Particulate Air Pollution and Osteoporosis: A Systematic Review

Ambient PM2.5 components might exacerbate bone loss among middle-aged and elderly women: evidence from a population-based cross-sectional study

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.

Pollution and endometriosis: A deep dive into the environmental impacts on women's health

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.

Potential causal associations of PM2.5 and osteoporosis: a two-sample mendelian randomization study

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.

Road to maternal death: the pooled estimate of maternal near-miss, its primary causes and determinants in Africa: a systematic review and meta-analysis

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.

Long-term air pollution and adverse meteorological factors might elevate the osteoporosis risk among adult Chinese

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.

Epidemiology of proximal femur fractures in the young population of Qatar

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.

A comprehensive review on environmental pollutants and osteoporosis: Insights into molecular pathways

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.

Outdoor air pollution exposure, bone mineral density, osteoporosis, and osteoporotic fractures: A systematic review and meta-analysis

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.

Air pollution and decreased bone mineral density among Women's Health Initiative participants

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.

Air pollution, genetic factors and the risk of osteoporosis: A prospective study in the UK biobank

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

PM_2.5, NO₂, NO_x, 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 PM_2.5, PM₁₀, PM_2.5-10, NO₂, and NO_x. 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.

Ambient fine particulate matter exposures and oxidative protein damage in early pregnant women

The association between oxidative protein damage in early pregnant women and ambient fine particulate matter (PM_2.5) is unknown. We estimated the effect of PM_2.5 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 PM_2.5 exposure. Daily nitrogen dioxide (NO₂) exposure of each participant was estimated using city-level concentrations of NO₂. Single-day lag effect of PM_2.5 was analyzed using multivariable linear regression model. Net cumulative effect and distributed lag effect of PM_2.5 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 PM_2.5 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 PM_2.5 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, PM_2.5 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 PM_2.5 was the crucial PM_2.5 component. Wearing masks may be potentially preventive in PM_2.5 exposure and its related oxidative protein damage.

Association of air pollutants and osteoporosis risk: The modifying effect of genetic predisposition

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), PM_2.5 (1.94, 1.52-2.48), NO₂ (1.06, 1.02-1.10), and NO_X (1.03, 1.01-1.04). However, no significant association was observed between PM₁₀ or PM_2.5-10 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 PM_2.5 (P < 0.001), NO₂ (P = 0.001), and NOx (P = 0.002) exposure.

CONCLUSIONS

Exposure to PM_2.5, 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 PM_2.5, NO₂ and NOx exposure and osteoporosis is modified by genetic variations.

Osteoporosis in Patients With Respiratory Diseases

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.

Associations between Long-Term Air Pollution Exposure and Risk of Osteoporosis-Related Fracture in a Nationwide Cohort Study in South Korea

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.

Assessing the roles of demographic, social, economic, environmental, health-related, and political factors on risk of osteoporosis diagnosis among older adults

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.