Ten-year risk of osteoporotic fractures in postmenopausal Chinese women according to clinical risk factors and BMD T-scores: a prospective study

Persistent Calcium Inadequacy in Korean Adults over 20 Years: Analysis of the 1998-2018 Korea National Health and Nutrition Examination Survey

Calcium inadequacy in Asian populations has been well documented, but whether it has improved over time remains uncertain. We analyzed dietary calcium intake and its association with osteoporosis prevalence over a 20-year period in 48,653 adults (21,932 men and 26,721 women, aged 19 years and older) in Korea, using data from the first to the seventh Korea National Health and Nutrition Examination Survey (1998-2018). Over the past 20 years, Korean adults consistently fell short of the recommended dietary calcium intake, with women and older adults particularly affected, typically consuming only 40-80% of the recommended levels. The 30-49 age group had the highest calcium intake (497-568 mg/day), while those aged 75+ had the lowest (319-457 mg/day). A significant inverse relationship was found between calcium intake and osteoporosis risk, with lower calcium intake associated with higher odds of developing osteoporosis, as determined by both physician diagnoses and bone mineral density measurements (p < 0.001). Notably, over the past 20 years, 68-70% of dietary calcium consistently came from plant-based foods. This study strongly emphasizes the urgent need to enhance calcium-rich food availability and implement targeted interventions to increase calcium intake among those most affected by inadequacy, particularly the elderly and women. Further research with recent data would be valuable for understanding current intake levels and evolving nutritional needs.

Olink Proteomics for the Identification of Biomarkers for Early Diagnosis of Postmenopausal Osteoporosis

This investigation aims to employ Olink proteomics in analyzing the distinct serum proteins associated with postmenopausal osteoporosis (PMOP) and identifying prognostic markers for early detection of PMOP via molecular mechanism research on postmenopausal osteoporosis. Postmenopausal women admitted to Beijing Jishuitan Hospital were randomly selected and categorized into three groups based on their dual-energy X-ray absorptiometry (DXA) T-scores: osteoporosis group (n = 24), osteopenia group (n = 20), and normal bone mass group (n = 16). Serum samples from all participants were collected for clinical and bone metabolism marker measurements. Olink proteomics was utilized to identify differentially expressed proteins (DEPs) that are highly associated with postmenopausal osteoporosis. The functional analysis of DEPs was performed using Gene Ontology and Kyto Encyclopedia Genes and Genomes (KEGG). The biological characteristics of these proteins and their correlation with PMOP were subsequently analyzed. ROC curve analysis was performed to identify potential biomarkers with the highest diagnostic accuracy for early stage PMOP. Through Olink proteomics, we identified five DEPs highly associated with PMOP, including two upregulated and three downregulated proteins. TWEAK and CDCP1 markers exhibited the highest area under the curve (0.8188 and 0.8031, respectively). TWEAK and CDCP1 have the potential to serve as biomarkers for early prediction of postmenopausal osteoporosis.

The Fracture Risk of Elderly Patients With Atopic Dermatitis

Background: A higher fracture risk has been reported previously in patients with atopic Dermatitis (AD). The bone mineral density (BMD) was not accounted for in these studies. Objective: To investigate the fracture risk in AD patients after adjustment for factors including BMD. Methods: We retrospectively analyzed AD patients (≥45 years) who underwent BMD examination at our hospital from July 2010 to February 2023. Individuals who received BMD examinations during a health checkup were identified as the controls. We documented their clinical characteristics, BMD, 10-year risk for a major fracture based on FRAX (Fracture Risk Assessment Tool), and development of osteoporotic fractures. Patients were followed until development of new onset fracture or the end of the study period. A cross-sectional comparison of BMD between AD patients and controls at baseline was performed using the Mann-Whitney U test after propensity score matching (PSM). Their fracture risks were compared using the multivariate Cox regression model. BMD and fracture risk were also compared between AD patients who received systemic therapy and those who did not. Results: A total of 50 AD patients and 386 controls were enrolled. The median age was older in AD patients when compared with controls (70 years vs 60 years). Their BMD at all sites was similar after PSM. After a median follow-up of 1.7-2.0 years, 13 osteoporotic fractures were identified. In the multivariate Cox regression analysis, AD was not associated with new onset fractures of all sites (adjusted hazard ratio [aHR] 2.55, 95% confidence interval [CI] 0.72-9.01) but was significantly associated with new onset vertebral fractures (aHR 6.80, 95% CI 1.77-26.17). The BMD and incidence of fractures were similar between AD who received systemic therapy and those who did not. Conclusions: Elderly AD patients had similar BMD but a higher short-term risk for vertebral fractures when compared with the controls.

