Obesity is associated with early hip fracture risk in postmenopausal women: a 25-year follow-up

Association of body mass index and hip fracture has been controversial. In this study, women with lowest and highest body weight had the highest fracture incidence. A 25-year follow-up indicated that obesity associates with early hip fracture risk and suggested increasing trend in normal-weight women at a later stage.

INTRODUCTION

Obesity is a pandemic health issue. Its association with hip fracture risk remains controversial. We studied the long-term relationship of body mass index and hip fracture incidence in postmenopausal women.

METHODS

The cohort of 12,715 Finnish women born in 1932-1941 was followed for 25 years, covering ages from 58 up to 83. Fractures and deaths were obtained from national registries. Women were investigated in deciles of BMI as well as in WHO weight categories (normal, overweight, or obese). The follow-up analysis was carried out in two age strata as "early" (58-70 years) and "late" (> 70 years). Body weight information was updated accordingly. Femoral neck BMD was recorded for a subsample (n = 3163). Altogether, 427 hip fractures were observed.

RESULTS

A higher risk of early hip fracture was observed in obese and normal-weight compared with overweight women with hazard ratios (HRs) of 2.3 ((95% CI) 1.4-3.7) and 2.0 (1.3-3.1) while no difference was observed in late hip fracture risk between the three WHO categories (log rank p = 0.14). All-cause mortality during the follow-up was 19.3%. Compared with normal weight women, the obese women had a higher risk of death with an HR of 1.6 (1.4-1.8) and higher baseline BMD (p < 0.001). Faster bone loss was observed in the obese compared with other women (p < 0.001).

CONCLUSION

Obesity associates with earlier hip fracture and higher postfracture mortality. The obese women with low BMD have clearly the highest risk of hip fracture. This combination increases hip fracture risk more than either of the factors alone. After 75 years of age, risk appears to increase more in normal weight women, but this trend is in need of further confirmation.

A fall in the previous 12 months predicts fracture in the subsequent 5 years in postmenopausal women

PURPOSE

The purpose of this study was to evaluate if a history of falls predicts future postmenopausal fractures and if this prediction variesaccording to frequency, mechanism, and severity of falls and site of fractures.

METHODS

This study used data from OSTPRE prospective cohort. Total study population consisted of 8744 postmenopausal women (mean age 62.2 years) who responded to postal enquiry in 1999 (baseline) and in 2004 (follow-up).

RESULTS

Women were classified by frequency (non/occasional/frequent fallers), mechanism (slip/nonslip), and severity (injurious/ non-injurious) of falls and fractures by site (major osteoporotic/other). A total of 1693 (19.4%) women reported a fall during the preceding 12 months in 1999; 812 a slip fall, 654 a nonslip, 379 an injurious fall, and 1308 a non-injurious fall. A total of 811 women (9.3%) sustained a fracture during the 5-year follow-up period (1999-2004); 431 major osteoporotic fractures and 380 other fractures. Compared with non-fallers, earlier falls predicted subsequent fractures with an OR of 1.41 (95% CI 1.19-1.67, p ≤ 0.001), 1.43 (95% CI 1.14-1.80, p = 0.002) for earlier slip falls, and 1.35 (95% CI 1.04-1.74, p = 0.02) for earlier nonslip falls. Earlier injurious falls predicted future fractures (OR = 1.64, 95% CI 1.21-2.23, p ≤ 0.01), especially other fractures (OR = 1.86, 95% CI 1.24-2.80, p ≤ 0.01), but not major osteoporotic fractures (OR = 1.37, 95% CI 0.89-2.10, p = 0.151). Fracture risk predictions for earlier non-injurious falls was OR = 1.36, 95% CI 1.12-1.64, p = 0.002. These risk patterns remain same after adjustments.

CONCLUSION

History of falls (especially injurious falls) predicts subsequent fractures (mainly other fractures compared with major osteoporotic fractures) inpostmenopausal women. We aimed to investigate if history of falls (frequency, mechanism, and severity) is a predictor of future fractures in postmenopausal women. Our results indicate that history of falls (especially injurious falls) appeared to be an indicator for subsequent fracture overall. Earlier injurious falls were stronger predictors for future other fractures than for typical major osteoporotic fractures.

Role of musculoskeletal disorders in falls of postmenopausal women

We aimed to investigate the role of musculoskeletal disorders (MSDs) as risk factors for falls among postmenopausal women. Our results indicate that MSDs are common and are associated with increased falling risk, especially nonslip falls. Excess number of falls due to MSDs is greater than that due to any other disease class.

PURPOSE

Falls are a major public health problem worldwide. The aim of the study was to investigate the role of MSDs as risk factors for falls among postmenopausal women.

METHODS

This cohort study utilized data from a population-based, prospective cohort study (OSTPRE). The study population consisted of 8656 women aged 57-66 years (in 1999) living in Kuopio Province, Eastern Finland, who responded to postal enquiries in 1999 and 2004. Information on MSDs and other morbidities was obtained from the 1999 enquiry and information on falls from the 2004 enquiry. Women were classified as fallers or non-fallers according to their falling events in the preceding 12 months. The fallers were further divided into women with slip and nonslip falls.

RESULTS

Of the study sample, 53.3% reported a MSD and 39.2% reported a fall during the preceding 12 months. MSDs predicted falls (OR = 1.38; 95% CI 1.26-1.50) and the association was stronger for nonslip (OR = 1.56; 95% CI 1.39-1.75) than slip falls (OR 1.22; 95% CI 1.08-1.38) compared to the women without MSDs. The risk of falls increased with increasing number (1, 2, ≥ 3) of MSDs: 1.25 (95%CI 1.13-1.38), 1.48 (95%CI 1.30-1.68), and 1.92 (95%CI 1.60-2.31), respectively. After adjustments, the risk of falling related to MSDs reduced by about 5% (adjusted p < 0.001). The population attributable fraction of falls due to MSDs was 10.3% of all falls, greater than that due to any other disease class.

CONCLUSION

MSDs are common and an important risk factor for falls and especially nonslip falls among postmenopausal women. The number of excess falls due to MSDs in this population group is greater than that due to any other disease class.

Long-term effects of functional impairment on fracture risk and mortality in postmenopausal women

Our findings imply that simple functional tests can predict both hip fracture risk and excess mortality in postmenopausal women. Since the tests characterize general functional capacity (one-legged stance, squatting down, and grip strength), these simple measures should have clinical utility in the assessment of women at risk of falls and fragility fracture.

INTRODUCTION

Functional impairment is associated with the risk of fall, which is the leading cause of hip fracture. We aimed to determine how clinical assessments of functional impairment predict long-term hip fracture and mortality.

METHODS

A population-based prospective cohort involved 2815 Caucasian women with the average baseline age of 59.1 years. The mean follow-up time in 1994-2014 was 18.3 years. Three functional tests and their combinations assessed at baseline were treated as dichotomous risk factors: (1) inability to squat down and touch the floor (SQ), (2) inability to stand on one leg for 10 s (SOL), and (3) having grip strength (GS) within the lowest quartile (≤ 58 kPa, mean 45.6 kPa). Bone mineral density (BMD) at the proximal femur was measured by DXA. Fractures and deaths were verified from registries. Hazard ratios were determined by using Cox proportional models. Age, body mass index (BMI), and BMD were included as covariates for fracture risk estimates. Age, BMI, and smoking were used for mortality.

RESULTS

Altogether, 650 (23.1%) women had 718 follow-up fractures, including 86 hip fractures. The mortality during the follow-up was 16.8% (n = 473). Half of the women (56.8%, n = 1600) had none of the impairments and were regarded as the referent group. Overall, women with any of the three impairments (43.2%, n = 1215) had higher risks of any fracture, hip fracture, and death, with hazard ratios (HR) of 1.3 ((95% CI) 1.0-1.5, p < 0.01), 2.4 (1.5-3.4, p < 0.001), and 1.5 (1.3-1.8, p < 0.001), respectively. The strongest single predictor for hip fracture was failing to achieve a one-leg stand for 10 s (prevalence 7.1%, n = 200), followed by inability to squat down (27.0%, n = 759) and weak grip strength (24.4%, n = 688), with their respective HRs of 4.3 (2.3-8.0, p < 0.001), 3.1 (2.0-5.0, p < 0.001), and 2.0 (1.2-3.4, p < 0.001). In addition, age, lower BMD, BMI, and smoking were significant covariates.

CONCLUSIONS

These findings suggest that functional tests provide long-term prediction of fracture and death in postmenopausal women. Whether reversal of these impairments is associated with a reduction in adverse outcomes is an area for future trials.

Relationship of body anthropometric measures with skeletal muscle mass and strength in a reference cohort of young Finnish women

OBJECTIVES

1) To study if limb length explains variability in appendicular and total muscle mass better than height and 2) if muscle mass adjusted for limb length rather than height correlates better with grip and knee extension strength.

METHODS

400 healthy women aged 20-40 were recruited as a reference population. Body composition, limb length, grip strength and knee extension strength were measured. New relative muscle mass indexes were computed by adjusting upper limb muscle mass for upper limb length (ULRSMI) and lower limb muscle mass for lower limb length (LLRSMI).

RESULTS

Height correlated strongest with all muscle mass measures. Height had the highest R² values for predicting variability in appendicular skeletal muscle mass (0.33), upper limb skeletal muscle mass (0.20), lower limb skeletal muscle mass (0.34) and total skeletal muscle mass (0.36). Correlation of relative skeletal muscle mass index (RSMI) with grip and knee extension strength (r=0.47 and 0.43) was higher when compared with correlation of ULRSMI and LLRSMI with these measures.

