.261,0.093). Additionally, acceptable levels of horizontal pleiotropy and heterogeneity were observed. Conclusion: In contrast to most observational studies, our research did not discover a potential causal relationship between PM2.5 and the development of osteoporosis.
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Affiliation(s)
- Yi Zhang
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Jinsheng Yu
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Hang Pei
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Xinzheng Zhao
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Chao Wang
- Anji County Hospital of Traditional Chinese Medicine, Anji, China
| | - Guanyin Wang
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Zan Shen
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Jiang Hua
- First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China
| | - Bangjian He
- First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China
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Habte A, Bizuayehu HM, Lemma L, Sisay Y. Road to maternal death: the pooled estimate of maternal near-miss, its primary causes and determinants in Africa: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:144. [PMID: 38368373 PMCID: PMC10874058 DOI: 10.1186/s12884-024-06325-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/06/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Maternal near-miss (MNM) is defined by the World Health Organization (WHO) working group as a woman who nearly died but survived a life-threatening condition during pregnancy, childbirth, or within 42 days of termination of pregnancy due to getting quality of care or by chance. Despite the importance of the near-miss concept in enhancing quality of care and maternal health, evidence regarding the prevalence of MNM, its primary causes and its determinants in Africa is sparse; hence, this study aimed to address these gaps. METHODS A systematic review and meta-analysis of studies published up to October 31, 2023, was conducted. Electronic databases (PubMed/Medline, Scopus, Web of Science, and Directory of Open Access Journals), Google, and Google Scholar were used to search for relevant studies. Studies from any African country that reported the magnitude and/or determinants of MNM using WHO criteria were included. The data were extracted using a Microsoft Excel 2013 spreadsheet and analysed by STATA version 16. Pooled estimates were performed using a random-effects model with the DerSimonian Laired method. The I2 test was used to analyze the heterogeneity of the included studies. RESULTS Sixty-five studies with 968,555 participants were included. The weighted pooled prevalence of MNM in Africa was 73.64/1000 live births (95% CI: 69.17, 78.11). A high prevalence was found in the Eastern and Western African regions: 114.81/1000 live births (95% CI: 104.94, 123.59) and 78.34/1000 live births (95% CI: 67.23, 89.46), respectively. Severe postpartum hemorrhage and severe hypertension were the leading causes of MNM, accounting for 36.15% (95% CI: 31.32, 40.99) and 27.2% (95% CI: 23.95, 31.09), respectively. Being a rural resident, having a low monthly income, long distance to a health facility, not attending formal education, not receiving ANC, experiencing delays in health service, having a previous history of caesarean section, and having pre-existing medical conditions were found to increase the risk of MNM. CONCLUSION The pooled prevalence of MNM was high in Africa, especially in the eastern and western regions. There were significant variations in the prevalence of MNM across regions and study periods. Strengthening universal access to education and maternal health services, working together to tackle all three delays through community education and awareness campaigns, improving access to transportation and road infrastructure, and improving the quality of care provided at service delivery points are key to reducing MNM, ultimately improving and ensuring maternal health equity.
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Affiliation(s)
- Aklilu Habte
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia.