Decomposing and simplifying the Fracture Risk Assessment Tool-a module from the Taiwan-specific calculator

The Fracture Risk Assessment Tool (FRAX®) is a widely utilized country-specific calculator for identifying individuals with high fracture risk; its score is calculated from 12 variables, but its formulation is not publicly disclosed. We aimed to decompose and simplify the FRAX® by utilizing a nationwide community survey database as a reference module for creating a local assessment tool for osteoporotic fracture community screening in any country. Participants (n = 16384; predominantly women (75%); mean age = 64.8 years) were enrolled from the Taiwan OsteoPorosis Survey, a nationwide cross-sectional community survey collected from 2008 to 2011. We identified 11 clinical risk factors from the health questionnaires. BMD was assessed via dual-energy X-ray absorptiometry in a mobile DXA vehicle, and 10-year fracture risk scores, including major osteoporotic fracture (MOF) and hip fracture (HF) risk scores, were calculated using the FRAX®. The mean femoral neck BMD was 0.7 ± 0.1 g/cm2, the T-score was -1.9 ± 1.2, the MOF was 8.9 ± 7.1%, and the HF was 3.2 ± 4.7%. Following FRAX® decomposition with multiple linear regression, the adjusted R2 values were 0.9206 for MOF and 0.9376 for HF when BMD was included and 0.9538 for MOF and 0.9554 for HF when BMD was excluded. The FRAX® demonstrated better prediction for women and younger individuals than for men and elderly individuals after sex and age stratification analysis. Excluding femoral neck BMD, age, sex, and previous fractures emerged as 3 primary clinical risk factors for simplified FRAX® according to the decision tree analysis in this study population. The adjusted R2 values for the simplified country-specific FRAX® incorporating 3 premier clinical risk factors were 0.8210 for MOF and 0.8528 for HF. After decomposition, the newly simplified module provides a straightforward formulation for estimating 10-year fracture risk, even without femoral neck BMD, making it suitable for community or clinical osteoporotic fracture risk screening.

Home Meal Replacement Fortified with Eggshell Powder and Vitamin D Prevents Bone Loss in Postmenopausal Women: A Randomized, Double-Blind, Controlled Study

Calcium and vitamin D deficiencies have been ongoing problems in Koreans due to a lack of food sources of calcium and vitamin D. Postmenopausal women aged 50 to 64 years (n = 25) were randomly assigned to consume three home meal replacements (HMRs)/week with (treatment) and without (control) eggshell powder and vitamin D for 6 months. Additionally, subjects who agreed to continue the study consumed the same three HMRs/week for an additional 6 months in this randomized double-blind study. We confirmed the high compliance of the study participants by analyzing carotenoids, the bioactive substances of HMRs, in the blood. The treatment group consumed an additional 261 mg/d of calcium and 10.3 μg/d of vitamin D from the HMRs, thus meeting the recommended intakes of calcium and vitamin D for Koreans. As a result of consuming fortified HMRs for 6 months, the decline in femoral neck bone density was significantly reduced in the treatment group (p = 0.035). This study indicates that inexpensive eggshell powder may be a good source of calcium for populations with low consumption of milk and dairy products. Additionally, functional HMRs fortified with eggshell powder and vitamin D can be a good dietary strategy for bone health.