CONCLUSION

Compared to limb length, height correlates better with regional and total muscle mass. Muscle mass adjusted for height correlates better with grip strength and knee strength when compared with muscle mass adjusted for limb length.

Inclusion of Regional Body Composition Parameters Improves Bone Mineral Density Cross-Calibration Between GE Lunar Prodigy and iDXA Densitometers

Since 1989, the Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE, n = 14220) Study has followed long-term changes of bone mineral density (BMD) and body composition in women with GE Lunar devices. During the course of OSTPRE, the dual-energy X-ray absorptiometry device had to be replaced by a newer model. Then, it was essential to determine whether systematic measurement differences in BMD and body composition will occur. As a part of the OSTPRE study, BMD was measured in 54 women, whereas body composition was determined in 55 women, aged 27-71, by using both the GE Healthcare Lunar Prodigy and iDXA narrow-angle fan beam densitometers during the same visit. The total body fat mass (FM) and lean body mass (LBM) results of these scanners showed a high linear correlation (r = 0.981-0.994, p < 0.0001). However, the mean total body FM and LBM values measured by iDXA were on average 2.3% (0.5 kg, 95% confidence interval: 0.3-0.7 kg) higher and 0.8% (0.3 kg, 95% confidence interval: 0.1-0.6 kg) lower, respectively, than those measured by Prodigy. Inclusion of local soft tissue measurements (total body LBM, legs/android FM) improved the agreement of total body, total hip, and lumbar spine BMD values between the devices but not femoral neck BMD agreement. Equations, based on linear regression analyses, were derived to minimize differences between the instruments. Then, the differences in BMD and body composition measurements were negligible between Prodigy and iDXA. Using correction equations enables an objective comparison of longitudinal BMD and body composition measurements.

Association of adipokines and estradiol with bone and carotid calcifications in postmenopausal women

OBJECTIVES

Carotid artery calcifications (CAC) and high carotid artery intima-media thickness (cIMT) are associated with low bone mineral density (BMD) by unknown mechanisms in postmenopausal women. Leptin, adiponectin and estradiol may mediate these associations. Our aim was to study the relationships of the aforementioned factors to bone health (BMD) and carotid atherosclerosis (CAC and cIMT).

METHOD

Participants (n = 290, mean age 73.6 years) for this cross-sectional OSTPRE-BBA study (Kuopio Osteoporosis Risk Factor and Prevention - Bone, Brain and Atherosclerosis) were randomly selected from the OSTPRE cohort in 2009. Femoral neck and total body BMDs, trunk and total body fat mass were measured with dual-energy X-ray absorptiometry, and cIMT (mm) and CAC (no/yes) were measured with B-type ultrasound. Free estradiol, adiponectin and leptin were measured from serum samples.

RESULTS

Circulating estradiol levels were associated with leptin (β = 0.131, p < 0.001), but not with adiponectin (p > 0.05), when adjusted for total body fat mass. There were no associations between estradiol tertiles and BMDs, or with cIMT or CAC. Adiponectin levels were inversely associated with femoral neck BMD (p = 0.019, β = -0.138) and total body BMD (p = 0.009, β = -0.142), adjusted for total body fat mass, age, current smoking and estradiol, but showed no relationship with CAC or cIMT. Leptin levels were not associated with BMDs or cIMT; but the odds ratio was 1.5 between the CAC and leptin quartiles (p = 0.014), adjusted for total body fat mass, age, statin use and calcium intake.

CONCLUSION

The adipokines are associated with vascular calcification and low BMD. Moreover, estradiol was not independently associated with BMD or CAC.

Body fat distribution is associated with lumbar spine bone density independently of body weight in postmenopausal women

OBJECTIVE

To assess the association between the body fat distribution and axial bone mineral density (BMD) in postmenopausal women with or without hormone replacement therapy (HRT).

DESIGN

Cross-sectional population-based study.

SETTING

University of Eastern Finland, Bone and Cartilage Research Unit, Kuopio, Finland.

POPULATION

198 postmenopausal women, mean age 67.5 (1.9 SD), mean BMI 27.1 (3.9 SD).

METHODS

Regional body composition and BMD assessed by dual X-ray absorptiometry (DXA, Prodigy).

MAIN OUTCOME MEASURES

Spinal and Femoral BMD.

RESULTS

Out of the body composition parameters, FM was the main determinant of postmenopausal bone mass. Only the lumbar spine (L2-L4) BMD, not the femoral neck BMD, was positively associated with the trunk FM. Positive trends for association were revealed between the spinal BMD and the trunk FM regardless of the use of HRT. Adjustments did not change the results.

CONCLUSIONS

Higher trunk fat mass was associated with the spinal BMD, but not with the hip BMD in postmenopausal women, irrespective of the HRT use. In addition to biological factors, uncertainties related to DXA measurements in patients with varying body mass may contribute to this phenomenon.

Bone health-related factors and the use of bisphosphonates in community setting--15-year follow-up study

The present study investigated the bone health related factors that were associated with the use of bisphosphonates (BP) among 2,050 postmenopausal Finnish women. Low BMD + low trauma energy fracture was the strongest determinant of BP use, while other secondary causes of osteoporosis were less strongly related with BP use. BP use was associated with reduced femoral neck (FN) and lumbar spine (LS) bone loss rate.

INTRODUCTION

The aim was to identify bone health related factors associated with the use of BP in a community setting.

METHODS

A population-based sample of 2,050 Finnish postmenopausal women was measured with dual X-ray absorptiometry at the FN and LS in 1989, 1994, 1999 and 2004, and information on osteoporosis risk factors, including low-trauma energy fractures, were collected with postal inquiries. Self-reported use of BP in 2004 was considered as the end point variable.

RESULTS

Among BP users, 12% had T-score > -2.0 SD and no fracture during follow-up (FU). In women without any bone medication, 26% had T-score < -2.0 SD or low-trauma energy fracture or both during the FU. In BP users, a significant reduction in FN and LS bone loss rate, cumulative with duration of use, was observed in ANCOVA (p < 0.001). Among BP users, there was a significantly higher proportion of women with several independent risk factors for osteoporosis and more spine and humerus fractures but less ankle fractures. T-score < -2 SD combined with low-trauma energy fracture was significantly related to the use of BPs (p < 0.001, OR = 15.96) and T-score < -2 SD was a stronger predictor of BP use (p < 0.001, OR = 13.29) than fracture (p > 0.05, OR = 1.35) in multivariate logistic regression. Other factors related with BP use were vitamin D use (p = 0.001, OR = 2.27), high number of medications (p < 0.001, OR = 1.26) and rheumatoid arthritis (p < 0.05, OR 2.55).

CONCLUSIONS

These findings reveal the recent bone health-related indications for BP prescription.

Effect of calcium and vitamin D supplementation on bone mineral density in women aged 65-71 years: a 3-year randomized population-based trial (OSTPRE-FPS)

SUMMARY

The Osteoporosis Risk Factor and Prevention-Fracture Prevention Study (OSTPRE-FPS) was a randomized population-based open trial (n = 593). The supplementation group (n = 287) received daily cholecalciferol 800 IU + calcium 1,000 mg for 3 years while the control group (n = 306) received neither supplementation nor placebo. Daily vitamin D and calcium supplementation have a positive effect on the skeleton in ambulatory postmenopausal women.

INTRODUCTION

vitamin D deficiency is common in the elderly, and vitamin D levels are associated with low bone mineral density (BMD). The working hypothesis was that vitamin D and calcium supplementation could prevent bone loss in ambulatory postmenopausal women.

METHODS

the OSTPRE-FPS was a randomized population-based open trial with a 3-year follow-up in 3,432 women (aged 66 to 71 years). A randomly selected subsample of 593 subjects underwent BMD measurements. The supplementation group (n = 287) received daily cholecalciferol 800 IU + calcium 1,000 mg for 3 years while the control group (n = 306) received neither supplementation nor placebo.

RESULTS

in the intention-to-treat analysis, total body BMD (n = 362) increased significantly more in the intervention group than in the control group (0.84% vs. 0.19%, p = 0.011). The BMD change differences at the lumbar spine (p = 0.372), femoral neck (p = 0.188), trochanter (p = 0.085), and total proximal femur (p = 0.070) were statistically nonsignificant. Analyses in compliant women (≥ 80% of use) resulted in stronger and statistically significant effects at the total body and femoral regions.

CONCLUSION

daily vitamin D and calcium supplementation have a positive effect on the skeleton in ambulatory postmenopausal women with adequate nutritional calcium intake.

Association between functional capacity tests and fractures: an eight-year prospective population-based cohort study

This study of postmenopausal women (n=2,928) with an eight-year follow-up revealed that impairment in functional status associated with the increased fracture risk. The standing-on-one-foot and grip strength tests and a question about self-assessed ability to move can be used to identify women with a high risk of suffering a fracture.

INTRODUCTION

Poor functional status has pointed to associate with injurious falls and consequent fractures. Our aim was to define association between functional capacity and fractures.

METHODS

This study was based on the Osteoporosis Risk Factor and Prevention Study (OSTPRE). A total of 2,928 postmenopausal women took part in the functional capacity and muscle strength tests. The duration of fracture follow-up varied from 6.43 to 9.86 (mean 8.37) years and the first fracture was the end-point event for the statistical analyses. All analyses were done with Cox-regression.

