Risk factors for prevalent vertebral fractures in black and white female densitometry patients

Racial and Ethnic Disparities in Bone Health and Outcomes in the United States

Osteoporosis is a bone disease classified by deterioration of bone microarchitecture and decreased bone strength, thereby increasing subsequent risk of fracture. In the United States, approximately 54 million adults aged 50 years and older have osteoporosis or are at risk due to low bone mass. Osteoporosis has long been viewed as a chronic health condition affecting primarily non-Hispanic white (NHW) women; however, emerging evidence indicates racial and ethnic disparities in bone outcomes and osteoporosis management. The primary objective of this review is to describe disparities in bone mineral density (BMD), prevalence of osteoporosis and fracture, as well as in screening and treatment of osteoporosis among non-Hispanic black (NHB), Hispanic, and Asian adults compared with NHW adults living on the US mainland. The following areas were reviewed: BMD, osteoporosis prevalence, fracture prevalence and incidence, postfracture outcomes, DXA screening, and osteoporosis treatments. Although there are limited studies on bone and fracture outcomes within Asian and Hispanic populations, findings suggest that there are differences in bone outcomes across NHW, NHB, Asian, and Hispanic populations. Further, NHB, Asian, and Hispanic populations may experience suboptimal osteoporosis management and postfracture care, although additional population-based studies are needed. There is also evidence that variation in BMD and osteoporosis exists within major racial and ethnic groups, highlighting the need for research in individual groups by origin or background. Although there is a clear need to prioritize future quantitative and qualitative research in these populations, initial strategies for addressing bone health disparities are discussed. © 2021 American Society for Bone and Mineral Research (ASBMR).

Diabetes-Related Fracture Risk Is Different in African Americans Compared With Hispanics and Caucasians

CONTEXT

Diabetes mellitus (DM) has been associated with a 60% to 90% increased risk of fracture but few studies have been performed in African American and Hispanic subjects.

OBJECTIVE

The aim of the present study was to quantify the risk of incident major osteoporotic fractures (MOFs) of the hip, wrist, and humerus in African Americans, Hispanics, and Caucasians with DM compared with those with hypertension (HTN).

METHODS

We performed a retrospective cohort study of 19,153 subjects with DM (7618 Caucasians, 7456 African Americans, and 4079 Hispanics) and 26,217 with HTN (15,138 Caucasians, 8301 African Americans, and 2778 Hispanics) aged ≥40 years, treated at a large health care system in Philadelphia, Pennsylvania. All information about the subjects was obtained from electronic health records.

RESULTS

The unadjusted MOF rates for each race/ethnicity were similar among those with DM and those with HTN (Caucasians, 1.85% vs 1.84%; African Americans, 1.07% vs 1.29%; and Hispanics, 1.69% vs 1.33%; P = NS for all). However, the MOF rates were higher for Caucasians and Hispanics with DM than for African Americans with DM (P < 0.01). In a multivariable model controlled for age, body mass index, sex, and previous MOF, DM was a statistically significant predictor of MOFs only for Caucasians and Hispanics [hazard ratio (HR), 1.23; 95% CI, 1.02 to 1.48; P = 0.026] but not for African Americans (HR, 0.92; 95% CI, 0.68 to 1.23; P = 0.56).

CONCLUSIONS

Hispanics had a DM-related fracture risk similar to that of Caucasians, but AAs did not have an additional fracture risk conferred by DM.

Association of trabecular bone score (TBS) and prior fracture differs among minorities in NHANES 2005-2008

The study investigates the association of trabecular bone score (TBS) and fractures among minority populations. In NHANES 2005-2008, TBS was associated with history of fractures in Caucasian subjects but demonstrated somewhat weaker associations in African American and Mexican American women.

INTRODUCTION

Trabecular bone score (TBS), a textural analysis of the lumbar spine DXA image, predicts fractures well in Caucasian (CA) and Asian populations but is less well studied in African American (AA) and Mexican American (MA) subjects. It is not clear whether TBS is associated with or is predictive of fragility in these racial/ethnic groups.