East Asians' T-scores for the diagnosis of osteoporosis should be calculated using ethnicity- and gender-specific BMD reference ranges: justifications

The 2013 ISCD consensus recommended a Caucasian female reference database for T-score calculation in men, which says "A uniform Caucasian (non-race adjusted) female reference database should be used to calculate T-scores for men of all ethnic groups." However, this statement was recommended for the US population, and no position was taken with respect to BMD reference data or ethnicity matching outside of the USA. In East Asia, currently, a Japanese BMD reference database is universally adopted in Japan for clinical DXA diagnosis, while both local BMD and Caucasian BMD reference databases are in use in Mainland China, South Korea, Taiwan, and Singapore. In this article, we argue that an ethnicity- and gender-specific BMD database should be used for T-score calculations for East Asians, and we list the justifications why we advocate so. Use of a Caucasian BMD reference database leads to systematically lower T-scores for East Asians and an overestimation of the prevalence of osteoporosis. Using a female BMD reference database to calculate T-scores for male patients leads to higher T-score values and an underestimation of the prevalence of osteoporosis. Epidemiological evidence does not support using a female BMD reference database to calculate T-scores for men. We also note that BMD reference databases collected in Asia should be critically evaluated for their quality.

Osteoporosis and low bone mass among schizophrenia and bipolar disorder: A cross-sectional study with newly diagnosed, drug-naïve subjects

BACKGROUND

A growing body of data shows that schizophrenia (SCZ) and bipolar disorder (BD) have substantial metabolic risks; however, few studies have focused on bone metabolism. This study aimed to assess the prevalence and associated influencing factors of low bone mass and osteoporosis in SCZ and BD before pharmacological effects occur.

METHODS

108 healthy controls (HCs) and drug-naïve individuals with SCZ (n = 56) and BD (n = 130) had their lumbar spine (L1-L4) and left femur (Neck/Trochanter/Ward's triangle) bone mineral density (BMD) determined using dual-energy X-ray absorptiometry. Besides, we measured bone turnover markers (BTMs) levels, including procollagen I N-terminal propeptide, osteocalcin, and C-terminal cross-linking telopeptide of type I collagen in different groups.

RESULTS

Individuals with SCZ and BD had significantly lower BMD and significantly higher prevalence of low bone mass and osteoporosis compared with HCs. In the main observation regions of the total lumbar (F = 18.368, p < 0.001) and left femur (F = 14.790, p < 0.001), BMD was lower in individuals with SCZ and BD than HCs, with SCZ showing lower BMD than BD. The osteocalcin (H = 11.421, p = 0.003) levels were significantly higher in SCZ and BD than HCs. Binary regression analysis showed that SCZ or BD was an independent risk factor for low bone mass and osteoporosis. In addition, sex, age, and BTMs also influenced the occurrence of low bone mass and osteoporosis.

LIMITATIONS

Cross-sectional study.

CONCLUSION

The results findings of the study might contribute to our understanding of the increased risk of bone metabolism in SCZ and BD.

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn, identifier ChiCTR1900021379.

Fracture risk prediction in old Chinese people-a narrative review

With aging, the burden of osteoporotic fracture (OF) increases substantially, while China is expected to carry the greatest part in the future. The risk of fracture varies greatly across racial groups and geographic regions, and systematically organized evidence on the potential predictors for fracture risk is needed for Chinese. This review briefly introduces the epidemiology of OF and expands on the predictors and predictive tools for the risk of OF, as well as the challenges for their potential translation in the old Chinese population. There are regional differences of fracture incidence among China. The fracture incidences in Hong Kong and Taiwan have decreased in recent years, while it is still increasing in mainland China. Although the application of dual-energy X-ray absorptiometry (DXA) is limited among old Chinese in the mainland, bone mineral density (BMD) by DXA has a predictive value similar to that worldwide. Other non-DXA modalities, especially heel QUS, are helpful in assessing bone health. The fracture risk assessment tool (FRAX) has a good discrimination ability for OFs, especially the FRAX with BMD. And some clinical factors have added value to FRAX, which has been verified in old Chinese. In addition, although the application of the osteoporosis self-assessment tool for Asians (OSTA) in Chinese needs further validation, it may help identify high-risk populations in areas with limited resources. Moreover, the translation use of the muscle quality and genetic or serum biomarkers in fracture prediction needs further works. More applicable and targeted fracture risk predictors and tools are still needed for the old Chinese population.

