Sex- and age-specific associations between income and incident major osteoporotic fractures in Canadian men and women: a population-based analysis

Osteoporosis incidence and its associated factors in the older Korean population: findings from a population-based cohort study

In South Korea, osteoporosis incidence among the elderly was unclear. Our study revealed an incidence of 18.4 per 1000 person-years, with higher rates in females and those with lower education. The findings indicate a need for targeted prevention strategies to guide health policy for improved osteoporosis care for the elderly.

BACKGROUND

Although osteoporosis significantly affects morbidity and mortality among the older population in South Korea, the incidence of osteoporosis and its associated factors within this demographic group remains unclear.

METHOD

We analyzed data from the Korean National Health Panel Survey, a nationally representative, population-based panel survey covering 2008 to 2018, to compute the incidence of osteoporosis among South Koreans aged 50 and older. Using the stepwise Cox Proportional Hazard model, we then identified and determined the associated factors of osteoporosis.

RESULT

Out of the 7304 study participants in our analysis, we identified 792 osteoporosis events, resulting in an overall cumulative incidence rate of 18.4 per 1000 person-years. The incidence of osteoporosis increased steadily with age and was higher among those with lower levels of education. We also found that female study participants were at a statistically significant 7.2-fold higher risk (aHR = 7.2, 95% CI = 5.8-8.8) of developing osteoporosis compared to males. At the same time, those with hyperlipidemia had a statistically significant 1.3-fold increased risk (aHR = 1.3, 95% CI = 1.1-1.4) of developing osteoporosis.

CONCLUSION

Our study highlights a significant proportion of the older South Korean population developed osteoporosis, especially among those who are older, females, and who have hyperlipidemia. This indicates the pressing need for the government's and healthcare systems' consideration of osteoporosis diagnosis and prevention strategies to ensure the health and well-being of the older South Korean population.

AI-based opportunistic quantitative image analysis of lung cancer screening CTs to reduce disparities in osteoporosis screening

Osteoporosis is underdiagnosed, especially in ethnic and racial minorities who are thought to be protected against bone loss, but often have worse outcomes after an osteoporotic fracture. We aimed to determine the prevalence of osteoporosis by opportunistic CT in patients who underwent lung cancer screening (LCS) using non-contrast CT in the Northeastern United States. Demographics including race and ethnicity were retrieved. We assessed trabecular bone and body composition using a fully-automated artificial intelligence algorithm. ROIs were placed at T12 vertebral body for attenuation measurements in Hounsfield Units (HU). Two validated thresholds were used to diagnose osteoporosis: high-sensitivity threshold (115-165 HU) and high specificity threshold (<115 HU). We performed descriptive statistics and ANOVA to compare differences across sex, race, ethnicity, and income class according to neighborhoods' mean household incomes. Forward stepwise regression modeling was used to determine body composition predictors of trabecular attenuation. We included 3708 patients (mean age 64 ± 7 years, 54 % males) who underwent LCS, had available demographic information and an evaluable CT for trabecular attenuation analysis. Using the high sensitivity threshold, osteoporosis was more prevalent in females (74 % vs. 65 % in males, p < 0.0001) and Whites (72 % vs 49 % non-Whites, p < 0.0001). However, osteoporosis was present across all races (38 % Black, 55 % Asian, 56 % Hispanic) and affected all income classes (69 %, 69 %, and 91 % in low, medium, and high-income class, respectively). High visceral/subcutaneous fat-ratio, aortic calcification, and hepatic steatosis were associated with low trabecular attenuation (p < 0.01), whereas muscle mass was positively associated with trabecular attenuation (p < 0.01). In conclusion, osteoporosis is prevalent across all races, income classes and both sexes in patients undergoing LCS. Opportunistic CT using a fully-automated algorithm and uniform imaging protocol is able to detect osteoporosis and body composition without additional testing or radiation. Early identification of patients traditionally thought to be at low risk for bone loss will allow for initiating appropriate treatment to prevent future fragility fractures. CLINICALTRIALS.GOV IDENTIFIER: N/A.

Association between socioeconomic deprivation and bone health status in the UK biobank cohort participants

The effect of deprivation on total bone health status has not been well defined. We examined the relationship between socioeconomic deprivation and poor bone health and falls and we found a significant association. The finding could be beneficial for current public health strategies to minimise disparities in bone health.