| | | | - Lire Lemma
- Department of Health Informatics, School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Yordanos Sisay
- Department of Epidemiology, College of Health Science and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
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5
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Sun H, Wan Y, Pan X, You W, Shen J, Lu J, Zheng G, Li X, Xing X, Zhang Y. Long-term air pollution and adverse meteorological factors might elevate the osteoporosis risk among adult Chinese. Front Public Health 2024; 12:1361911. [PMID: 38347931 PMCID: PMC10859497 DOI: 10.3389/fpubh.2024.1361911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/12/2024] [Indexed: 02/15/2024] Open
Abstract
Objective This study aims to investigate the relationship between exposure to air pollution and adverse meteorological factors, and the risk of osteoporosis. Methods We diagnosed osteoporosis by assessing bone mineral density through Dual-Energy X-ray absorptiometry in 2,361 participants from Jiangsu, China. Additionally, we conducted physical examinations, blood tests, and questionnaires. We evaluated pollution exposure levels using grid data, considering various lag periods (ranging from one to five years) based on participants' addresses. We utilized logistic regression analysis, adjusted for temperature, humidity, and individual factors, to examine the connections between osteoporosis and seven air pollutants: PM₁, PM₂.₅, PM₁₀, SO₂, NO₂, CO, and O₃. We assessed the robustness of our study through two-pollutant models and distributed lag non-linear models (DLNM) and explored susceptibility using stratified analyses. Results In Jiangsu, China, the prevalence of osteoporosis among individuals aged 40 and above was found to be 15.1%. A consistent association was observed between osteoporosis and the five-year average exposure to most pollutants, including PM₂.₅, PM₁₀, CO, and O₃. The effects of PM₁₀ and CO remained stable even after adjusting for the presence of a second pollutant. However, the levels of PM₁ and PM₂.₅ were significantly influenced by O₃ levels. Individuals aged 60 and above, those with a BMI of 25 or higher, and males were found to be more susceptible to the effects of air pollution. Interestingly, males showed a significantly higher susceptibility to PM₁ and PM₂.₅ compared to females. This study provides valuable insights into the long-term effects of air pollution on osteoporosis risk among the adult population in China. Conclusion This study indicates a potential association between air pollutants and osteoporosis, particularly with long-term exposure. The risk of osteoporosis induced by air pollution is found to be higher in individuals aged 60 and above, those with a BMI greater than 25, and males. These findings underscore the need for further research and public health interventions to mitigate the impact of air pollution on bone health.
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Affiliation(s)
- Hong Sun
- Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Yanan Wan
- Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Xiaoqun Pan
- Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Wanxi You
- Luhe District Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Jianxin Shen
- Wujiang District Center for Disease Control and Prevention, Suzhou, Jiangsu, China
| | - Junhua Lu
- Chongchuan District Center for Disease Control and Prevention, Nantong, Jiangsu, China
| | - Gangfeng Zheng
- Jingjiang Center for Disease Control and Prevention, Taizhou, Jiangsu, China
| | - Xinlin Li
- Nantong Center for Disease Control and Prevention, Nantong, Jiangsu, China
| | - Xiaoxi Xing
- Quanshan District Center for Disease Control and Prevention, Xuzhou, Jiangsu, China
| | - Yongqing Zhang
- Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, China
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Hantouly AT, AlBarazanji A, Al-Juboori M, Alebbini M, Toubasi AA, Mohammed A, Alzobi O, Ahmed G. Epidemiology of proximal femur fractures in the young population of Qatar. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:21-29. [PMID: 37548762 PMCID: PMC10771613 DOI: 10.1007/s00590-023-03664-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
PURPOSE To review the epidemiological characteristics of proximal femur fractures in the young population (< 60 years) of Qatar between 2017 and 2019. METHODS All patient treated for proximal femur fractures at Hamad General Hospital (HGH), a level one trauma center, were retrospectively reviewed between Jan 2017 and Dec 2019. All adults (18-60 years) with proximal femur fracture (femur head, femur neck, intertrochanteric and subtrochanteric fractures) were included with no restriction to the AO/OTA classification or fractures subtypes. Excluded cases were pathological fractures, cases with insufficient documentation or no radiographs. RESULTS A total of 203 patients with a mean age of 40.07 ± 11.76 years were included, of who 89.9% were males. The incidence of proximal femur fracture was 3.12/100,000/year. Fall from height (48.1%) followed by road traffic accidents (26.9%) were common cause of injury. The most common fracture type was intertrochanteric fracture (36.1%) followed by femur neck fractures (33.7%). CONCLUSION This study provides the initial insights into the proximal femur fractures in the young population of Qatar. This is the first study to investigate of the epidemiology of such fractures in this particular patient group. Contrary to the existing literature on older age groups, the majority of the injuries were observed in males. Falls from height followed by road traffic accidents were the primary mechanisms leading to these fractures. Improved understanding of the profile of these injuries can aid in their prevention by implementing more effective safety measures.
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Affiliation(s)
- Ashraf T Hantouly
- Department of Orthopedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar
| | - Asim AlBarazanji
- Department of Orthopedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Al-Juboori
- Department of Orthopedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar
| | - Mohanad Alebbini
- Department of Orthopedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar
| | | | - Asma Mohammed
- Department of Orthopedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar
| | - Osama Alzobi
- Department of Orthopedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar
| | - Ghalib Ahmed
- Department of Orthopedic Surgery, Surgical Specialty Center, Hamad Medical Corporation, Doha, Qatar.