Development and validation of common data model-based fracture prediction model using machine learning algorithm

The need for an accurate country-specific real-world-based fracture prediction model is increasing. Thus, we developed scoring systems for osteoporotic fractures from hospital-based cohorts and validated them in an independent cohort in Korea. The model includes history of fracture, age, lumbar spine and total hip T-score, and cardiovascular disease.

PURPOSE

Osteoporotic fractures are substantial health and economic burden. Therefore, the need for an accurate real-world-based fracture prediction model is increasing. We aimed to develop and validate an accurate and user-friendly model to predict major osteoporotic and hip fractures using a common data model database.

METHODS

The study included 20,107 and 13,353 participants aged ≥ 50 years with data on bone mineral density using dual-energy X-ray absorptiometry from the CDM database between 2008 and 2011 from the discovery and validation cohort, respectively. The main outcomes were major osteoporotic and hip fracture events. DeepHit and Cox proportional hazard models were used to identify predictors of fractures and to build scoring systems, respectively.

RESULTS

The mean age was 64.5 years, and 84.3% were women. During a mean of 7.6 years of follow-up, 1990 major osteoporotic and 309 hip fracture events were observed. In the final scoring model, history of fracture, age, lumbar spine T-score, total hip T-score, and cardiovascular disease were selected as predictors for major osteoporotic fractures. For hip fractures, history of fracture, age, total hip T-score, cerebrovascular disease, and diabetes mellitus were selected. Harrell's C-index for osteoporotic and hip fractures were 0.789 and 0.860 in the discovery cohort and 0.762 and 0.773 in the validation cohort, respectively. The estimated 10-year risks of major osteoporotic and hip fractures were 2.0%, 0.2% at score 0 and 68.8%, 18.8% at their maximum scores, respectively.

CONCLUSION

We developed scoring systems for osteoporotic fractures from hospital-based cohorts and validated them in an independent cohort. These simple scoring models may help predict fracture risks in real-world practice.

Cost Effectiveness of Denosumab for Secondary Prevention of Osteoporotic Fractures Among Postmenopausal Women in China: An Individual-Level Simulation Analysis

OBJECTIVE

This study evaluated the cost effectiveness of denosumab versus alendronate for secondary prevention of osteoporotic fractures among post-menopausal women in China.

METHODS

A validated individual-level simulation model of osteoporotic fractures in the Chinese setting was adapted. Allowing both treatment discontinuation and waning effects, the analysis aimed to evaluate the incremental cost-effectiveness ratio of denosumab compared to alendronate by simulating a cohort of previously fractured individuals over the residual lifetime from the healthcare system perspective. Hip, vertebral, and wrist/humeral fractures were tracked along with the associated medical costs and quality-adjusted life-years. Age-related health state utility values, health state utility values of fractures, costs, fracture incidence, and mortality risks for Chinese were used whenever available. Comparative effectiveness data were obtained from a published network meta-analysis. One-way and probabilistic sensitivity analyses were conducted.

RESULTS

In the base case, denosumab was dominated by alendronate with incremental costs of CN¥2743 (US$425) and incremental health outcomes of - 0.20 quality-adjusted life-years at its current price in mainland China. It remained dominated in all one-way sensitivity analysis robustness checks. However, denosumab was cost effective if both drugs did not carry any waning effects. In the probabilistic sensitivity analysis, denosumab remained dominated in all replications.

CONCLUSIONS

Denosumab is not cost effective for preventing secondary fractures among overall postmenopausal women in China. It is advisable to identify alternative denosumab regimens for high-risk subgroups among previously fractured postmenopausal women.