PURPOSE

Socioeconomic deprivation is associated with many illnesses including increased fracture incidence in older people. However, the effect of deprivation on total bone health status has not been well defined. To examine the relationship between socioeconomic deprivation and poor bone health and falls, we conducted a cross-sectional study using baseline measures from the United Kingdom (UK) Biobank cohort comprising 502,682 participants aged 40-69 years at recruitment during 2006-2010.

METHOD

We examined four outcomes: 1) low bone mineral density/osteopenia, 2) fall in last year, 3) fracture in the last five years, and 4) fracture from a simple fall in the last five years. To measure socioeconomic deprivation, we used the Townsend index of the participant's residential postcode.

RESULTS

At baseline, 29% of participants had low bone density (T-score of heel < -1 standard deviation), 20% reported a fall in the previous year, and 10% reported a fracture in the previous five years. Among participants experiencing a fracture, 60% reported the cause as a simple fall. In the multivariable logistic regression model after controlling for other covariates, the odds of a fall, fracture in the last five years, fractures from simple fall, and osteopenia were respectively 1.46 times (95% confidence interval [CI] 1.42-1.49), 1.26 times (95% CI 1.22-1.30), 1.31 times (95% CI 1.26-1.36) and 1.16 times (95% CI 1.13-1.19) higher for the most deprived compared with the least deprived quantile.

CONCLUSION

Socioeconomic deprivation was significantly associated with poor bone health and falls. This research could be beneficial to minimise social disparities in bone health.

Assessment of causal association between the socio-economic status and osteoporosis and fractures: a bidirectional Mendelian randomization study in European population

The correlation between socio-economic status (SES) and bone-related diseases garners increasing attention, prompting a bidirectional Mendelian randomization (MR) analysis in this study. Genetic data on SES indicators (average total household income before tax, years of schooling completed, and Townsend Deprivation Index at recruitment), femoral neck bone mineral density (FN-BMD), heel bone mineral density (eBMD), osteoporosis, and five different sites of fractures (spine, femur, lower leg-ankle, foot, and wrist-hand fractures) were derived from genome-wide association summary statistics of European ancestry. The inverse variance weighted method was employed to obtain the causal estimates, complemented by alternative MR techniques, including MR-Egger, weighted median, and MR-pleiotropy residual sum and outlier (MR-PRESSO). Furthermore, sensitivity analyses and multivariable MR were performed to enhance the robustness of our findings. Higher educational attainment exhibited associations with increased eBMD (β: .06, 95% confidence interval [CI]: 0.01-0.10, P = 7.24 × 10-3), and reduced risks of osteoporosis (OR: 0.78, 95% CI: 0.65-0.94, P = 8.49 × 10-3), spine fracture (OR: 0.76, 95% CI: 0.66-0.88, P = 2.94 × 10-4), femur fracture (OR: 0.78, 95% CI: 0.67-0.91, P = 1.33 × 10-3), lower leg-ankle fracture (OR: 0.79, 95% CI: 0.70-0.88, P = 2.05 × 10-5), foot fracture (OR: 0.78, 95% CI: 0.66-0.93, P = 5.92 × 10-3), and wrist-hand fracture (OR: 0.83, 95% CI: 0.73-0.95, P = 7.15 × 10-3). Material deprivation appeared to increase the risk of spine fracture (OR: 2.63, 95% CI: 1.43-4.85, P = 1.91 × 10-3). A higher FN-BMD level positively affected increased household income (β: .03, 95% CI: 0.01-0.04, P = 6.78 × 10-3). All these estimates were adjusted for body mass index, type 2 diabetes, smoking initiation, and frequency of alcohol intake. The MR analyses show that higher educational levels is associated with higher eBMD, reduced risk of osteoporosis and fractures, while material deprivation is positively related to spine fracture. Enhanced FN-BMD correlates with increased household income. These findings provide valuable insights for health guideline formulation and policy development.

Socio-economic inequalities in fragility fracture incidence: a systematic review and meta-analysis of 61 observational studies

Individuals with low socio-economic status (SES) have a more than 25% higher risk of fragility fractures than individuals with high SES. Body mass index and lifestyle appear to mediate the effect of SES on fracture risk. Strategies to prevent fractures should aim to reduce unhealthy behaviours through tackling structural inequalities.

INTRODUCTION

This systematic review and meta-analysis aimed to evaluate the impact of socio-economic status (SES) on fragility fracture risk.