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Snega Priya P, Pratiksha Nandhini P, Arockiaraj J. A comprehensive review on environmental pollutants and osteoporosis: Insights into molecular pathways. ENVIRONMENTAL RESEARCH 2023; 237:117103. [PMID: 37689340 DOI: 10.1016/j.envres.2023.117103] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/28/2023] [Accepted: 09/06/2023] [Indexed: 09/11/2023]
Abstract
A significant problem that has an impact on community wellbeing is environmental pollution. Environmental pollution due to air, water, or soil pollutants might pose a severe risk to global health, necessitating intense scientific effort. Osteoporosis is a common chronic condition with substantial clinical implications on mortality, morbidity, and quality of life. It is closely linked to bone fractures. Worldwide, osteoporosis affects around 200 million people, and every year, there are almost 9 million fractures. There is evidence that certain environmental factors may increase the risk of osteoporosis in addition to traditional risk factors. It is crucial to understand the molecular mechanisms at play because there is a connection between osteoporosis and exposure to environmental pollutants such as heavy metals, air pollutants, endocrine disruptors, metal ions and trace elements. Hence, in this scoping review, we explore potential explanations for the link between pollutants and bone deterioration through deep insights into molecular pathways. Understanding and recognizing these pollutants as modifiable risk factors for osteoporosis would possibly help to enhance environmental policy thereby aiding in the improvement of bone health and improving patient quality of life.
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Affiliation(s)
- P Snega Priya
- Toxicology and Pharmacology Laboratory, Department of Biotechnology, SRM Institute of Science and Technology, Faculty of Science and Humanities, Kattankulatur, 603203, Chengalpattu District, Tamil Nadu, India
| | - P Pratiksha Nandhini
- Toxicology and Pharmacology Laboratory, Department of Biotechnology, SRM Institute of Science and Technology, Faculty of Science and Humanities, Kattankulatur, 603203, Chengalpattu District, Tamil Nadu, India
| | - Jesu Arockiaraj
- Toxicology and Pharmacology Laboratory, Department of Biotechnology, SRM Institute of Science and Technology, Faculty of Science and Humanities, Kattankulatur, 603203, Chengalpattu District, Tamil Nadu, India.
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Mousavibaygei SR, Bisadi A, ZareSakhvidi F. Outdoor air pollution exposure, bone mineral density, osteoporosis, and osteoporotic fractures: A systematic review and meta-analysis. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 865:161117. [PMID: 36586679 DOI: 10.1016/j.scitotenv.2022.161117] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/08/2022] [Accepted: 12/18/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The prevalence of osteoporosis and osteoporotic fractures is expected to increase with the aging of the population in the coming decades. In this study, we systematically reviewed the evidence on the association between exposure to air pollution and osteoporosis-related outcomes. METHODS We systematically searched evidence according to the PRISMA on PubMed, Scopus, and Web of Science (until August 2022). The risk of bias (RoB) was assessed using the Risk of Bias in the Non-randomized Studies of Exposures (ROBINS-E) tool. Random effects meta-analysis was applied to calculate combined estimates. We evaluated the heterogeneity using Cochran's Q test and quantified it by I2 and tau2 statistics. The overall body of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system (GRADE) tool. RESULTS Out of 5254 retrieved articles, 19 studies (11 cross-sectional, seven cohorts, and one case-control) met our inclusion criteria. Most of the studies had a high probability of RoB (n = 17), and only two had a moderate RoB. Different outcomes including bone mineral density, bone mineral content, osteoporotic fracture, osteoporosis, and osteopenia were reported across the studies. The associations were reported for different air pollutants including PM2.5, PM10, nitrogen oxides, nitrogen dioxide, ozone, black carbon, carbon monoxide, sulfur dioxide, nitrogen oxide, and coarse particulate matter. Evidence was suggestive of the negative role of PM10, PM2.5, and nitrogen dioxide (e.g. bone mineral density pooled estimate: -0.02, 95%CI: -0.03: -0.01). The overall body of evidence for most of the exposure-outcome pairs was low and very low. CONCLUSIONS The evidence on the association between air pollution exposure and osteoporosis-related outcomes is heterogenic. However, the evidence suggests an increased risk of osteoporotic fracture and osteoporosis in outdoor air pollutants. Due to the small number of studies in each group, also observed heterogeneity, and publication bias, the results should be interpreted with caution.