METHODS

We analyzed data from subjects from NHANES 2005-2008 over the age of 40 who had TBS: 1178 CA, 467 AA, and 397 MA women and 1200 CA, 502 AA, and 386 MA men. TBS was categorized into normal, ≥ 1.310, partially degraded < 1.310, and > 1.230, or degraded, ≤ 1.230. History of fracture was assessed by questionnaire.

RESULTS

Among women, there was an increasing prevalence of fracture with worsening TBS category. However, when controlling for age, BMI, and low T-score, the association between TBS category and previous fracture was only significant in CA women (OR 1.49 per worsening category, 95% CI 1.20-1.85). In men, there was also an increase in the prevalence of fracture with worsening TBS category in all races/ethnicities. When controlling for age, BMI, and low T-score, the association between TBS category and previous fracture was only significant in CA men (OR 1.47 per worsening category, 95% CI 1.10-1.95), though analysis was somewhat limited by small fracture numbers.

CONCLUSIONS

The association of fracture and TBS varies by race/ethnicity and gender with weaker association observed in AA and MA women. More research is needed to define the proper use of TBS for predicting fractures in minority groups.

Dual-energy X-ray Absorptiometry

Bone mineral density (BMD) measurement by dual-energy X-ray absorptiometry (DXA) is the most commonly used method to assess fracture risk. DXA utilizes two different energy X-rays to calculate BMD and, by comparison to a young normative database, the T-score. In 1994, the World Health Organization defined osteoporosis based on T-score, changing the paradigm of the field and forever placing DXA measurements in the center of osteoporosis diagnosis. Since then, many large studies have demonstrated the predictive value of BMD by DXA-for every standard deviation decline in BMD, there is a relative risk of 1.5-2.5 for fracture. This predictive ability is similar to how blood pressure can predict myocardial infarction. Limitations of DXA are also important to consider. While BMD by DXA can identify those at risk, there is a significant overlap in the BMD of patients who will and will not fracture. Special considerations are also needed in men and ethnic minority groups. These groups may have different bone size, thus affecting the normative range of BMD, and/or distinct bone structure that affect the association between BMD and fractures. Finally, BMD can be affected by positioning errors or artifacts, including osteoarthritis, fracture, and jewelry. Of course, DXA has tremendous strengths as well-namely its wide availability, its low radiation exposure, and a large body of evidence that relate DXA measurements to fracture risk. For these reasons, DXA remains the cornerstone of fracture assessment now and for the foreseeable future.

Worldwide prevalence and incidence of osteoporotic vertebral fractures

We investigated the prevalence and incidence of vertebral fractures worldwide. We used a systematic Medline search current to 2015 and updated as per authors' libraries. A total of 62 articles of fair to good quality and comparable methods for vertebral fracture identification were considered. The prevalence of morphometric vertebral fractures in European women is highest in Scandinavia (26%) and lowest in Eastern Europe (18%). Prevalence rates in North America (NA) for White women ≥50 are 20-24%, with a White/Black ratio of 1.6. Rates in women ≥50 years in Latin America are overall lower than Europe and NA (11-19%). In Asia, rates in women above ≥65 are highest in Japan (24%), lowest in Indonesia (9%), and in the Middle East, Lebanon, rates are 20%. The highest-lowest ratio between countries, within and across continents, varied from 1.4-2.6. Incidence data is less abundant and more heterogeneous. Age-standardized rates in studies combining hospitalized and ambulatory vertebral fractures are highest in South Korea, USA, and Hong Kong and lowest in the UK. Neither a North-South gradient nor a relation to urbanization is evident. Conversely, the incidence of hospitalized vertebral fractures in European patients ≥50 shows a North-South gradient with 3-3.7-fold variability. In the USA, rates in Whites are approximately 4-fold higher than in Blacks. Vertebral fractures variation worldwide is lower than observed with hip fractures, and some of highest rates are unexpectedly from Asia. Better quality representative studies are needed. We investigate the occurrence of vertebral fractures, worldwide, using published data current until the present. Worldwide, the variation in vertebral fractures is lower than observed for hip fractures. Some of the highest rates are from North America and unexpectedly Asia. The highest-lowest ratio between countries, within and across continents, varied from 1.4-2.6. Better quality representative data is needed.