METHODS

Medline, Embase, and CINAHL databases were searched from inception to 28 April 2021 for studies reporting an association between SES and fragility fracture risk among individuals aged ≥50 years. Risk ratios (RR) were combined in meta-analyses using random restricted maximum likelihood models, for individual-based (education, income, occupation, cohabitation) and area-based (Index of Multiple Deprivation, area income) SES measures.

RESULTS

A total of 61 studies from 26 different countries including more than 19 million individuals were included. Individual-based low SES was associated with an increased risk of fragility fracture (RR 1.27 [95% CI 1.12, 1.44]), whilst no clear association was seen when area-based measures were used (RR 1.08 [0.91, 1.30]). The strength of associations was influenced by the type and number of covariates included in statistical models: RR 2.69 [1.60, 4.53] for individual-based studies adjusting for age, sex and BMI, compared with RR 1.06 [0.92, 1.22] when also adjusted for health behaviours (smoking, alcohol, and physical activity). Overall, the quality of the evidence was moderate.

CONCLUSION

Our results show that low SES, measured at the individual level, is a risk factor for fragility fracture. Low BMI and unhealthy behaviours are important mediators of the effect of SES on fracture risk. Strategies to prevent fractures and reduce unhealthy behaviours should aim to tackle structural inequalities in society thereby reducing health inequalities in fragility fracture incidence.

Prevalence and diagnosis experience of osteoporosis in postmenopausal women over 50: Focusing on socioeconomic factors

Osteoporosis is the most common disease of the musculoskeletal system in old age. Therefore, research on osteoporosis risk factors is actively being conducted. However, whether socioeconomic inequality is associated with the prevalence and diagnosis experience of osteoporosis remains largely unexplored. This study aims to investigate whether socioeconomic inequality can be a risk factor for osteoporosis in postmenopausal women. Cross-sectional data of 1,477 postmenopausal women aged over 50 obtained from the Korea National Health and Nutrition Examination Survey V-2 were analyzed. Univariate analyses were performed to calculate the prevalence of osteoporosis and the rate of osteoporosis diagnosis experience according to the risk factor categories. Multivariate logistic regression analysis was performed to identify the independent variables' associations with osteoporosis prevalence and diagnosis experience. The prevalence of osteoporosis was 34.8%, while the diagnosis experience rate was 22.1%. The higher the age, the higher the probability of osteoporosis presence and diagnosis experience. The lowest household income level was associated with a 1.63 times higher risk of osteoporosis. On the contrary, this factor was not significant for diagnosis experience. These results were similar for the 50-59 and 60-69 age groups. Among postmenopausal women, those who are older and have low socioeconomic levels are at a high risk of developing osteoporosis. Moreover, the lower the socioeconomic level, the lower the awareness of osteoporosis. Therefore, there is a need to develop more proactive preventive measures in postmenopausal women with low socioeconomic levels.

Fracture risk following high-trauma versus low-trauma fracture: a registry-based cohort study

Prior high-trauma fractures identified through health services data are associated with low bone mineral density (BMD) and future fracture risk to the same extent as fractures without high-trauma.

INTRODUCTION

Some have questioned the usefulness of distinguishing high-trauma fractures from low-trauma fractures. The aim of this study is to compare BMD measurements and risk of subsequent low-trauma fracture in patients with prior high- or low-trauma fractures.

METHODS

Using a clinical BMD registry for the province of Manitoba, Canada, we identified women and men age 40 years or older with fracture records from linked population-based healthcare data. Age- and sex-adjusted BMD Z-scores and covariate-adjusted hazard ratios (HR) with 95% confidence intervals (CI) for incident fracture were studied in relation to prior fracture status, categorized as high-trauma if associated with external injury codes and low-trauma otherwise.

RESULTS

The study population consisted of 64,428 women and men with no prior fracture (mean age 63.7 years), 858 with prior high-trauma fractures (mean age 65.1 years), and 14,758 with prior low-trauma fractures (mean age 67.2 years). Mean Z-scores for those with any prior high-trauma fracture were significantly lower than in those without prior fracture (P < 0.001) and similar to those with prior low-trauma fracture. Median observation time for incident fractures was 8.8 years (total 729,069 person-years). Any prior high-trauma fracture was significantly associated with increased risk for incident major osteoporotic fracture (MOF) (adjusted HR 1.31, 95% CI 1.08-1.59) as was prior low-trauma fracture (adjusted HR 1.55, 95% CI 1.47-1.63), and there was no significant difference between the two groups (prior trauma versus low-trauma fracture P = 0.093). A similar pattern was seen when incident MOF was studied in relation to prior hip fracture or prior MOF, or when the outcome was incident hip fracture or any incident fracture.