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Affiliation(s)
- Seyed Rohallah Mousavibaygei
- Assistant professor of orthopedic surgery, Department of orthopedic surgery Qom University of Medical Sciences, Qom, Iran
| | - Amir Bisadi
- Assistant professor of orthopedic surgery, Department of orthopedic surgery Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Prada D, Crandall CJ, Kupsco A, Kioumourtzoglou MA, Stewart JD, Liao D, Yanosky JD, Ramirez A, Wactawski-Wende J, Shen Y, Miller G, Ionita-Laza I, Whitsel EA, Baccarelli AA. Air pollution and decreased bone mineral density among Women's Health Initiative participants. EClinicalMedicine 2023; 57:101864. [PMID: 36820096 PMCID: PMC9938170 DOI: 10.1016/j.eclinm.2023.101864] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/25/2023] [Accepted: 01/26/2023] [Indexed: 02/17/2023] Open
Abstract
Background Osteoporosis heavily affects postmenopausal women and is influenced by environmental exposures. Determining the impact of criteria air pollutants and their mixtures on bone mineral density (BMD) in postmenopausal women is an urgent priority. Methods We conducted a prospective observational study using data from the ethnically diverse Women's Health Initiative Study (WHI) (enrollment, September 1994-December 1998; data analysis, January 2020 to August 2022). We used log-normal, ordinary kriging to estimate daily mean concentrations of PM10, NO, NO2, and SO2 at participants' geocoded addresses (1-, 3-, and 5-year averages before BMD assessments). We measured whole-body, total hip, femoral neck, and lumbar spine BMD at enrollment and follow-up (Y1, Y3, Y6) via dual-energy X-ray absorptiometry. We estimated associations using multivariable linear and linear mixed-effects models and mixture effects using Bayesian kernel machine regression (BKMR) models. Findings In cross-sectional and longitudinal analyses, mean PM10, NO, NO2, and SO2 averaged over 1, 3, and 5 years before the visit were negatively associated with whole-body, total hip, femoral neck, and lumbar spine BMD. For example, lumbar spine BMD decreased 0.026 (95% CI: 0.016, 0.036) g/cm2/year per a 10% increase in 3-year mean NO2 concentration. BKMR suggested that nitrogen oxides exposure was inversely associated with whole-body and lumbar spine BMD. Interpretation In this cohort study, higher levels of air pollutants were associated with bone damage, particularly on lumbar spine, among postmenopausal women. These findings highlight nitrogen oxides exposure as a leading contributor to bone loss in postmenopausal women, expanding previous findings of air pollution-related bone damage. Funding US National Institutes of Health.
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Affiliation(s)
- Diddier Prada
- Department of Environmental Health Science, Mailman School of Public Health, Columbia University, New York, NY, USA
- Instituto Nacional de Cancerología – México, Mexico City, Mexico
| | - Carolyn J. Crandall
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Allison Kupsco
- Department of Environmental Health Science, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - James D. Stewart
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Duanping Liao
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Jeff D. Yanosky
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Andrea Ramirez
- Instituto Nacional de Cancerología – México, Mexico City, Mexico
| | - Jean Wactawski-Wende
- School of Public Health and Health Professions, University at Buffalo, State University of New York, New York, USA
| | - Yike Shen
- Department of Environmental Health Science, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Gary Miller
- Department of Environmental Health Science, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Iuliana Ionita-Laza
- Department of Environmental Health Science, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Eric A. Whitsel
- Department of Epidemiology, Gillings School of Global Public Health and Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Andrea A. Baccarelli
- Department of Environmental Health Science, Mailman School of Public Health, Columbia University, New York, NY, USA
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10
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Yu XH, Cao HW, Bo L, Lei SF, Deng FY. Air pollution, genetic factors and the risk of osteoporosis: A prospective study in the UK biobank. Front Public Health 2023; 11:1119774. [PMID: 37026121 PMCID: PMC10071034 DOI: 10.3389/fpubh.2023.1119774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/02/2023] [Indexed: 04/08/2023] Open
Abstract