Ethnic Differences in Osteoporosis After Cardiac Transplantation

Cardiac transplantation is associated with a high risk of fracture. African Americans (AAs) are believed to have a lower risk of osteoporosis than Caucasians, but it is not clear whether they are also protected from osteoporosis resulting from the use of glucocorticoids and/or organ transplantation. We examined possible ethnic differences in 33 cardiac transplant recipients (16 AAs) in a cross-sectional analysis. In addition to bone mineral density and vertebral fracture assessment, we also compared biochemical variables, trabecular bone score, total body dual-energy X-ray absorptiometry, and disability. Overall fracture rates were low in both groups, with only 6 total subjects with fractures on vertebral fracture assessment or history of fracture. While T-scores were similar between groups, Z-scores were lower in AA with the difference reaching statistical significance when controlling for important covariates. The trabecular bone score was also lower in AAs than in Caucasians even when adjusting for age and tissue thickness (1.198 ± 0.140 vs 1.312 ± 0.140, p = 0.03). While AAs are generally thought to be protected from osteoporosis, our study instead suggests that AAs may be at higher risk of bone deterioration after cardiac transplantation and may need to be managed more aggressively than suggested by current guidelines.

Vertebral fracture prevalence in black and white South African women

Black women are generally regarded as being less prone to the development of osteoporosis. This study reports a similar prevalence of morphometric vertebral fractures in black (9.1 %) and white (5.0 %) South African women. Clinical risk factors and bone strength parameters contributed differently to fracture risk in the two ethnic cohorts.

PURPOSE

Vertebral fracture represents one of the most common osteoporotic fractures and is a significant cause of morbidity and mortality. Little is known regarding the prevalence of vertebral fractures on the African continent. We therefore prospectively examined the prevalence of vertebral fracture on radiographs of the thoraco-lumbar spine in otherwise healthy community-dwelling older black and white South African women.

METHODS

Radiographs of the spine (T4-L5) were obtained randomly in 189 women (47 % black), aged 40 years or older, for the analysis of vertebral fracture. Radiographs were evaluated by a single radiologist, blinded to clinical data, using Genant's semi-quantitative method. Clinical risk factors for osteoporosis, risk factors for falls (fall history, quadriceps strength, lateral sway and reaction time), areal and volumetric bone mineral density of the spine and hip, calcaneal ultrasonography (QUS) and vertebral macro-geometry were assessed in the two ethnic groups and the association with prevalent vertebral fractures examined.

RESULTS

Vertebral fracture prevalence in older South African black and white women was similar (9.1 % in black and 5.0 % in white women). In black women, lower body weight and lower areal and volumetric bone mineral density (BMD) at all sites could serve as markers of increased fracture risk. Older age, physical inactivity, lower muscle strength and lower femoral BMD were associated with vertebral fracture risk in whites.

CONCLUSION

Our findings are noteworthy and the first attempt to compare vertebral fracture risk in women of different ethnicities on the African continent. A similar vertebral fracture risk between black and white women in South Africa must be considered at present to ensure appropriate evaluation in all subjects who present with clinical risk factors for osteoporosis, regardless of ethnicity.

Vertebral fracture risk factors in postmenopausal women over 50 in Valencia, Spain. A population-based cross-sectional study

PURPOSE

This study aims to estimate the prevalence of risk factors for osteoporotic vertebral fracture and analyze the possible associations between these factors and the presence of densitometric osteoporosis and prevalent morphometric vertebral fracture.

METHODS

Data from a population-based cross-sectional sample of 804 postmenopausal women over the age of 50 years old living in the city of Valencia (Spain) were used. The women were interviewed to identify the prevalence of osteoporotic fracture risk factors and underwent a densitometry and a dorsolumbar spine X-ray.