RESULTS

A total of 261 end-point fractures occurred. In multivariate analysis the inability to stand-on-one-foot for 10 seconds increased the risk of hip fracture (hazard ratio with 95% CI) 9.11-fold (1.98-42.00). Decreased grip strength associated with 1.05-fold (1.01-1.09) increased risk of hip fractures. Low leg extension strength associated with 1.02-fold (1.00-1.03) higher risk for all fractures. The self-assessed ability to walk less than 100 meters at baseline increased the risk of ankle 2.36-fold (1.10-5.08), hip 11.57-fold (2.73-49.15) and clinical vertebral fractures 3.85-fold (1.45-10.22).

CONCLUSION

According to these results the standing-on-one-foot less than 10 seconds, grip strength and a question about ability to walk less than 100 meters may help to predict postmenopausal fractures.

Is discordance in bone measurements affected by body composition or anthropometry? A comparative study between peripheral and central devices

Screening of osteoporosis using peripheral bone measurements has become more common, even though diagnostic discrepancies are known to exist between peripheral dual-energy X-ray (pDXA) or quantitative ultrasound (QUS) and central DXA measurements. Values of diagnostic parameters such as bone mineral density, speed of (ultra)sound, and broadband ultrasound attenuation are affected by bone size and soft tissue composition. However, their significance for the discordance between peripheral and central techniques is unclear. In this study, bone status and total body composition of 139 women (mean age 68.3 yr [1.7 SD], mean body mass index 26.5 kg/m2 [3.6 SD]) were assessed by 3 GE Lunar devices. Heel pDXA and heel QUS were conducted using peripheral instantaneous X-ray imaging (PIXI) and Achilles, respectively, and central DXA measurements were taken at the posterior-anterior lumbar spine (L2-L4) and at the left femoral neck using Prodigy. Positive significant associations were found between body height or fat (%) and most DXA or QUS parameters. The discordance between the site-dependent DXA or QUS T-score values typically increased (p<0.05) as a function of body weight or fat (%), but not with body height. On an average, body adiposity accounted for less than 11% of the differences between the techniques; however, increase of total body fat from 20% to 45% led to a discrepancy of one T-score between DXA(HEEL) and QUS(HEEL). To avoid diagnostic bias, comparative assessment of the devices using the same population is recommended.

Incident open-angle glaucoma and intraocular pressure

PURPOSE

To evaluate the role of baseline intraocular pressure (b-IOP) as a risk factor for incident open-angle glaucoma (OAG) in participants of African origin from the Barbados Eye Studies.

DESIGN

Population-based 9-year cohort study.

PARTICIPANTS

Three thousand two hundred twenty-two persons examined during the study period who were free of glaucoma at baseline and at risk of developing OAG during the 9-year follow-up.

METHODS

Study protocols were standardized and included ophthalmic and other measurements, automated perimetry, applanation tonometry, fundus photography, and comprehensive ophthalmologic examination for those referred. The product-limit approach was used to estimate incidence. Relationships between b-IOP and incidence were evaluated by adjusted relative risk ratios (RRs) with 95% confidence intervals (CIs), based on Cox regression models.

MAIN OUTCOME MEASURE

The 9-year incidence of OAG was based on both visual field and optic disc abnormalities, with ophthalmologic evaluations to exclude other possible causes.

RESULTS

The overall 9-year incidence of OAG was 4.4% (95% CI, 3.7%-5.2%), and the mean (standard deviation) b-IOP among persons at risk was 18.0 mmHg (4.1). Among the 125 incident OAG cases, the mean b-IOP was 21.9 mmHg and 46% had b-IOP of >21 mmHg. In contrast, the nonincident group had a mean b-IOP of 17.8 mmHg and only 12% had b-IOP of >21 mmHg. Overall, OAG risk increased by 12% with each 1-mmHg increase in IOP (RR, 1.12; 95% CI, 1.08-1.16). Incidence steadily increased from 1.8% (95% CI, 1.2%-2.7%) for persons with b-IOP of < or =17 mmHg (referent group) to 22.3% (95% CI, 15.8%-31.1%) for those with b-IOP > 25 mmHg, resulting in an adjusted RR of 13.1 (95% CI, 7.1-24.1) among the latter group. The attributable risk for IOP of >25 mmHg was 19%. Using 21 mmHg as a cutoff, the RR was 7.9 (95% CI, 3.8-16.2) and the attributable risk was 37%.

CONCLUSIONS

After 9 years' follow-up, the risk of OAG was positively related to IOP levels at baseline. Although persons with b-IOP of >25 mmHg had a 13-fold RR of developing OAG, most cases arose with lower b-IOP. This study thus confirms the role of IOP as an influential risk factor, yet at the same time underscores its limitations in predicting OAG.

Nine-Year Incidence of Open-Angle Glaucoma in the Barbados Eye Studies

PURPOSE

To determine the 9-year incidence of open-angle glaucoma (OAG) in African-descent participants of the Barbados Eye Studies.

DESIGN

Nine-year cohort study with 81% to 85% participation.

PARTICIPANTS

Three thousand two hundred twenty-two persons without definite OAG at baseline, at risk of developing OAG at follow-up.

METHODS

The standardized protocol included automated perimetry and various ophthalmic measurements, with a comprehensive ophthalmologic examination for those referred. Fundus photographs were evaluated independently by masked graders. Incidence was estimated by the product-limit approach. Relative risk (RR) ratios with 95% confidence intervals (CIs) were based on Cox regression models with discrete time.

MAIN OUTCOME MEASURE

Nine-year incidence of definite OAG, based on the development of visual field defects and glaucomatous optic neuropathy, with ophthalmologic confirmation.

RESULTS

The 9-year incidence of definite OAG was 4.4% (95% CI, 3.7%-5.2%), or an average of 0.5%/year, based on 125 new cases. Incidence increased greatly with age, from 2.2% at ages 40 to 49 years to 7.9% at ages 70 years or older, and tended to be higher in men than women (4.9% vs. 4.1%; RR, 1.3; 95% CI, 0.9-1.8). More than half (53%) of new cases were undetected, and of these, one third had intraocular pressure of 21 mmHg or less. When 141 persons developing suspected/probable OAG were considered, the total incidence was 9.4% (8.4%-10.6%), averaging approximately 1%/year, also increasing with age, and significantly higher in men than women (10.7% vs. 8.6%; RR, 1.31; 95% CI, 1.02-1.67).

CONCLUSIONS

These new data provide a measure of the long-term risk of OAG in an African-descent population, which is markedly higher than in persons of European ancestry. Results confirm the increased risk with age and in men. The incidence data fill a gap in our understanding of OAG risk and have implications for public health policy and planning; they also will allow the study of factors related to the risk of OAG development.

The use of multiple sites for the diagnosis of osteoporosis

INTRODUCTION

It has been suggested that bone mineral density (BMD) measurements should be made at multiple sites, and that the lowest T-score should be taken for the purpose of diagnosing osteoporosis.

PURPOSE

The aim of this study was to examine the use of BMD measurements at the femoral neck and lumbar spine alone and in combination for fracture prediction.

METHODS

We studied 19,071 individuals (68% women) from six prospective population-based cohorts in whom BMD was measured at both sites and fracture outcomes documented over 73,499 patient years. BMD values were converted to Z-scores, and the gradient of risk for any osteoporotic fracture and for hip fracture was examined by using a Poisson model in each cohort and each gender separately. Results of the different studies were merged using weighted beta-coefficients.

RESULTS

The gradients of risk for osteoporotic fracture and for hip fracture were similar in men and women. In men and women combined, the risk of any osteoporotic fracture increased by 1.51 [95% confidence interval (CI)=1.42-1.61] per standard deviation (SD) decrease in femoral-neck BMD. For measurements made at the lumbar spine, the gradient of risk was 1.47 (95% CI=1.38-1.56). Where the minimum of the two values was used, the gradient of risk was similar (1.55; 95% CI=1.45-1.64). Higher gradients of risk were observed for hip fracture outcomes: with BMD at the femoral neck, the gradient of risk was 2.45 (95% CI=2.10-2.87), with lumbar BMD was 1.57 (95% CI=1.36-1.82), and with the minimum value of either femoral neck and lumbar spine was 2.11 (95% CI=1.81-2.45). Thus, selecting the lowest value for BMD at either the femoral neck or lumbar spine did not increase the predictive ability of BMD tests. By contrast, the sensitivity increased so that more individuals were identified but at the expense of specificity. Thus, the same effect could be achieved by using a less stringent T-score for the diagnosis of osteoporosis.

CONCLUSIONS

Since taking the minimum value of the two measurements does not improve predictive ability, its clinical utility for the diagnosis of osteoporosis is low.

Maintenance of muscle strength may counteract weight-loss-related postmenopausal bone loss--a population-based approach

INTRODUCTION

Weight loss significantly increases postmenopausal bone loss, but the effects of muscle strength change on weight-loss-associated bone loss remain unclear. The study population, 587 peri- and postmenopausal women, was a random sample of the original Osteoporosis Risk Factor and Prevention Study (OSTPRE) study cohort (n=14,220) in Kuopio, Finland. Bone mineral density (BMD) at the lumbar spine (LS) and femoral neck (FN) was measured with dual x-ray absorptiometry, and grip strength was measured with a pneumatic squeeze dynamometer at baseline in 1989-1991 and at the 10-year follow-up in 1999-2001.

METHODS

Women were divided into three groups according to change in age-grouped grip-strength quartile in both of the measurements: "decreased" (n=133), "maintained" (n=300), and "improved" (n=154). In addition, the study sample was divided into two groups according to weight change during the follow-up: weight losers (n=156) and weight gainers (n=431).