Purpose To reveal relationship between air pollution exposure and osteoporosis (OP) risk. Methods Based on large-scale data from the UK Biobank, we evaluated the relationship between OP risk and several air pollutants. Then air pollution scores (APS) were constructed to assess the combined effects of multiple air pollutants on OP risk. Finally, we constructed a genetic risk score (GRS) based on a large genome-wide association study of femoral neck bone mineral density and assessed whether single or combined exposure to air pollutants modifies the effect of genetic risk on OP and fracture risk. Results PM2.5, NO2, NOx, and APS were significantly associated with an increased risk of OP/fracture. OP and fracture risk raised with increasing concentrations of air pollutants: compared to the lowest APS quintile group, subjects in the highest quintile group had a hazard ratio (HR) (95% CI) estimated at 1.140 (1.072-1.213) for OP and 1.080 (1.026-1.136) for fracture. Moreover, participants with low GRS and the highest air pollutant concentration had the highest risk of OP, the HRs (95% CI) of OP were 1.706 (1.483-1.964), 1.658 (1.434-1.916), 1.696 (1.478-1.947), 1.740 (1.506-2.001) and 1.659 (1.442-1.908), respectively, for PM2.5, PM10, PM2.5-10, NO2, and NOx. Similar results were also observed for fractures. Finally, we assessed the joint effect of APS and GRS on the risk of OP. Participants with higher APS and lower GRS had a higher risk of developing OP. Similar results were observed in the joint effect of GRS and APS on fracture. Conclusions We found that exposure to air pollution, individually or jointly, could improve the risk of developing OP and fractures, and increased the risk by interacting with genetic factors.
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Affiliation(s)
- Xing-Hao Yu
- School of Public Health, Center for Genetic Epidemiology and Genomics, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Soochow University, Jiangsu, China
| | - Han-Wen Cao
- School of Public Health, Center for Genetic Epidemiology and Genomics, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Soochow University, Jiangsu, China
| | - Lin Bo
- Department of Rheumatology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shu-Feng Lei
- School of Public Health, Center for Genetic Epidemiology and Genomics, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Soochow University, Jiangsu, China
- Collaborative Innovation Center of Bone and Immunity Between Sihong Hospital and Soochow University, Jiangsu, China
- Shu-Feng Lei
| | - Fei-Yan Deng
- School of Public Health, Center for Genetic Epidemiology and Genomics, Medical College of Soochow University, Suzhou, China
- Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, Soochow University, Jiangsu, China
- *Correspondence: Fei-Yan Deng
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Yang J, Chu M, Gong C, Gong X, Han B, Chen L, Wang J, Bai Z, Zhang Y. Ambient fine particulate matter exposures and oxidative protein damage in early pregnant women. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2023; 316:120604. [PMID: 36347414 DOI: 10.1016/j.envpol.2022.120604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 06/16/2023]
Abstract
The association between oxidative protein damage in early pregnant women and ambient fine particulate matter (PM2.5) is unknown. We estimated the effect of PM2.5 exposures within seven days before blood collection on serum 3-nitrotyrosine (3-NT) and advanced oxidation protein products (AOPP) in 100 women with normal early pregnancy (NEP) and 100 women with clinically recognized early pregnancy loss (CREPL). Temporally-adjusted land use regression model was applied for estimation of maternal daily PM2.5 exposure. Daily nitrogen dioxide (NO2) exposure of each participant was estimated using city-level concentrations of NO2. Single-day lag effect of PM2.5 was analyzed using multivariable linear regression model. Net cumulative effect and distributed lag effect of PM2.5 and NO2 within seven days were analyzed using distributed lag non-linear model. In all 200 subjects, the serum 3-NT were significantly increased with the single-day lag effects (4.72%-8.04% increased at lag 0-2), distributed lag effects (2.32%-3.49% increased at lag 0-2), and cumulative effect within seven days (16.91% increased). The single-day lag effects (7.41%-10.48% increased at lag 0-1), distributed lag effects (3.42%-5.52% increased at lag 0-2), and cumulative effect within seven days (24.51% increased) of PM2.5 significantly increased serum 3-NT in CREPL group but not in NEP group. The distributed lag effects (2.62%-4.54% increased at lag 0-2) and cumulative effect within seven days (20.25% increased) of PM2.5 significantly increased serum AOPP in early pregnant women before the coronavirus disease (COVID-19) pandemic but not after that, similarly to the effects of NO2 exposures. In conclusion, PM2.5 exposures were associated with oxidative stress to protein in pregnant women in the first trimester, especially in CREPL women. Analysis of NO2 exposures suggested that combustion PM2.5 was the crucial PM2.5 component. Wearing masks may be potentially preventive in PM2.5 exposure and its related oxidative protein damage.