RESULTS

The most prevalent risk factors were densitometric osteoporosis (31.7%), history of parental hip fracture (19.4%), hypoestrogenism (19%), and body mass index (BMI) ≥ 30 kg/m(2) (35.2%). After adjusting for all covariables, densitometric osteoporosis was associated with increased age [odds ratio (OR)(65-69 years): 2.84, 95% confidence interval (CI): 1.75-4.61; OR(70-74 years): 4.01, 95% CI: 2.47-6.52; OR(75+years): 5.96, 95% CI: 3.27-10.87] and inversely associated with high BMI (OR(25.0-29.9): 0.51, 95% CI: 0.34-0.76; OR(≥ 30): 0.30, 95% CI: 0.19-0.46). Morphometric vertebral fracture was associated with age (OR(65-69 years): 2.04, 95% CI: 1.03-4.05; OR(70-74 years): 4.05, 95% CI: 2.11-7.77; OR(75+years): 8.43, 95% CI: 3.97-17.93), poor educational level (OR: 1.70, 95% CI: 1.06-2.72) and with densitometric osteoporosis and BMI ≥ 30 kg/m(2) (OR: 3.35, 95% CI: 1.85-6.07).

CONCLUSIONS

The most prevalent osteoporotic fracture risk factors were having a high BMI and the presence of densitometric osteoporosis. A higher risk of morphometric vertebral fracture in women with both low bone mineral density and high BMI was found. This association, if confirmed, has important implications for clinical practice and fracture risk tools. We also found a higher risk in women with a poor educational level. More attention should be addressed to these populations in order to control modifiable risk factors.

Prevalence of vertebral fractures in women and men in the population-based Tromsø Study

Background

Osteoporotic vertebral fractures are, as the hip fractures, associated with increased morbidity and mortality. Norway has one of the highest reported incidences of hip fractures in the world. Because of methodological challenges, vertebral fractures are not extensively studied. The aim of this population based study was to describe, for the first time, the age- and sex specific occurrence of osteoporotic vertebral fractures in Norway.

Methods

Data was collected in the Tromso Study, 2007/8 survey. By the use of dual x-ray absorptiometry (GE Lunar Prodigy) vertebral fracture assessments were performed in 2887 women and men aged from 38 to 87 years, in addition to measurements of bone mineral density at the femoral sites. Information on lifestyle was collected through questionnaires. Comparisons between fractures and non-fractures were done sex stratified, by univariate analyses, adjusting for age when relevant.

Results

The prevalence of vertebral fractures varied from about 3% in the age group below 60 to about 19% in the 70+ group in women, and from 7.5% to about 20% in men, with an overall prevalence of 11.8% in women and 13.8% in men (p = 0.07). Among those with fractures, only one fracture was the most common; two and more fractures were present in approximately 30% of the cases. Fractures were seen from the fourth lumbar to the fifth thoracic vertebrae, most common between first lumbar and sixth thoracic vertebrae. The most common type of fracture was the wedge type in both sexes. Bone mineral density at the hip differed significantly according to type of fracture, being highest in those with wedge fractures and lowest in those with compression fractures.

Conclusions

The prevalence of vertebral fractures increased by age in women and men, but the overall prevalence was lower than expected, considering the high prevalence of hip and forearm fractures in Norway. In both sexes, the wedge type was the fracture type most frequently observed and most common in the thoracic region.

Prevalence of vertebral fractures on chest radiographs of elderly African American and Caucasian women

The prevalence of vertebral fractures on routine chest radiographs of elderly Caucasian women was only 1.3 times higher than in African American (AA) women, a difference considerably smaller than reported in population studies. AAs with medical problems may have higher risk of vertebral fractures than previously suspected.

INTRODUCTION

Earlier studies noted a 1.9- to 3.7-fold higher prevalence of vertebral fractures in Caucasian (CA) compared to African American (AA) women. These studies, however, may have suffered from selection bias. We reported that among women referred for bone density testing, the prevalence of vertebral fractures in AA was the same as in CA women. Suspecting that the latter might have been due to a referral bias, we examined the racial difference in the prevalence of vertebra fractures on chest radiographs of patients seeking general medical care, not selected for osteoporosis.