Bone Mineral Density Screening Interval and Transition to Osteoporosis in Asian Women

BACKGRUOUND

Bone mineral density (BMD) testing is indicated for women aged 65 years, but screening strategies for osteoporosis are controversial. Currently, there is no study focusing on the BMD testing interval in Asian populations. The current study aimed to evaluate the estimated time interval for screening osteoporosis.

METHODS

We conducted a study of 6,385 subjects aged 50 years and older who underwent dual-energy X-ray absorptiometry screening more than twice at Samsung Medical Center as participants in a routine health checkup. Subjects were divided based on baseline T-score into mild osteopenia (T-score, <-1.0 to >-1.5), moderate osteopenia (T-score, ≤-1.5 to >-2.0), and severe osteopenia (T-score, ≤-2.0 to >-2.5). Information about personal medical and social history was collected by a structured questionnaire.

RESULTS

The adjusted estimated BMD testing interval for 10% of the subjects to develop osteoporosis was 13.2 years in mild osteopenia, 5.0 years in moderate osteopenia, and 1.5 years in severe osteopenia.

CONCLUSION

Our study provides extended information about BMD screening intervals in Asian female population. Baseline T-score was important for predicting BMD screening interval, and repeat BMD testing within 5 years might not be necessary in mild osteopenia subjects.

10-Year Fracture Risk in Postmenopausal Women with Osteopenia and Osteoporosis in South Korea

BACKGROUND

In South Korea, women aged 66 years are eligible for complimentary bone mineral density (BMD) screening via the National Screening Program for Transitional Ages. We aimed to evaluate the 10-year fracture risk in women receiving BMD screening between January 2008 and December 2015.

METHODS

BMD was classified as normal (T-score ≥-1.0 standard deviation [SD]), osteopenia (T-score <-1.0 SD and >-2.5 SD), and osteoporosis (T score ≤-2.5 SD) from dual-energy X-ray absorptiometry. Follow-up continued from the screening date until a diagnosis for clinical fragility fracture (including sites of the vertebrae, hip, pelvis, clavicle, humerus, forearm, wrist, lower leg, and ankle), censored at the earliest date of trauma, death, or December 2017; fracture was ascertained using diagnostic codes from the National Health Insurance Service database. A multivariable Cox proportional hazard model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk of fracture in women with osteopenia or osteoporosis relative to women with normal BMD.

RESULTS

Among the 271,197 women screened, 44.0% had osteopenia and 35.2% had osteoporosis. The 10 year cumulative incidence of fragility fractures was 31.1%, 37.5%, and 44.3% in women with normal BMD, osteopenia, and osteoporosis, respectively. Fracture risk was higher in women with osteopenia (HR, 1.31; 95% CI, 1.28 to 1.34) and osteoporosis (HR, 1.68; 95% CI, 1.64 to 1.72) than in women with normal BMD.

CONCLUSION

Women with osteopenia and women with osteoporosis, identified by the national BMD screening program, demonstrated a substantially elevated risk of fracture.

Establishment and validation of a nomogram and web calculator for the risk of new vertebral compression fractures and cement leakage after percutaneous vertebroplasty in patients with osteoporotic vertebral compression fractures

PURPOSE

The aim of this work was to investigate the risk factors for cement leakage and new-onset OVCF after Percutaneous vertebroplasty (PVP) and to develop and validate a clinical prediction model (Nomogram).

METHODS

Patients with Osteoporotic VCF (OVCF) treated with PVP at Liuzhou People's Hospital from June 2016 to June 2018 were reviewed and met the inclusion criteria. Relevant data affecting bone cement leakage and new onset of OVCF were collected. Predictors were screened using univariate and multi-factor logistic analysis to construct Nomogram and web calculators. The consistency of the prediction models was assessed using calibration plots, and their predictive power was assessed by tenfold cross-validation. Clinical value was assessed using Decision curve analysis (DCA) and clinical impact plots.