RESULTS

There were no differences in the change status of grip (muscle) strength between the weight loss and weight gain groups (p>0.500, Pearson chi-square test). Women losing weight during the follow-up and within the improved grip-strength-change group had a significantly lower bone loss rate compared with those in the maintained and decreased grip-strength-change groups (p<0.01 in comparison to the decreased group). This was in contrast to women who gained weight during the follow-up (not significant between any grip-strength-change groups). Furthermore, women who lost body weight and were in the improved grip-strength-change group had a bone loss rate comparable with that of the women who gained body weight (not significant). This was in contrast to the maintained (p<0.05 between weight losers versus gainers in LS) and decreased grip-strength-change groups (p<0.01 weight losers versus gainers in LS and FN).

CONCLUSION

The present study suggests that maintaining muscle strength may counteract postmenopausal bone loss related to weight loss. Accordingly, exercise that improves muscle strength may be encouraged for postmenopausal women with weight loss intentions for other health reasons.

Cross-calibration of Lunar DPX-IQ and DPX dual-energy x-ray densitometers for bone mineral measurements in women: effect of body anthropometry

When dual-energy X-ray absorptiometry (DXA) instruments are replaced, it is essential to determine if systematic differences in measurements occur. As a part of the Kuopio Osteoporosis Risk Factor and Prevention study (N=14,220), a group of women, aged 36 to 69 yr underwent anteroposterior lumbar spine L2 to L4 (n=89) and proximal femur scans (n=88) by the Lunar DPX and DPX-IQ, respectively, during the same visit. A high linear association (r from 0.944 to 0.989, p<0.001) between the two scanners was established for lumbar spine and proximal femur bone mineral density (BMD). The average DPX values for BMD were 1.1% and 2.0% higher than those of DPX-IQ for the lumbar spine (p<0.001) and Ward's triangle (p=0.001), respectively. Femoral neck BMD values by the DPX were 1.4% lower (p<0.001) compared to DPX-IQ. The difference between trochanter BMD results (0.1%) was not significant (p=0.809). In the femoral neck and trochanter, but not in the lumbar spine or Ward's triangle, the differences in BMD values of the two machines were found to depend on body mass index. After linear formulas based on simple and multivariate linear regression analyses were calculated, the differences were negligible, enabling objective comparison of longitudinal measurements.

Calcaneal ultrasound predicts early postmenopausal fractures as well as axial BMD. A prospective study of 422 women

Low calcaneal ultrasound measurement (quantitative ultrasound, QUS) has been shown to predict fractures in elderly women. However, only a few studies have examined its ability to predict perimenopausal and early postmenopausal fractures. We conducted a prospective population-based cohort study to assess the capability of QUS as compared to axial BMD measurement to predict early postmenopausal fractures at that age. Four hundred and twenty-two women (mean age 59.6, range 53.7-65.3) from the Kuopio Osteoporosis Risk Factor and Prevention Study (OSTPRE) were randomly chosen to undergo a calcaneal ultrasound measurement. In all, 9.4% of these women were premenopausal at the time of measurement. Thirty-two follow-up fractures were reported during the mean follow-up of 2.6 years (SD 0.7). These were validated with patient record perusal. Broadband ultrasound attenuation (BUA), speed of sound (SOS) and stiffness index (SI) were significantly lower among women with than without fracture ( P-values 0.028, 0.001 and 0.001, respectively). Mean T-score adapted from SI was -1.5 (95% CI -1.7 to -1.2) for fracture group and -1.0 (95% CI -1.1 to -0.9) for the non-fracture group. All QUS measurements predicted fractures even after adjusting for age, weight, height, previous fracture history, femoral neck BMD and use of hormone replacement therapy according to Cox regression. The adjusted hazard ratios (HR, 95% confidence interval) of a follow-up fracture for a 1 SD decrease were 1.80 (1.27-2.56), 1.72 (1.21-2.45) and 1.43 (1.01-2.03) for SOS, SI and BUA, respectively. Similarly, the adjusted HR for a 1 SD decrease of spinal BMD was 1.27 (0.85-1.94) and for that of femoral neck BMD 1.14 (0.78-1.70). In receiver operator analyses, the area under the curve (AUC) was greatest for QUS measurements: SOS (AUC=0.68), stiffness (AUC=0.67), BUA (AUC=0.62) and least for lumbar BMD (AUC=0.56), while and femoral neck BMD (AUC=0.59). The difference between AUCs was statistically significant between SI and lumbar BMD ( P=0.02, Duncan's P=0.07). We conclude that low calcaneal QUS predicts early postmenopausal fractures as well as or even better than axial BMD.

Changes in body weight and onset of hypertension in perimenopausal women

We assessed the determinants of onset of hypertension in a large, prospective population-based study of perimenopausal women from the Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE) study. The data collection started in 1989, when a baseline postal inquiry was sent to all women aged 47-56 years (n=14 220) residing in the Kuopio Province in Eastern Finland. Names, social security numbers and addresses were obtained from the Population Register Centre of Finland. A total of 11 798 women responded at baseline and at 5-year follow-up in 1994. After the exclusion of 1777 women with prevalent hypertension at baseline and women with missing height or weight information, the study population consisted of 9485 without established hypertension at baseline. New cases of established hypertension during the follow-up (n=908) were ascertained with the Registry of Specially Refunded Drugs of the Finnish Social Insurance Institution (SII). According to the National Health Insurance, the SII granted 90% reimbursement for drug costs in defined chronic illnesses necessitating continuous medication, like arterial hypertension. Weight and weight gain both raised the risk by 5% per kg (P<0.001). Weight gain of 4-6 kg increased the risk of hypertension 1.25 times and a gain of more than 7 kg 1.65 times compared with the control (zero) group. To conclude, the onset of hypertension in peri- and early postmenopausal women was related to an increase in body weight despite controlling for initial body weight, reported physical activity and use of HRT. Therefore, preventing weight gain by dietary means and exercise is of great importance at menopausal age.

Interaction of nutritional calcium and HRT in prevention of postmenopausal bone loss: a prospective study

The aim of this study was to investigate the interactive effects between nutritional calcium (Ca) intake and hormone replacement therapy (HRT) on bone loss. The study population, 937 peri- and postmenopausal women, was selected from a random sample (n = 2025) of the OSTPRE-study cohort (n = 13,100) in Kuopio, Finland. Of them, 545 women had never used HRT and 392 women reported its use during the follow-up period of 6 years. Women were divided in groups according to self-reported daily nutritional Ca intake (mg/day): <648 (1st), 648-927 (2nd), >927 (3rd). Bone mineral density of the lumbar spine and femoral neck was measured with dual X-ray absorptiometry at baseline in 1989-91 and at the 5-year follow-up in 1994-97. According to analysis of variance, there were no statistically significant differences in annual bone loss rate between Ca intake tertiles in HRT never users. In HRT users the annual bone loss at the femoral neck was significantly lower in the third tertile than in the second and first tertiles. In a linear regression model, Ca intake prevented femoral bone loss in HRT users (P < 0.001) but contrast had no effect in never users. At lumbar spine, the corresponding Ca effect was weak (P = 0.063). Adjustment for potentially modifying parameters did not change these effects. In addition, HRT prevented femoral bone loss only among women with the highest Ca intake. At the lumbar spine, the difference between HRT users/non-users was significant in all tertiles but was greater in the second and third tertiles than in the first. In conclusion, nutritional Ca intake may protect HRT users from bone loss and vice versa, low nutritional calcium intake may be a risk factor for non-response to HRT.

Self-reported happiness in life and suicide in ensuing 20 years

OBJECTIVE

The aim of this study was to investigate the relationship between self-reported unhappiness and suicide.

METHODS

A sample of adult Finns unselected for health status (N = 29,067) responded to a question on happiness in life with five alternatives: very happy (15.9 %), fairly happy (63.4 %), cannot say (12.9 %), fairly unhappy (6.9 %), very unhappy (1 %). Cox regression was used to study the suicide risk.

RESULTS

From 1976 to 1995, 182 suicides occurred. At baseline, unhappiness was associated with older age, male gender, sickness, living alone, smoking, heavy alcohol consumption, physical inactivity and belonging to intermediate social class. The risk of suicide increased with decreasing happiness. The very unhappy compared with the very happy had an age-adjusted hazard ratio (HR) of 10.84 (95 % CI 3.93-29.94) for suicide. After adjusting for the above-mentioned factors this HR was 7.01 (95% CI 2.44-20.08).

CONCLUSION

Self-reported unhappiness is strongly associated with subsequent suicide in a long follow-up. Moreover, it seems to indicate also cumulative health hazards.

Risk factors associated with peri- and postmenopausal bone loss: does HRT prevent weight loss-related bone loss?

In the present study we evaluated the risk factors associated with peri- and postmenopausal bone loss and the effect of hormone replacement therapy (HRT) on weight-loss-related bone loss. The study population, 940 peri- and postmenopausal women, was selected from a random sample (n = 2025) of the OSTPRE study cohort (n = 13 100) in Kuopio, Finland. Bone mineral density (BMD; g/cm(2)) at the lumbar spine and femoral neck, and body weight, were measured at baseline in 1989-91 and at 5-year follow-up in 1994-97 by trained personnel. Five hundred and forty-seven women had never used HRT and 393 women used part-time or continuous HRT during follow-up of 3.8-7.9 years (mean 5.8 years). Similarly, of the 172 weight losers, 97 had never used HRT while 75 used it during follow-up. According to multiple regression analysis on the total study population (n = 940), HRT use, years since menopause and weight increase significantly predicted lower annual bone loss at both the lumbar spine and femoral neck (p < 0.005). Low baseline weight and higher age predicted higher bone loss only at the lumbar spine (p < 0.001) and high grip strength predicted lower bone loss only at the femoral neck (p = 0.021). In a sub-analysis on weight losers, weight loss predicted greater bone loss in HRT non-users (p < 0.05), whereas this was not observed in HRT users. These results remained similar after adjustment for age, weight, height, calcium intake, duration of menopause, baseline BMD and bone-affecting diseases/medication. In conclusion, the transition to menopause, HRT and weight change are the most important determinants of bone loss at both the lumbar spine and femoral neck. Furthermore, HRT seems to be effective in prevention of weight loss related bone loss.