CONCLUSIONS

High-trauma and low-trauma fractures showed similar relationships with low BMD and future fracture risk. This supports the inclusion of high-trauma fractures in clinical assessment for underlying osteoporosis and in the evaluation for intervention to reduce future fracture risk.

Is there a social gradient of sarcopenia? A meta-analysis and systematic review protocol

INTRODUCTION

Sarcopenia (or loss of muscle mass and function) is a relatively new area within the field of musculoskeletal research and medicine. Investigating whether there is a social gradient, including occupation type and income level, of sarcopenia, as observed for other diseases, will contribute significantly to the limited evidence base for this disease. This new information may inform the prevention and management of sarcopenia and widen the evidence base to support existing and future health campaigns.

METHODS AND ANALYSIS

We will conduct a systematic search of the databases PubMed, Ovid, CINAHL, Scopus and EMBASE to identify articles that investigate associations between social determinants of health and sarcopenia in adults aged 50 years and older. Eligibility of the selected studies will be determined by two independent reviewers. The methodological quality of eligible studies will be assessed according to predetermined criteria. Established statistical methods to identify and control for heterogeneity will be used, and where appropriate, we will conduct a meta-analysis. In the event that heterogeneity prevents numerical synthesis, a best evidence analysis will be employed. This systematic review protocol adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols reporting guidelines and will be registered with the International Prospective Register of Systematic Reviews (PROSPERO).

ETHICS AND DISSEMINATION

This systematic review will use published data, thus ethical permissions will not be required. In addition to peer-reviewed publication, our results will be presented at (inter)national conferences relevant to the field of sarcopenia, ageing and/or musculoskeletal health and disseminated both electronically and in print.

PROSPERO REGISTRATION NUMBER

CRD42017072253.

The effect of social deprivation on hip fracture incidence in England has not changed over 14 years: an analysis of the English Hospital Episodes Statistics (2001-2015)

Deprivation predicts increased hip fracture risk. Over 14 years, hip fracture incidence increased among men with persisting inequalities. Among women, inequalities in incidence were less pronounced; whilst incidence decreased overall, this improvement was seen marginally less in women from the most deprived areas. Hip fracture prevention programmes have not reduced inequalities.

PURPOSE

Deprivation is associated with increased hip fracture risk. We examined the effect of area-level deprivation on hip fracture incidence in England over 14 years to determine whether inequalities have changed over time.

METHODS

We used English Hospital Episodes Statistics (2001/2002-2014/2015) to identify hip fractures in adults aged 50+ years and mid-year population estimates (2001-2014) from the Office for National Statistics. The Index of Multiple Deprivation measured local area deprivation. We calculated age-adjusted incidence rate ratios (IRR) for hip fracture, stratified by gender and deprivation quintiles.

RESULTS

Over 14 years, we identified 747,369 hospital admissions with an index hip fracture; the number increased from 50,640 in 2001 to 55,092 in 2014; the proportion of men increased from 22.2% to 29.6%. Whereas incidence rates decreased in women (annual reduction 1.1%), they increased in men (annual increase 0.6%) (interaction p < 0.001). Incidence was higher in more deprived areas, particularly among men: IRR most vs. least deprived quintile 1.50 [95% CI 1.48, 1.52] in men, 1.17 [1.16, 1.18] in women. Age-standardised incidence increased for men across all deprivation quintiles from 2001 to 2014. Among women, incidence fell more among those least compared to most deprived (year by deprivation interaction p < 0.001).

CONCLUSIONS

Deprivation is a stronger relative predictor of hip fracture incidence in men than in women. However, given their higher hip fracture incidence, the absolute burden of deprivation on hip fractures is greater in women. Despite public health efforts to prevent hip fractures, the health inequality gap for hip fracture incidence has not narrowed for men, and marginally widened among women.

Risk of Vertebral Fracture in Patients Diagnosed with a Depressive Disorder: A Nationwide Population-Based Cohort Study

OBJECTIVE:

Previous studies have reported that depression may play a crucial role in the occurrence of vertebral fractures. However, a clear correlation between depressive disorders and osteoporotic fractures has not been established. We explored the association between depressive disorders and subsequent new-onset vertebral fractures. Additionally, we aimed to identify the potential risk factors for vertebral fracture in patients with a depressive disorder.