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Affiliation(s)
- Junnan Yang
- Department of Family Planning, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Mengyu Chu
- Department of Family Planning, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Chen Gong
- Department of Family Planning, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xian Gong
- Department of Family Planning, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Bin Han
- State Key Laboratory of Environmental Criteria and Risk Assessment, Chinese Research Academy of Environmental Sciences, Beijing, China
| | - Li Chen
- School of Geographic and Environmental Sciences, Tianjin Normal University, Tianjin, China
| | - Jianmei Wang
- Department of Family Planning, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Zhipeng Bai
- State Key Laboratory of Environmental Criteria and Risk Assessment, Chinese Research Academy of Environmental Sciences, Beijing, China; Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, WA, USA
| | - Yujuan Zhang
- Department of Family Planning, The Second Hospital of Tianjin Medical University, Tianjin, China; State Key Laboratory of Environmental Criteria and Risk Assessment, Chinese Research Academy of Environmental Sciences, Beijing, China.
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Xu C, Weng Z, Liu Q, Xu J, Liang J, Li W, Hu J, Huang T, Zhou Y, Gu A. Association of air pollutants and osteoporosis risk: The modifying effect of genetic predisposition. ENVIRONMENT INTERNATIONAL 2022; 170:107562. [PMID: 36228550 DOI: 10.1016/j.envint.2022.107562] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/20/2022] [Accepted: 10/02/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Limited studies have examined the association between air pollutants and osteoporosis incidence; however, the results are conflicting. We aimed to quantify the effects of selected air pollutants on osteoporosis risk and explore the modifying effect of genetic predisposition. METHODS A total of 422,955 subjects who did not have osteoporosis at baseline in the UK Biobank were included from 2006 to 2010. We conducted a Cox proportional hazards model with adjustment for covariates to examine the association between air pollutant scores and individual air pollutants and incident osteoporosis. Furthermore, a polygenic risk score (PRS) of osteoporosis was built and examined to determine whether genetic susceptibility modified the effect of air pollutants on osteoporosis. The relationship between air pollutants and osteoporosis was examined by using a restricted cubic spline (RCS) method. RESULTS After confounder adjustment, the results showed a remarkable increase in the risk of osteoporosis with each 10 unit increase in exposure to air pollution (hazard ratio: 1.06, 95 % confidence interval: 1.03-1.08), PM2.5 (1.94, 1.52-2.48), NO2 (1.06, 1.02-1.10), and NOX (1.03, 1.01-1.04). However, no significant association was observed between PM10 or PM2.5-10 exposure and osteoporosis. Subjects with high air pollutant exposure levels and a high PRS had a noteworthy increase in osteoporosis risk compared to those with low air pollutant exposure levels and a low PRS. Air pollutants and genetic variants exerted additive effects on the risk of osteoporosis. Positive correlations were observed between osteoporosis and PM2.5 (P < 0.001), NO2 (P = 0.001), and NOx (P = 0.002) exposure. CONCLUSIONS Exposure to PM2.5, NO2 and NOx was associated with an increase in osteoporosis risk, and this effect was more pronounced in populations with high genetic risk. The association between PM2.5, NO2 and NOx exposure and osteoporosis is modified by genetic variations.