Relation of statin use and bone loss: a prospective population-based cohort study in early postmenopausal women

Recent experimental and epidemiologic studies have suggested that the lipid-lowering drugs, statins, may have bone-protective effects. We studied the effects of statin use on the change in bone mineral density (BMD) in a prospective 4.5-year cohort study based on subjects from the Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE) Study, Finland. Six hundred and twenty women aged 53-64 years were divided into four groups: 55 women reported continuous and 63 women occasional statin use during the follow-up; 142 non-users of statins reported hypercholesterolemia whereas 360 non-users did not. Spinal and femoral BMDs were measured by dual-energy X-ray densitometry in 1995-1996 and 1999-2000 and the BMD changes of the four groups were compared. Characteristics of the study population were obtained with postal inquiries. The mean annual spinal and femoral BMD changes of the study groups were 0.29% and -0.50% for the continuous statin users, 0.19% and -0.57% for the occasional statin users, 0.52% and -0.29% for the hypercholesterolemic non-users of statins, and 0.39% and -0.33% for the non-users of statins without hypercholesterolemia, ( p = 0.398 and p = 0.404) respectively. The corresponding BMD changes adjusted for age, years since menopause, body mass index, BMD at baseline, calcium intake, estrogen and cortisone therapy, duration of follow-up and statin use before the baseline were -0.20% and -0.47%, 0.19% and -0.54%, 0.54% and -0.32%, 0.47% and -0.33% ( p = 0.134 and p = 0.628), respectively. Our results suggest that statins do not protect from early postmenopausal bone loss. Randomized trials are needed to confirm these results.

Life dissatisfaction as a predictor of fatal injury in a 20-year follow-up

OBJECTIVE

To investigate the role of life satisfaction (LS) in fatal injuries with special references to unintentional injuries and whether health status modifies this relationship.

METHOD

A sample of adult Finns unselected for health status (n=29 173) responded in 1975 to a LS scale. Nationwide registry for deaths was used. The dissatisfied were compared with the satisfied by Cox regression.

RESULTS

During 1976-1995, 469 fatal injuries occurred, of which 235 were unintentional. Dissatisfaction predicted fatal unintentional [hazard ratio (HR)=2.83; 95% confidence interval (CI) 1.77-4.51] and intentional injury (HR=3.26; 2.01-5.30). The risk of fatal unintentional injury was 7.8-fold (women) and 4.0-fold (men) increased in the sick and dissatisfied compared with the healthy and satisfied. A repeatedly reported dissatisfaction (1975, 1981) provided a HR of 5.17 (1.48-18.0) for unintentional injury death during 1981-1995. The found effect was partly mediated through health behavior and social situation.

CONCLUSION

Life dissatisfaction predicts both unintentional and intentional injury death.

Lifestyle and other factors predict ankle fractures in perimenopausal women: a population-based prospective cohort study

The Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE) study examines the risk factors for fractures and low bone density in middle-aged women. In the present study we investigated lifestyle and other risk factors for ankle fracture. The study population consisted of 11,798 women, aged 47-56 years at baseline. During the 5 year follow-up, these women sustained 194 validated malleolar fractures, giving an incidence of 3.4 fractures/1000 person-years. Four independent predictors for malleolar fracture were detected: smoking; multipharmacy; fracture history; and overweight status. The hazard ratio (HR) for positive fracture history was 1.63 (p = 0.005). In women with a body mass index (BMI) of 25-30 kg/m(2) vs. those with a BMI <25 kg/m(2), HR was 1.69 (p = 0.003). Those who used three or more prescribed drugs had an HR of 2.03 (p = 0.0003) vs. those who used no drugs. Smoking had a dose-response effect, with HRs of 1.73 (p = 0.016) in those smoking 1-19 cigarettes/day, and 2.94 (p = 0.001) in those smoking > or =20 cigarettes/day. Lifestyle factors and fracture history appear to be important predictors of ankle fracture.

Recent decline in heavy outdoor work activity predicts occurrence of fractures among the home-dwelling elderly

The contribution of reduced physical activity of a defined duration to the risk of fall-related fractures and serious soft tissue injuries is not known. We conducted a prospective population-based study among the home-dwelling elderly to examine the association between a recent decline in physical activity and the occurrence of fall-related fractures and soft tissue injuries. The study population consisted of representative sample of home-dwelling older adults who conducted heavy outdoor work activity at least once a week at baseline (n = 284; 136 men, 148 women) and among whom in 93 persons (33%) heavy outdoor work activity was found to have declined during the 2 1/2 years follow-up. Fall-related fractures (n = 24) and serious soft tissue injuries (n = 49) were recorded from the time of the follow-up examination until the end of a further follow-up period lasting 3 1/2 years on average. A decline in heavy outdoor work activity did not predict the occurrence of soft tissue injuries (Mantel-Cox 0.795, p = 0.373), but a greater proportion of those with a decline (n = 14, 15%) than of others (n = 10, 5%) suffered fractures (Mantel-Cox 10.231, p = 0.001). Other risk factors for fractures were female sex (p = 0.03), slow choice reaction time (p = 0.02) and dependency as regards at least one basic activity of daily living (p = 0.01). According to the Cox proportional hazard model, the adjusted hazard ratio of fracture as regards a decline in heavy outdoor work activity was 2.7 (95% CI 1.14-6.62). A recent decline in heavy outdoor work activity predicts the occurrence of fractures, but not the occurrence of serious soft tissue injuries. Early recognition of a decline in physical activity may help in prevention of fractures among the elderly.

Leisure-time physical activity and rate of bone loss among peri- and postmenopausal women: a longitudinal study

We examined the association between continuous leisure-time physical activity and the change in bone mineral density (BMD) and bone mineral content (BMC) in a population-based random sample of 1873 peri- and postmenopausal women. Leisure-time physical activities were registered with self-administered questionnaires in 1989 and 1994, and with an assisted questionnaire in 1995-1997. BMD and BMC were measured from lumbar vertebrae L2-4 and left femoral neck using dual-energy X-ray absorptiometry (DXA) in 1989-1991 and 1994-1997. During the average 5.6 year follow-up, annual loss of lumbar BMC was 124 mg (311 vs. 435 mg, p = 0.036) and annual loss of lumbar BMD was 1.22 mg/cm(2) (4.15 vs. 5.37 mg/cm(2), p = 0.21) smaller among women with regular (at least 1 h each week) weight-bearing leisure-time exercise compared with sedentary women. The advantage was even larger in women with walking or jogging as their only regular weight-bearing leisure-time exercise; that is, their annual loss of lumbar BMC was 180 mg (272 vs. 452 mg, p = 0.022), and annual loss of lumbar BMD was 2.78 mg/cm(2) (2.96 vs. 5.74 mg/cm(2), p = 0.029) smaller than in sedentary women. Continuous leisure-time physical activity did not have any association with loss of BMC or BMD in the femoral neck Physical activity during 12 months before the last bone densitometry was not associated with loss of BMC or BMD at any site. Our results suggest that regular weight-bearing exercise diminishes lumbar bone loss, but might be ineffective in the prevention of femoral osteoporosis among peri- and early postmenopausal women.

Life satisfaction and suicide: a 20-year follow-up study

OBJECTIVE

The authors investigated whether self-reported life satisfaction predicted suicide over a period of 20 years (1976-1995) in adults unselected for mental health status.

METHOD

A nationwide sample of adults aged 18-64 years (N=29,173) from the Finnish Twin Cohort responded to a health questionnaire that included a life satisfaction scale (score range=4-20, with higher scores indicating greater dissatisfaction) that covered four items: interest in life, happiness, general ease of living, and feeling of loneliness. "Dissatisfied" subjects (life satisfaction score=12-20) were compared to "satisfied" subjects (score=4-6). Mortality data were derived from the national registry and analyzed with Cox regression.

RESULTS

Dissatisfaction at baseline (life satisfaction score=12-20) was associated with a higher risk of suicide throughout the 20-year follow-up period (age-adjusted hazard ratio=3.02, 95% confidence interval [CI]=1.83-4.98). The association was somewhat stronger in the first decade (hazard ratio=4.46, 95% CI=1.95-10.20) than in the second (hazard ratio=2.34, 95% CI=1.24-4.45). A dose-response relationship was also found. Men with the highest degrees of dissatisfaction (life satisfaction score=19-20) were 24.85 times as prone to commit suicide as satisfied men during the first 10 years of the follow-up period. Throughout the entire follow-up, life dissatisfaction still predicted suicide after adjusting for age, sex, baseline health status, alcohol consumption, smoking status, and physical activity (hazard ratio=1.74, 95% CI=1.02-2.97). Subjects who reported dissatisfaction at baseline and again 6 years later showed a high suicide risk (hazard ratio=6.84, 95% CI=1.99-23.50) compared to those who repeatedly reported satisfaction.

CONCLUSIONS

Life dissatisfaction has a long-term effect on the risk of suicide, and this seems to be partly mediated through poor health behavior. Life satisfaction seems to be a composite health indicator.