RESULTS

Higher BMI was associated with lower bone mineral density (BMD). Higher BMI, lower BMD, multiple vertebral fractures, no previous anti-osteoporosis treatment, and steroid use were independent risk factors for new vertebral fractures. Cement injection volume, time to surgery, and multiple vertebral fractures were risk factors for cement leakage after PVP. The development and validation of the Nomogram also demonstrated the predictive ability and clinical value of the model.

CONCLUSIONS

The established Nomogram and web calculator (https://dr-lee.shinyapps.io/RefractureApp/) (https://dr-lee.shinyapps.io/LeakageApp/) can effectively predict the occurrence of cement leakage and new OVCF after PVP.

Distal radius fracture: An opportunity for osteoporosis intervention

Background

Distal radius fractures have been reported as a predictor of subsequent osteoporotic fragility fractures. This retrospective study evaluated the proportion of patients with distal radius fractures at a government hospital in Hong Kong who received diagnostic evaluation or treatment for osteoporosis within 1 year.

Methods

Five hundred sixty-one postmenopausal women aged >50 years admitted to a public hospital between 2013 and 2017 for a low-energy distal radius fracture were analysed for initiation of osteoporosis medications and/or arrangement of dual-energy X-ray absorptiometry screening within 1 year of injury.

Results

Within 1 year, 8.4% of patients were prescribed osteoporosis medication and 6.1% of patients had dual-energy X-ray absorptiometry arranged. Patients with a previous fracture were more likely to receive osteoporosis medication (18.6% vs 7.5%, P = 0.012) and either intervention (screening or medication) overall (23.3% vs 10.4%, P = 0.011).

Conclusions

Few postmenopausal women who suffered a distal radius fracture received osteoporosis intervention within 1 year. Orthopaedic surgeons should be aware of the possibility of underlying osteoporosis and opportunity for intervention when managing fragility distal radius fractures.

Relationship between bone mineral density and fragility fracture risk: a case-control study in Changsha, China

Background

Fragility fracture is associated with bone mineral density (BMD), and most databases used in related researches are instrument-matched. Little is known about the relationship between BMD and fragility fracture risk of native Chinese, especially using local databases as reference databases.

Objective

To investigate relationship between BMD and risk of fragility fracture in native China.

Methods

3,324 cases, including 2,423 women (67.7 ± 8.9 years) and 901 men (68.4 ± 11.6 years) having radiological fragility fractures and 3,324 age- and gender-matched controls participated in the study. We measured BMD at posteroanterior spine and hip using dual-energy X-ray absorptiometry (DXA), calculated BMD measurement parameters based on our own BMD reference database.

Results

BMDs and mean T-scores were lower in case group (with clinical fragility) than in control group (without clinical fragility). In patients with fragility fractures, prevalence of lumbar osteoporosis, low bone mass, and normal BMD were 78.9 %, 19.3 %, and 1.8 %, respectively, in women, and 49.5, 44.8 %, and 5.7 %, respectively, in men. In hip, these prevalence rates were 67.2 %, 28.4 %, and 4.4 % in females, and 43.2 %, 45.9 %, and 10.9 % in males, respectively, showing differences between females and males. Multivariate Cox regression analysis showed that after adjusting age, height, weight, and body mass index, fracture hazard ratio (HR) increased by 2.7–2.8 times (95 % CI 2.5–3.1) and 3.6–4.1 times (95 %CI 3.0–5.1) for women and men respectively with decreasing BMD parameters. In both sexes, risk of fragility fracture increased approximately 1.6–1.7 times (95 % CI 1.5–1.8) for every 1 T-score reduction in BMD.

Conclusions

Risk of clinical fragility fracture increases with decreasing BMD measurement parameters and anthropometric indicators in native China, and fracture HR varies from gender and site.

Effect of meteorological factors and air pollutants on fractures: a nationwide population-based ecological study

OBJECTIVE

To determine the association of meteorological factors and air pollutants (MFAPs) with fracture and to estimate the effect size/time lag.