METHODS:

We studied patients listed in the Taiwan National Health Insurance Research Database who were diagnosed with a depressive disorder by a psychiatrist. The comparison cohort consisted of age- and sex-matched patients without a depressive disorder. The incidence rate and hazard ratios of subsequent vertebral fracture were evaluated. We used Cox regression analysis to evaluate the risk of vertebral fracture among patients with a depressive disorder.

RESULTS:

The total number of patients with and without a depressive disorder was 44,812. The incidence risk ratio (IRR) between these 2 cohorts indicated that depressive disorder patients had a higher risk of developing a subsequent vertebral fracture (IRR=1.41, 95% confidence interval [CI]=1.26-1.57, p<0.001). In the multivariate analysis, the depressive disorder cohort showed a higher risk of vertebral fracture than the comparison cohort (adjusted hazard ratio=1.24, 95% CI=1.11-1.38, p<0.001). Being older than 50 years, having a lower monthly income, and having hypertension, diabetes mellitus, cerebrovascular disease, chronic obstructive pulmonary disease, autoimmune disease, or osteoporosis were considered predictive factors for vertebral fracture in patients with depressive disorders.

CONCLUSIONS:

Depressive disorders may increase the risk of a subsequent new-onset vertebral fracture.

Choosing the tool for osteoporosis risk prediction

PURPOSE OF REVIEW

Predicting fracture risk is a major challenge because it allows the prevention of major osteoporotic fracture in high-risk populations. With the aging of the population, this matter will become of even greater importance. In recent years, novel clinical, biochemical, and imaging tools have been developed to improve the assessment of fracture risk.

RECENT FINDINGS

The present review summarizes novel clinical strategies, Dual energy X-ray absorptiometry (DXA)-derived tools, imaging techniques, and biochemical markers that have been developed recently to improve fracture risk prediction.

SUMMARY

DXA and clinical fracture risk prediction tools are preferential markers of fracture risk. Clinical fracture risk alone might be used if DXA facilities are unavailable. The fracture risk assessment tool may be used in osteoporosis consultation in many countries. Other tools may be used soon after more studies are performed, particularly trabecular bone score, quantitative ultrasound, bone turnover markers. Specific factors for example falls, hip axis length, vertebral fracture assessment could be used in individual patients. This may significantly improve the clinical decision-making.

The social gradient of fractures at any skeletal site in men and women: data from the Geelong Osteoporosis Study Fracture Grid

Age-specific and age-standardized associations between socioeconomic status (SES) and fractures in adults showed a social gradient of fracture, irrespective of fracture site. Compared to the highest SES, males in the lowest SES group had a sixfold increased odds for any fracture, whilst females had a twofold increased odds.

INTRODUCTION

The effective identification of predisposing risk factors for fracture requires understanding any association with SES. These investigations should consider both sexes, span the adult age range and include any fractures. We investigated age- and sex-specific and age-standardized associations between SES and fractures at any skeletal site in Australians aged ≥ 50 years.

METHODS

Incident fractures that occurred 2006-2007 for adults aged ≥ 50 years were identified from radiological reports extracted for the Barwon Statistical Division, in south-eastern Australia. SES was determined by cross-referencing residential addresses with Australian Bureau of Statistics census data and then categorized in quintiles. We compared frequencies of observed vs. expected fractures for SES quintiles using χ (2) comparison, calculated age-specific fracture incidence across SES and compared age-standardized fracture rates in SES quintile 1 to quintile 5.

RESULTS

We identified 3943 incident fractures (69.4 % female); 47.4 % had occurred at major osteoporotic fracture (MOF) sites (hip, humerus, spine and forearm/wrist). Differences existed in observed vs. expected fractures across SES quintiles (p ≤ 0.001, sexes combined); all fractures showed an inverse association with SES (p ≤ 0.001, sexes combined). Compared to the highest SES quintile, individuals from the lowest SES quintile had between two to six times greater standardized fracture rates.

CONCLUSIONS

Disadvantaged men and women have an increased fracture incidence compared to their less disadvantaged counterparts. The large differences in fracture rates between SES groups warrant further research into designing appropriate, targeted interventions for those demographics at most risk.