Self-reported life satisfaction and recovery from depression in a 1-year prospective study

OBJECTIVE

To study the relationship of a self-rated four-item life satisfaction scale (LS) to the self-rated 21-item Beck Depression Inventory (BDI) and the 17-item Hamilton Rating Scale for Depression (HAMD) and to study LS changes during recovery from depression.

METHOD

A 1-year prospective study on 188 depressive patients receiving standard psychiatric outpatient treatment; 137 of the patients had major depression.

RESULTS

LS correlated strongly with BDI and HAMD. It explained 46.6%) of the variation in BDI at baseline and 66.2% at 12 months. LS improved substantially during recovery. The main recovery occurred during the first 6 months, the change in the LS score explaining 46.5% of the change in the BDI score (P < 0.001).

CONCLUSION

Life satisfaction is strongly affected in depression, but it improves concurrently with recovery from depression. LS scale may prove useful in screening for those whose subjective wellbeing deserves attention and in assessing alleviation from depression.

The protective effect of hormone-replacement therapy on fracture risk is modulated by estrogen receptor alpha genotype in early postmenopausal women

Genetic factors regulate bone mineral density (BMD) and possibly development of osteoporosis. It has been suggested that estrogen receptor alpha (ERalpha) genotype is associated with BMD, but the association between ERalpha genotype, fracture risk, and postmenopausal hormone replacement therapy (HRT) has not been studied. Therefore, we evaluated whether ERalpha polymorphism is associated with fracture risk in a 5-year trial with HRT in a population-based, randomized group of 331 early postmenopausal women. The participants consisted of two treatment groups: the HRT group (n = 151) received a sequential combination of 2 mg of estradiol valerate (E2Val) and 1 mg of cyproterone acetate with or without vitamin D3, 100-300 IU + 93 mg calcium as lactate per day; and the non-HRT group (n = 180) received 93 mg of calcium alone or in combination with vitamin D3, 100-300 IU/day. All new symptomatic, radiographically defined fractures were recorded. Pvu II restriction fragment length polymorphism of the ERalpha was determined using polymerase chain reaction (PCR). In all, 28 women sustained 33 fractures during the approximately 5.1-year follow-up. In the HRT group, the ERalpha genotype (PP, Pp, and pp) was not significantly associated with fracture risk (p = 0.138; Cox proportional hazards model). When the genotype was dichotomized (PP + Pp vs. pp), the incidence of new fractures in the HRT group was significantly reduced in women with the P allele (p = 0.046) with the relative risk (HR) of 0.25 (95% CI, 0.07-0.98), in comparison with the non-P allele group. After adjustment for time since menopause and previous fracture, the association between the dichotomous genotype and fracture risk persisted with HR of 0.24 (95% CI, 0.06-0.95;p = 0.042). In the non-HRT group, the ERalpha genotype was not significantly associated with fracture risk. During HRT, women with the pp genotype have a greater fracture risk than those with the P allele. The results suggest that the pp genotype is a relatively hormone-insensitive genotype, and it appears that women with the P allele may benefit more from the protective effect of HRT on fracture risk than women with the pp genotype.

Self-reported life satisfaction and 20-year mortality in healthy Finnish adults

The authors investigated the role of self-reported life satisfaction in mortality with a prospective cohort study (1976-1995). A nationwide sample of healthy adults (18-64 years, n = 22,461) from the Finnish Twin Cohort responded to a questionnaire about life satisfaction and known predictors of mortality in 1975. A summary score for life satisfaction (LS), defined as interest in life, happiness, loneliness, and general ease of living (scale range, 4-20), was determined and used as a three-category variable: the satisfied (LS, 4-6) (21%), the intermediate group (LS, 7-11) (65%), and the dissatisfied (LS, 12-20) (14%). Mortality data were analyzed with Cox regression. Dissatisfaction was linearly associated with increased mortality. The age-adjusted hazard ratios of all-cause, disease, or injury mortality among dissatisfied versus satisfied men were 2.11 (95% confidence interval (CI): 1.68, 2.64), 1.83 (95% CI: 1.40, 2.39), and 3.01 (95% CI: 1.94, 4.69), respectively. Adjusting for marital status, social class, smoking, alcohol use, and physical activity diminished these risks to 1.49 (95% CI: 1.16, 1.92), 1.35 (95% CI: 1.01, 1.82), and 1.93 (95% CI: 1.19, 3.12), respectively. Dissatisfaction was associated with increased disease mortality, particularly in men with heavy alcohol use (hazard ratio = 3.76, 95% CI: 1.61, 8.80). Women did not show similar associations between life satisfaction and mortality. Life dissatisfaction may predict mortality and serve as a general health risk indicator. This effect seems to be partially mediated through adverse health behavior.

Visually significant cystoid macular edema in pseudophakic and aphakic patients with glaucoma receiving latanoprost

PURPOSE

To investigate the incidence of visually significant cystoid macular edema associated with the use of latanoprost in patients with glaucoma after cataract surgery.

PATIENTS AND METHODS

This is a multicenter, retrospective study of 185 patients, of whom 173 were pseudophakic (212 eyes) and 12 were aphakic (13 eyes), who were treated for glaucoma with latanoprost 0.005%. The posterior lens capsule was intact in 125 eyes, open or absent as a result of surgery in 25 eyes, and status-post-yttrium-aluminum-garnet capsulotomy in 75 eyes. Visual acuity was documented before and after initiating latanoprost therapy, and patients with a reduction of two or more lines on the Snellen chart were examined by fluorescein angiography for cystoid macular edema.

RESULTS

Visual reduction was documented in four (2.16%) patients. Three of the four patients had cystoid macular edema, and the fourth was thought to have lost a central island of vision from glaucoma. The three patients with cystoid macular edema all had ruptured posterior capsules, requiring anterior vitrectomy, and one had a previous episode of cystoid macular edema 3 years before starting latanoprost therapy.

CONCLUSION

These findings suggest that visually significant cystoid macular edema associated with latanoprost therapy in pseudophakic or aphakic patients is uncommon. If there is a cause-and-effect relationship between latanoprost therapy and clinically significant cystoid macular edema, the incidence appears to be low.

Early postmenopausal bone loss is associated with PvuII estrogen receptor gene polymorphism in Finnish women: effect of hormone replacement therapy

Genetic factors regulate bone mineral density (BMD) and possibly the development of osteoporosis. An association between estrogen receptor (ER) polymorphism, BMD, and postmenopausal hormone replacement therapy (HRT) has not been established. Therefore, we studied the influence of the ER genotype on BMD before and after a 5-year HRT in a placebo-controlled, population-based, randomized group of 322 early postmenopausal women. The participants were randomized into two treatment groups: the HRT group (n = 145) received a sequential combination of 2 mg estradiol valerate and 1 mg CPA with or without vitamin D3, 100-300 IU + 500 mg calcium lactate/day (equal to 93 mg Ca2+), and the non-HRT group (n = 177) received calcium lactate, 500 mg alone or in combination with vitamin D3, 100-300 IU/day. PvuII restriction fragment length polymorphism (RFLP) of the ERalpha was determined using polymerase chain reaction (PCR). BMDs of the lumbar spine (L2-4) and proximal femur were measured by using dual-energy X-ray absorptiometry (DXA). At the baseline, there were no significant differences in the lumbar or femoral neck BMDs between the three ER PvuII genotype groups (PP, Pp, pp). After 5 years, the BMD of the femoral neck remained unaltered and that of the lumbar spine increased by 1.7% in the HRT group, whereas both BMDs were decreased by 4-5% in the non-HRT group. The ER genotype did not modulate the femoral neck BMD change during the follow-up. In contrast, in the non-HRT-group the lumbar spine BMD decreased more in subjects with the ER genotypes PP (6.4%) and Pp (5.2%) than in subjects with the pp genotype (2.9%) (p = 0.002). In the HRT group, the relative changes of the lumbar spine BMD were similar in all three ER genotype groups. Thus without HRT, the pp genotype was associated with a smaller decrease in the lumbar spine BMD than the Pp and PP genotypes. Long-term HRT seemed to eliminate the ER genotype-related differences in the BMD. We conclude that subjects with the ER PvuII genotypes PP and Pp may have a greater risk of relatively fast bone loss after menopause than those with the pp genotype and that they may preferentially derive benefit from HRT.

Does apolipoprotein E genotype relate to BMD and bone markers in postmenopausal women?

OBJECTIVES

Bone mineral density (BMD) and development of osteoporosis are partly determined by genetic factors. The associations between one of suggested candidate, apolipoprotein E (apo E) genotype to bone mineral density (BMD) and bone biochemical markers was studied in 464 subjects recruited from a population-based group of early postmenopausal women (n = 13100). Additionally, the influence of apo E genotype on BMD changes during a 5-year follow-up with or without hormone replacement therapy (HRT) was investigated.

METHODS

Participants were randomized into two treatment groups: HRT group: Sequential combination of 2 mg estradiol valerate and 1 mg cyproterone acetate with or without vitamin D3, 100-300 IU/day + calcium lactate, 500 mg/day (n = 232), and the non-HRT group: Calcium lactate, 500 mg/day alone or in combination with vitamin D3, 100-300 IU/day (n = 232). BMD was measured from the lumbar spine and proximal femur at baseline and after 5 years of treatment (n = 352). In a subgroup (n = 59), the serum concentrations of bone biochemical markers (intact osteocalcin (OC), bone-specific alkaline phosphatase (BAP) and type I collagen carboxy-terminal telopeptide (ICTP)) were measured at baseline and after 1 year of follow-up.