DESIGN

This is a nationwide population-based ecological study from 2008 to 2017.

SETTING

Eight large metropolitan areas in Korea.

PARTICIPANTS

Of 8 093 820 patients with fractures reported in the Korea National Health Insurance database, 2 129 955 were analysed after the data set containing patient data (age, sex and site of fractures) were merged with MFAPs. Data on meteorological factors were obtained from the National Climate Data Center of the Korea Meteorological Administration. Additionally, data on air pollutants (atmospheric particulate matter ≤2.5 µm in diameter (PM_2.5), PM₁₀, ozone, nitrogen dioxide, sulfur dioxide and carbon monoxide) were obtained from the Air Korea database.

PRIMARY AND SECONDARY OUTCOME MEASURES

We hypothesised that there would be an association between MFAPs and the incidence of fracture. A generalised additive model was used while factoring in the non-linear relationship between MFAPs and fractures as well as a time lag ≤7 days. Multivariate analysis was performed. Backward elimination with an Akaike information criterion was used to fit the multivariate model.

RESULTS

Overall, in eight urban areas, 2 129 955 patients with fractures were finally analysed. These included 370 344, 187 370, 173 100, 140 358, 246 775, 6501, 228 346, 57 183 and 719 978 patients with hip, knee, shoulder, elbow, wrist, hand, ankle, foot and spine fractures, respectively. Various MFAPs (average temperature, daily rain, wind speed, daily snow and PM_2.5) showed significant association with fractures, with positive correlations at time lags 7, 5-7, 5-7, 3-7 and 6-7 days, respectively.

CONCLUSIONS

Various MFAPs could affect the occurrence of fractures. The average temperature, daily rain, wind speed, daily snow and PM_2.5 were most closely associated with fracture. Thus, improved public awareness on these MFAPs is required for clinical prevention and management of fractures.

Dietary calcium and vitamin K are associated with osteoporotic fracture risk in middle-aged and elderly Japanese women, but not men: the Murakami Cohort Study

Although dietary Ca, vitamin D and vitamin K are nutritional factors associated with osteoporosis, little is known about their effects on incident osteoporotic fractures in East Asian populations. This study aimed to determine whether intakes of these nutrients predict incident osteoporotic fractures. We adopted a cohort study design with a 5-year follow-up. Subjects were 12 794 community-dwelling individuals (6301 men and 6493 women) aged 40-74 years. Dietary intakes of Ca, vitamin D and vitamin K were assessed with a validated FFQ. Covariates were demographic and lifestyle factors. All incident cases of major osteoporotic limb fractures, including those of the distal forearm, neck of humerus, neck or trochanter of femur and lumbar or thoracic spine were collected. Hazard ratios (HR) for energy-adjusted Ca, vitamin D and vitamin K were calculated with the residual method. Mean age was 58·8 (sd 9·3) years. Lower energy-adjusted intakes of Ca and vitamin K in women were associated with higher adjusted HR of total fractures (Pfor trend = 0·005 and 0·08, respectively). When vertebral fracture was the outcome, Pfor trend values for Ca and vitamin K were 0·03 and 0·006, respectively, and HR of the lowest and highest (reference) intake groups were 2·03 (95 % CI 1·08, 3·82) and 2·26 (95 % CI 1·19, 4·26), respectively. In men, there were null associations between incident fractures and each of the three nutrient intakes. Lower intakes of dietary Ca and vitamin K were independent lifestyle-related risk factors for osteoporotic fracture in women but not men. These associations were robust for vertebral fractures, but not for limb fractures.

Development and Validation of a Risk Score to Predict the First Hip Fracture in the Oldest Old: A Retrospective Cohort Study

BACKGROUND

To evaluate whether the common risk factors and risk scores (FRAX, QFracture, and Garvan) can predict hip fracture in the oldest old (defined as people aged 80 and older) and to develop an oldest-old-specific 10-year hip fracture prediction risk algorithm.