METHODS

Consecutive chest radiographs (N = 1,200) of women over age 60 were evaluated using Genant's semi-quantitative method. Patients' race and the presence of diseases or medications associated with increased fracture risk were ascertained from the electronic medical records.

RESULTS

Among 1,011 women (76% AA) with usable radiographs, 11% had moderate or severe vertebral fractures. The prevalence of vertebral fractures was 10.3% in 773 AA and 13% in 238 CA women (p = 0.248 for difference between races). The lack of difference persisted after controlling for age, smoking, use of glucocorticoids, or presence of cancer, rheumatoid arthritis, organ transplantation, and end-stage renal disease. Among all subjects, CA women were more likely to be diagnosed and treated for osteoporosis (p <0.001).

CONCLUSION

Among subjects seeking medical care, the difference in the prevalence of vertebral fractures between AA and CA women is smaller than previously suspected. Greater attention to the detection of vertebral fractures and the management of osteoporosis is warranted in AA women with medical problems.

Prevalence and risk factors of radiographic vertebral fracture in postmenopausal Vietnamese women

BACKGROUND

Vertebral fracture is associated with an increased risk of atraumatic fracture and mortality. The prevalence of vertebral fractures among postmenopausal Caucasian women has been reported to range between 15% and 35%. Because there is no estimate of the magnitude of the problem in Vietnam, we undertook this study to estimate the prevalence and risk factors of vertebral fracture in Vietnam.

METHODS

Radiographs were taken from 209 postmenopausal women aged between 50 and 85 years (average 62) who were randomly sampled from various districts in Ho Chi Minh City. The presence of vertebral fracture was assessed by the Genant's semi-quantitative method with two independent readers. Bone mineral density (BMD) at the lumbar spine (LS), femoral neck (FN) and whole body was measured by DXA (Hologic QDR4500). Anthropometric and clinical data were obtained by a standardized questionnaire.

RESULTS

Among the 209 women, 48 were found to have at least one radiographic vertebral fracture, which yielded a prevalence of 23% (95%CI: 18-29%). Although fracture occurred in all vertebrae, most (83%) occurred at the L1-L5. Most fractures occurred at one vertebra, and only 12% occurred at multiple vertebrae. The prevalence increased with age such that it reached 39% among those aged 70+ years. There was no significant association between vertebral fracture and back pain, fall history, and dietary calcium intake. In simple log-binomial regression analysis, higher risk of vertebral fracture was associated with advancing age (prevalence ratio [PR] per 10 years: 1.40; 1.16-2.05) and lower lumbar spine BMD (PR per SD: 1.51; 1.18-1.92). In multivariable analysis, the two factors remained independently associated with fracture risk, with the area under the receiver operating characteristic curve being 0.66.

CONCLUSIONS

These data suggest that approximately one out of 4 postmenopausal women in Vietnam have a radiographic vertebral fracture, and this prevalence is as common as in Caucasian populations. The number of women needed to screen to identify one vertebral fracture is about 4 to 5, which seems to be cost-effective.

Vertebral Fracture Assessment: the 2007 ISCD Official Positions

Vertebral fracture assessment (VFA) is an established, low radiation method for detection of prevalent vertebral fractures. Vertebral fractures are usually not recognized clinically at the time of their occurrence, but their presence indicates a substantial risk for subsequent fractures independent of bone mineral density. Significant evidence supporting VFA use for many post-menopausal women and older men has accumulated since the last ISCD Official Position Statement on VFA was published. The International Society for Clinical Densitometry considered the following issues at the 2007 Position Development Conference: (1) What are appropriate indications for Vertebral Fracture Assessment; (2) What is the most appropriate method of vertebral fracture detection with VFA; (3) What is the sensitivity and specificity for detection of vertebral fractures with this method; (4) When should additional spine imaging be performed following a VFA; and (5) What are the reporting obligations for those interpreting VFA images?