RESULTS

At baseline, the BMDs were similar between the five apo E genotype groups (2/3, 2/4, 3/3, 3/4, 4/4). No significant differences in lumbar or femoral neck BMDs of women with the apo E4 allele were found compared with those without it. There was a statistically significant difference in 5-year BMD changes between the HRT and non-HRT groups. After 5 years, the BMD of the femoral neck had remained constant and the mean lumbar spine BMD had increased by 1.5% in the HRT group, whereas both BMDs had decreased by 4-5% in the non-HRT group. However, the apo E genotype did not modify the changes in BMD in either group. Additionally, the baseline concentrations of bone metabolic markers and their 1-year changes showed no genotype-related associations.

CONCLUSIONS

The results of our population-based study indicate that apo E genotype does not modify lumbar or femoral neck BMDs or serum bone biochemical markers or their response to HRT in early postmenopausal Caucasian women.

Risk factors for perimenopausal fractures: a prospective study

This prospective study was aimed at determining the risk factors for the development of fractures in perimenopausal women. The study group (n = 3068) was comprised of a stratified population sample of women aged between 47 and 56 years. During the follow-up period of 3.6 years, 257 (8.4%) of the women sustained a total of 295 fractures. After adjustment for covariates, the relative risk (RR) of sustaining a fracture was found to be 1.4 [95% confidence interval (CI) 1.2-1.6] for a 1 standard deviation (SD) decrease in the spinal and femoral neck bone mineral density (BMD). Women with a previous fracture history were found to have an increased risk of fracture [RR 1.7 (95% CI 1.3-2.2)] and those reporting three or more chronic illnesses exhibited a RR of 1.4 (95% CI 1.0-1.9). Women not using hormone replacement therapy (HRT) had a RR of 1.5 (95% CI 1.1-2.2) for all fracture types. When osteoporotic fractures (vertebral, hip, proximal humerus and wrist fractures; n = 98) were used as an endpoint, the independent risk factors were found to be a low BMD (RR for a 1 SD decrease in both spinal and femoral neck BMD was 1.6, 95% CI 1.3-2.0), a previous fracture history (RR 1.9, 95% CI 1.3-2.9) and nonuse of HRT (RR 2.2, 95% CI 1.3-4.0). The independent risk factors for all other fractures (n = 158) were a low BMD (RR for a 1 SD decrease in the spinal BMD was 1.4, 95% CI 1.2-1.6 and in the femoral neck BMD was 1.3, 95% CI 1.1-1.5), a previous fracture history (RR 1.6, 95% CI 1.1-2.2), smoking (RR 1.8, 95% CI 1.1-2.7) and having had three or more chronic illnesses (RR 1.6, 95% CI 1.1-2.2). Weight, height, age, menopausal status, maternal hip fracture, use of alcohol, coffee consumption or dietary calcium intake were not independently associated with the development of any particular type of fracture. We conclude that the independent risk factors for perimenopausal fractures are a low bone density, previous fracture history, nonuse of HRT, having had three or more chronic illnesses and smoking, the gradient of risk being similar for spinal and femoral neck BMD measurements in the perimenopausal population. The risk factors are slightly different for perimenopausal osteoporotic than for other types of fractures.

Identification of early postmenopausal women with no bone response to HRT: results of a five-year clinical trial

Hormone replacement therapy (HRT) prevents postmenopausal bone loss and fractures. However, the occurrence of women with no bone response to HRT has not been widely examined. We identified the densitometric nonresponders to long-term HRT and investigated some characteristics and biochemical variables as possible predictors of densitometric nonresponse in postmenopausal women. The study population was a subsample of the Kuopio Osteoporosis Study (n = 14,220). A total of 464 early postmenopausal women were randomized into four treatment groups: (1) HRT (sequential combination of 2 mg estradiol valerate and 1 mg cyproterone acetate); (2) vitamin D3; (3) HRT + Vitamin D3 combined; and (4) placebo. In this study, the data from HRT and placebo groups were analyzed. Lumbar (L2-4) and femoral neck bone mineral density (BMD) were determined by dual-energy X-ray absorptiometry (DXA) at baseline and after 5 years of treatment. A densitometric nonresponder was defined as a woman whose 5-year BMD change was similar to the mean BMD change (+95% CI) of the placebo group or worse. Altogether, 74 women in the HRT group and 104 women in the placebo group complied with the treatment. According to spinal BMD analysis, 11% of the women were classified as densitometric nonresponders; the corresponding proportion for femoral BMD analysis was 26%. Both smoking (p = 0.003) and low body weight (p = 0.028) were significant risk factors for densitometric nonresponse to HRT. After 6 months of treatment the densitometric nonresponders (hip) had a significantly higher mean serum follicle stimulating hormone (FSH) level (p = 0.038) and lower increases in serum estradiol levels (p = 0.006) than the densitometric responders. The mean changes in serum FSH and alkaline phosphatase levels were significantly lower among the densitometric nonresponders (spine) than responders (p = 0.043 and 0.017, respectively). In conclusion, this prospective study shows that especially current smokers and women with low body weight are at increased risk of poor bone response to HRT. Repeated serum FSH, estradiol and alkaline phosphatase measurements during the first months of long-term HRT may be helpful in identifying the women with no bone response to HRT.

Fracture risk associated with a fall according to type of fall among the elderly

The kinetic energy and direction of a fall contribute to the occurrence of fracture. However, the fracture risk associated with different types of fall, different amounts of energy and different landing directions is poorly understood. We recorded all falls and fall-related fractures over 7 years in an aged semi-rural home-dwelling population (n = 980), using intensive fall recording. The falls were classified according to type and place of occurrence into slip falls (SLFs), trip falls (TRFs), other extrinsic falls on the level (OEFs), intrinsic falls on the level (IFs), stair falls (STFs), falls from an upper level (ULFs) and nondefined falls (NDFs) occurring indoors or outdoors. Incidences of falls and fractures were calculated for the whole follow-up period. The population was clinically examined to assess general risk factors of fracture, after which the risk of fracture was determined in the first fall according to the different fall types. Comparison was made with intrinsic falling on the level. The overall incidences of indoor and outdoor falls were 328 (95% CI 314-345) and 198 (186 210) per 1000 person-years (PY), respectively, and those of fractures 23 (19-27) and 11 (8-4) per 1000 PY, respectively. Indoor SLFs, TRFs, OEFs, IFs, STFs, ULFs and NDFs occurred relatively evenly throughout the study period. The crude and adjusted relative fracture risks were greater in SLFs, OEFs and STFs compared with IFs. Indoor falls and fractures are more common than those occurring outdoors in aged home-dwelling persons. The kinetic energies produced in SLFs, OEFs and STFs may be higher than those generated in IFs, leading to increased risk of fracture.

Validity of self-reports of fractures in perimenopausal women

The validity of self-report of fractures in postal inquiry among perimenopausal women was evaluated. Self-reports of fractures in the 1989 baseline postal inquiry data of the Kuopio Osteoporosis Risk Factor and Prevention Study (OSTPRE) were compared with information in patient records. The study population consisted of 373 women who reported fractures sustained during the last 10 years and 200 randomly selected women who did not report fractures from a population base of 2,007 women aged 47-56 years. Self-report as a screening test for fracture was evaluated in the total sample of 2,007 women by estimating the number of false negative reports in all the women who did not report a fracture with the information on these 200 women. Of the self-reports of fractures, 84% proved to be true fractures, 12% soft tissue injuries, and the rest either self-diagnoses or misnomers. Self-report of wrist fracture was more accurate (95%). The sensitivity of self-report to detect fracture was 78% for all fractures and 95% for wrist fracture, while the respective specificities were 96 and 99%. Self-report is a relatively accurate way to obtain information about past major fractures in perimenopausal women. However, it is rather insensitive in the detection of minor fractures, if the reporting period is several years.

Self-reported life satisfaction and treatment factors in patients with schizophrenia, major depression and anxiety disorder

Our aim was to study the associations between life satisfaction and treatment factors and how depression affects these associations among patients with schizophrenia (n=403), major depression (n=349) and anxiety disorder (n=139) from a defined area. Treatment satisfaction and compliance were high, but life satisfaction was low regardless of diagnostic group. Patients with schizophrenia recorded better life satisfaction than patients with the other disorders. There were few independent associations between life satisfaction and treatment factors. Fortunately, factors amenable to treatment intervention, such as depression, problem-solving ability and social support, were independently related to life satisfaction in every diagnostic group. Depression decreased these associations significantly only in patients with schizophrenia. Life satisfaction and treatment satisfaction should be included as separate variables in treatment outcome studies.