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Affiliation(s)
- Cheng Xu
- State Key Laboratory of Reproductive Medicine, School of Public Health, Nanjing Medical University, Nanjing, China; Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Nanjing Medical University, Nanjing, China
| | - Zhenkun Weng
- State Key Laboratory of Reproductive Medicine, School of Public Health, Nanjing Medical University, Nanjing, China; Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Nanjing Medical University, Nanjing, China
| | - Qian Liu
- State Key Laboratory of Reproductive Medicine, School of Public Health, Nanjing Medical University, Nanjing, China; Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Nanjing Medical University, Nanjing, China
| | - Jin Xu
- State Key Laboratory of Reproductive Medicine, School of Public Health, Nanjing Medical University, Nanjing, China; Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Nanjing Medical University, Nanjing, China; Department of Maternal, Child, and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Jingjia Liang
- State Key Laboratory of Reproductive Medicine, School of Public Health, Nanjing Medical University, Nanjing, China; Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Nanjing Medical University, Nanjing, China
| | - Wenxiang Li
- State Key Laboratory of Reproductive Medicine, School of Public Health, Nanjing Medical University, Nanjing, China; Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Nanjing Medical University, Nanjing, China
| | - Jia Hu
- State Key Laboratory of Reproductive Medicine, School of Public Health, Nanjing Medical University, Nanjing, China; Suzhou Institute of Advanced Study in Public Health, Gusu School, Nanjing Medical University, Suzhou, China; Suzhou Center for Disease Prevention and Control, Suzhou, China
| | - Tao Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Yong Zhou
- CAS Key Laboratory of Tissue Microenvironment and Tumor, Shanghai Institute of Nutrition and Health, Shanghai Institutes for Biological Sciences, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Shanghai, China.
| | - Aihua Gu
- State Key Laboratory of Reproductive Medicine, School of Public Health, Nanjing Medical University, Nanjing, China; Key Laboratory of Modern Toxicology of Ministry of Education, Center for Global Health, Nanjing Medical University, Nanjing, China.
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Ma Y, Qiu S, Zhou R. Osteoporosis in Patients With Respiratory Diseases. Front Physiol 2022; 13:939253. [PMID: 35903070 PMCID: PMC9315364 DOI: 10.3389/fphys.2022.939253] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Climate change, environmental pollution, and virus epidemics have sharply increased the number of patients suffering from respiratory diseases in recent years. Prolonged periods of illness and drug use increase the occurrence of complications in these patients. Osteoporosis is the common bone metabolism disease with respiratory disturbance, which affects prognosis and increases mortality of patients. The problem of osteoporosis in patients with respiratory diseases needs more attention. In this review, we concluded the characteristics of osteoporosis in some respiratory diseases including COPD, asthma, COVID-19, tuberculosis, and lung cancer. We revealed that hypoxia was the common pathogenesis of osteoporosis secondary to respiratory diseases, with malnutrition and corticosteroid abuse driving the progression of osteoporosis. Hypoxia-induced ROS accumulation and activated HIF-1α lead to attenuated osteogenesis and enhanced osteoclastogenesis in patients with respiratory diseases. Tuberculosis and cancer also invaded bone tissue and reduced bone strength by direct infiltration. For the treatment of osteoporosis in respiratory patients, oral-optimized bisphosphonates were the best treatment modality. Vitamin D was a necessary supplement, both for calcium absorption in osteogenesis and for improvement of respiratory lesions. Reasonable adjustment of the dose and course of corticosteroids according to the etiology and condition of patients is beneficial to prevent the occurrence and development of osteoporosis. Additionally, HIF-1α was a potential target for the treatment of osteoporosis in respiratory patients, which could be activated under hypoxia condition and involved in the process of bone remodeling.