Prevention of femoral and lumbar bone loss with hormone replacement therapy and vitamin D3 in early postmenopausal women: a population-based 5-year randomized trial

The long term effects of hormone replacement therapy (HRT) and vitamin D3 (Vit D) on bone mineral density (BMD) were studied. A total of 464 nonosteoporotic early postmenopausal women from the Kuopio Osteoporosis Study (n = 13100) were randomized to four groups: 1) HRT (sequential combination of 2 mg estradiol valerate and 1 mg cyproterone acetate, 2) Vit D3 (300 and 100 IU/day during the fifth year), 3) HRT and Vit D combined, and 4) placebo. Lumbar (L2-L4) and femoral neck BMD were determined by dual x-ray absorptiometry (DXA) at baseline and after 2.5 and 5 yr of treatment. Intention to treat analysis (n = 464) showed that after 5 yr, lumbar BMD remained unchanged in the HRT and HRT plus Vit D groups [+0.2% (P = 0.658) and +0.9% (P = 0.117), respectively], whereas lumbar BMD decreased by 4.6% in the Vit D group and by 4.5% in the placebo group (P < 0.001 in both). The loss of femoral neck BMD was less in the HRT (-1.4%; P = 0.005) and HRT plus Vit D (-1.3%; P = 0.003) groups than in the Vit D and placebo groups (-4.3%; P < 0.001 in both). Among those 370 women who complied with the 5-yr treatment, the effect was more pronounced: lumbar BMD had increased by 1.5% in the HRT (P = 0.009) and by 1.8% in the HRT plus Vit D group (P = 0.005), with a plateau after 2.5 yr, whereas lumbar BMD had decreased in both the Vit D and placebo groups (4.6% and 4.7%; P < 0.001, respectively). Femoral neck BMD decreased again less in the HRT (-0.4%) and HRT plus Vit D (-0.6%) groups than in the Vit D and placebo groups (-4.4% in both). This study confirms the positive long term effect of HRT on BMD also seen in intention to treat analysis. The data suggest that low dose vitamin D3 supplementation does not prevent bone loss in healthy, nonosteoporotic, early postmenopausal women, and it confers no benefit additional to that of HRT alone.

HRT and Vit D in prevention of non-vertebral fractures in postmenopausal women; a 5 year randomized trial

OBJECTIVES

We investigated the incidence of new non-vertebral fractures during HRT or low-dose vitamin (Vit) D3 supplementation in a 5-year prospective trial.

METHODS

A total of 464 early postmenopausal women, (a subgroup of the Kuopio Osteoporosis Study, n = 13,100) were randomized to four groups: (1) HRT, a sequential combination of 2 mg estradiol valerate and 1 mg cyproterone acetate; (2) Vit D (300 IU/day and 100 IU/day during the fifth years); (3) HRT + Vit D; and (4) placebo. Lumbar (L2-4) and femoral neck bone mineral densities (BMD) were determined by dual X-ray absorptiometry (DXA) at baseline, after 2.5 and 5 years of treatment. All new symptomatic non-vertebral, radiographically defined fractures were recorded.

RESULTS

Altogether, 368 women (79%) completed the 5 year treatment. In all, 32 women had 39 non-vertebral fractures during a mean of 4.3 year follow-up (HRT 4, Vit D 10, HRT + Vit D 8 and placebo 17). The reduction in the incidence of new non-vertebral fractures was significant in women with HRT alone (P = 0.032) when adjusted by baseline BMD and previous fractures; observed also with the intention-to-treat principle (P = 0.048). When the HRT groups were pooled, HRT showed a significantly lower incidence of new non-vertebral fractures (P = 0.042) than women receiving placebo and also after adjusting as above (P = 0.016); both in valid-case and in the intention-to-treat analysis. In the Vit D group, the fracture incidence was non-significantly decreased (P = 0.229) in comparison with the placebo group. The estimated risk of new non-vertebral fractures among women treated with HRT alone was 0.29 (95% CI, 0.10-0.90) and with Vit D 0.47 (95% CI, 0.20-1.14) and with HRT + Vit D 0.44 (95% CI, 0.17-1.15), in comparison with the placebo group (adjusted by femoral BMD and previous fractures).

CONCLUSIONS

This study is the first prospective trial confirming the beneficial effect of HRT on prevention of peripheral fractures in non-osteoporotic postmenopausal women. The effect of low-dose Vit D remains to be proved.

Does vitamin D strengthen the increase in femoral neck BMD in osteoporotic women treated with estrogen?

The long-term effects on bone of estrogen therapy (HRT) combined with vitamin D3 supplementation were evaluated and compared with the effects of HRT without vitamin D3 supplementation in a 4-year prospective, partly randomized study among 60 osteoporotic women (mean age 55.4 years; range 49.7-59.4 years). The women studied were a subgroup of the population-based Kuopio Osteoporosis Risk Factor and Prevention Study (OSTPRE) (n = 13,100). The bone mineral densities (BMD) of the lumbar spine and femoral neck were determined by dual-energy X-ray absorptiometry (DXA) in 3236 perimenopausal women. Those 106 women with baseline BMD more than 2 SDs less than the mean value in this population, either at the lumbar spine (BMD < 0.826 g/cm2) and/or femoral neck (BMD < 0.684 g/cm2), were offered treatment for osteoporosis. After exclusions, 60 women were included in the analyses. Group allocation was: HRT (estradiol valerate (2 mg) plus cyproterone acetage, 1 mg, sequentially: ClimenR) (n = 21); HRT + Vit D: Climen + vitamin D3 (cholecalciferol, 300 IU/day, no intake during June-August) (n = 23); controls: 16 women who refused all treatment served as a non-randomized control group. In the HRT group, the highly significant increase in lumbar BMD was 5.4%, 5.3%, 4.7% and 4.0% after 1, 2, 3 and 4 years of treatment, respectively, all compared with the baseline values and with the control group. The increase in femoral neck BMD was statistically insignificant (1.4%, 2.2%, 1.9% and 2.1%, respectively; p > 0.05). In the HRT + Vit D group, the lumbar BMD increased by 3.7%, 4.9%, 4.9% and 4.9% (p < 0.001), whereas the 5.8% increase in femoral neck BMD reached significance at 4 years (p < 0.01) when compared with the control group as well as with the baseline values. However, there were no statistically significant differences in lumbar or femoral BMD changes between the two HRT groups. In conclusion, estrogen can substantially increase lumbar bone mass in patients with postmenopausal osteoporosis. In addition, the combination of HRT and vitamin D3 may increase femoral neck BMD in osteoporotic women more than estrogen alone.

Relationships between risk factors and fractures differ by type of fracture: a population-based study of 12,192 perimenopausal women

Relationships between selected factors and fractures according to type of fracture were retrospectively examined in 12,192 women aged 47-56 years responding to the baseline postal enquiry of the Kuopio Osteoporosis Study, Finland, in 1989. A total of 1358 women reported fractures sustained during the previous 9.4 years, i.e. at ages 38-57 years. The incidence of fractures per 1000 person-years was 17.2 after menopause and 9.5 before (p < 0.0001). The adjusted fracture risk was elevated in smokers versus non-smokers (OR = 1.5; (95% CI = 1.3-1.9) and in those with chronic health disorders versus the healthy (OR = 1.3; 95% CI 1.1-1.5). Long-term work disability was associated with fractures independently of health disorders (OR = 1.3; 95% CI 1.1-1.6). Anthropometric measures were not associated with the overall fracture risk. Menopause was strongly and linearly related to wrist fracture but not to ankle fracture. A 1 SD increase in body mass index decreased the risk of wrist fracture by 21% (p = 0.0001) but increased that of ankle fracture by 24% (p = 0.002). Smoking was related to ankle fracture (OR = 2.2; 95% CI 1.6-3.2) but not to wrist fracture (OR = 0.9; 95% CI 0.6-1.4). Health disorders were more markedly associated with fractures other than those of the wrist or ankle. Relationships between several risk factors and pre- and perimenopausal fractures vary by type of fracture. This may affect, for example, the comparability of studies with varying fracture profiles.

Lactose intolerance associated with fractures of weight-bearing bones in Finnish women aged 38-57 years

Lactose intolerance (LI) often results in decreased calcium intake. To test if long-term low intake of calcium affects bone strength, we examined fracture risks related to LI in women aged 38-57 years. The 11,619 Finnish women aged 47-56 years who responded to the baseline postal inquiry of the Kuopio Osteoporosis Risk Factor and Prevention Study in 1989 formed the study population. In all, 896 women reported LI and 1299 women reported a fracture in 1980-1989. Current intake of dairy calcium was lower in women with LI (570 mg/d) than in the other women (850 mg/d) (p < 0.0001). The fracture risk in general was slightly elevated in women with LI compared with the other women, with an odds ratio (OR) (95% CI) of 1.33 (1.09-1.62). However, the fractures at the three most common sites (wrist, ankle, and rib) were not related to LI. In contrast, fractures at the tibia and metatarsal were strongly related to LI with ORs of 3.31 (1.51-7.24) and 2.84 (1.47-5.50), respectively. The adjusted OR for nonankle lower body fractures combined was 2.15 (1.53-3.04), whereas that for all upper body fractures combined was 1.15 (0.88-1.54). The 10 women with LI and a tibial or metatarsal fracture showed a 19% lower femoral BMD than all the other women in the densitometry subsample of 3222 women (p < 0.001). Long-term premenopausal calcium deficiency differentially affects bones with weight-bearing nonankle bones being at the greatest risk of suffering reduced strength.

Physical activity in adolescence and bone density in peri- and postmenopausal women: a population-based study

The association between sports participation during adolescence and peri- and postmenopausal bone mineral density (BMD) was examined among 2025 women aged 48-58 years. Adolescent recreational and competitive sporting activities were registered with a self-administered questionnaire. Altogether, 881 (43.5%) women stated that they had taken part in sports during their adolescence. BMD was measured using dual X-ray absorptiometry (DXA) in lumbar vertebrae 2-4 and the left femoral neck. The unadjusted BMD was 2.4% higher (p = 0.001) and the adjusted BMD was 1.4% higher in the spine (p = 0.015 after adjusting for age, weight, time from menopause to densitometry, and duration of estrogen replacement therapy) among women who had taken part in sports during their adolescence compared to women who had been inactive. There was no significant difference in femoral neck BMD between these groups. The results of this population-based study suggest that intense recreational physical activity in adolescence could play some role in preventing axial osteoporosis in later life.