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Affiliation(s)
- Yue Ma
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shui Qiu
- Department of Orthopedics, First Hospital of China Medical University, Shenyang, China
| | - Renyi Zhou
- Department of Orthopedics, First Hospital of China Medical University, Shenyang, China
- *Correspondence: Renyi Zhou,
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Heo S, Kim H, Kim S, Choe SA, Byun G, Lee JT, Bell ML. Associations between Long-Term Air Pollution Exposure and Risk of Osteoporosis-Related Fracture in a Nationwide Cohort Study in South Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:2404. [PMID: 35206592 PMCID: PMC8872590 DOI: 10.3390/ijerph19042404] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/03/2022] [Accepted: 02/17/2022] [Indexed: 01/27/2023]
Abstract
Bone health is a major concern for aging populations globally. Osteoporosis and bone mineral density are associated with air pollution, but less is known about the impacts of air pollution on osteoporotic fracture. We aimed to assess the associations between long-term air pollution exposure and risk of osteoporotic fracture in seven large Korean cities. We used Cox proportional hazard models to estimate hazard rations (HRs) of time-varying moving window of past exposures of particulate matter (PM10), sulfur dioxide (SO2), carbon monoxide (CO), nitrogen dioxide (NO2), and ozone (O3) for osteoporotic fracture in Korean adults (age ≥ 50 years) in the National Health Insurance Service-National Sample Cohort data, followed 2002 to 2015. HRs were calculated for an interquartile range (IQR) increase. Comorbidity and prescription associated with osteoporosis, age, sex, body mass index, health behaviors, and income were adjusted in the models. Effect modification by age, sex, exercise, and income was examined. We assessed 56,467 participants over 535,481 person-years of follow up. Linear and positive exposure-response associations were found for SO2, while PM10 and NO2 showed nonlinear associations. SO2 was associated with osteoporosis-related fracture with marginal significance (HR for an IQR [2 ppb] increase = 1.04, 95% CI: 1.00, 1.09). The SO2 HR estimates were robust in analyses applying various moving windows of exposure (from one to three years of past exposure) and two-pollutant models. The central HR estimate of O3 implied positive associations but was not significant (HR for 0.007 ppm increase = 1.01, 95% CI: 0.97, 1.06). PM10, CO, and NO2 did not show associations. Vulnerable groups by sex, age, exercise, and income varied across air pollutants and there was no evidence of effect modifications. Long-term exposure to SO2, but not PM10, CO, NO2 and O3, was associated with increased osteoporotic fracture risks in Korean adults.
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Affiliation(s)
- Seulkee Heo
- School of the Environment, Yale University, New Haven, CT 06511, USA; (H.K.); (M.L.B.)
| | - Honghyok Kim
- School of the Environment, Yale University, New Haven, CT 06511, USA; (H.K.); (M.L.B.)
| | - Sera Kim
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul 02841, Korea; (S.K.); (G.B.); (J.-T.L.)
| | - Seung-Ah Choe
- College of Medicine, Korea University, Seoul 02841, Korea;
| | - Garam Byun
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul 02841, Korea; (S.K.); (G.B.); (J.-T.L.)
| | - Jong-Tae Lee
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul 02841, Korea; (S.K.); (G.B.); (J.-T.L.)
| | - Michelle L. Bell
- School of the Environment, Yale University, New Haven, CT 06511, USA; (H.K.); (M.L.B.)
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Assessing the roles of demographic, social, economic, environmental, health-related, and political factors on risk of osteoporosis diagnosis among older adults. Arch Osteoporos 2021; 16:177. [PMID: 34817704 PMCID: PMC8722370 DOI: 10.1007/s11657-021-01042-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/14/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Chronic stress from social/environmental pressures has been proposed to affect bone health through increased inflammation. We demonstrate that inflammation from prolonged stress does not cause changes to bone health through inflammation but instead impacts access to health care, social inequalities, and overall health, which in turn impact bone health. PURPOSE The study provides a comprehensive assessment of how determinants of health across demographic, psychological, mobility-related, health, environmental, and economic domains are associated with the diagnosis of osteoporosis and tests three hypotheses: (1) a diverse set of variables across domains will predict osteoporosis, (2) chronic inflammation as a result of stress (represented by high-sensitivity C-reactive protein) will not be associated with osteoporosis, and (3) the model developed will have high accuracy in predicting osteoporosis. METHODS Logistic regression and Cox proportional hazards models of osteoporosis diagnosis were estimated using data from 14,792 and 13,169 participants (depending on model) in the 2012-2016 waves of the Health and Retirement Study, including the Biomarker Study, the Contextual Data Resource, and validated measures of childhood socioeconomic status. Predictive accuracy was assessed using k-Nearest Neighbors Discriminant Analysis. RESULTS Demographic, environmental, and health-related factors were associated with osteoporosis diagnosis, and predictive accuracy of the models was good. High-sensitivity C-reactive protein was not associated with osteoporosis diagnosis. CONCLUSION Social determinants identified indicate access to health care, inequalities in the greater social environment (e.g., access to resources), and overall health (i.e., underlying medical conditions) are key components for developing osteoporosis and indicate underlying health inequities in this sample. There is a need to further address the interplay between primary health care and social determinants of health.
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