METHODS

Subjects aged 80 years and older without history of hip fracture were studied. For the derivation cohort (N = 251, mean age = 83), participants were enrolled with a median follow-up time of 8.9 years. For the validation cohort (N = 599, mean age = 85), outpatients were enrolled with a median follow-up of 2.6 years. A five-factor risk score (the Hong Kong Osteoporosis Study [HKOS] score) for incident hip fracture was derived and validated, and its predictive accuracy was evaluated and compared with other risk scores.

RESULTS

In the derivation cohort, the C-statistics were .65, .61, .65, .76, and .78 for FRAX with bone mineral density (BMD), FRAX without BMD, QFracture, Garvan, and the HKOS score, respectively. The category-less net reclassification index and integrated discrimination improvement of the HKOS score showed a better reclassification of hip fracture than FRAX and QFracture (all p < .001) but not Garvan, while Garvan, but not HKOS score, showed a significant over-estimation in fracture risk (Hosmer-Lemeshow test p < .001). In the validation cohort, the HKOS score had a C-statistic of .81 and a considerable agreement between expected and observed fracture risk in calibration.

CONCLUSION

The HKOS score can predict 10-year incident hip fracture among the oldest old in Hong Kong. The score may be useful in identifying the oldest old patients at risk of hip fracture in both community-dwelling and hospital settings.

Blindness increases the risk for hip fracture and vertebral fracture but not the risk for distal radius fracture: a longitudinal follow-up study using a national sample cohort

The risks for hip fracture and vertebral fracture, but not the risk for distal radius fracture, were significantly higher in the blindness group than in the control group with a maximum 12-year follow-up.

PURPOSE

To evaluate the influence of visual impairment on the risk for osteoporotic fractures at common sites: hip, thoracic/lumbar vertebra, and distal radius.

METHODS

This longitudinal follow-up study used a database of a national sample cohort from 2002 to 2013 provided by the Korean National Health Insurance Service. Of a total of 1,125,691 subjects, 3918 patients with visual impairment and age ≥ 50 years were enrolled in a 1:4 ratio; 15,672 control participants were matched for age, sex, income, and region of residence. Stratified Cox proportional-hazards models were used to evaluate the crude and adjusted (for steroid medication, rheumatoid arthritis, depression, osteoporosis, diabetes mellitus, and stroke history) hazard ratios (HRs) for each fracture site. Fracture diagnoses were based on the ICD-10 codes: hip fracture (S720, S721, S722), vertebral fracture (S220, S320), and distal radius fracture (S525).

RESULTS

The HRs for hip and vertebral fracture were significantly higher in the blindness group (adjusted HR = 2.46, p < 0.001 for hip fracture; adjusted HR = 1.42, p = 0.020 for thoracic/lumbar vertebral fracture) than in the matched control group. However, the HR for distal radius fracture was not higher in the blindness group. The HRs for all three fracture sites were not significantly higher in the non-blindness visual impairment group after adjustment.

CONCLUSION

The risks for hip fracture and vertebral fracture were significantly higher in the blindness group. However, the risk for distal radius fracture was not related to visual impairment including blindness.

Association between non-Caucasian-specific ASCC1 gene polymorphism and osteoporosis and obesity in Korean postmenopausal women

INTRODUCTION

Osteoporosis is a common disorder characterized by decreased bone mineral density (BMD). Interestingly, osteoporosis and obesity have several similar features, including a genetic predisposition and a common bone marrow stem cell. With aging, the composition of bone marrow shifts to adipocytes, osteoclast activity increases, and osteoblast function declines, resulting in osteoporosis.

MATERIALS AND METHODS

We performed a genome-wide association study (GWAS) analysis with osteoporosis and body mass index (BMI) and did identify an association in 349 and 384 SNPs by filtering with the significant p values (p < 0.001) of BMI and osteoporosis, respectively.

RESULTS

Only three of those SNPs were common (rs2326365, rs7097028, and rs11000205) between the SNPs significantly associated with BMI and/or osteoporosis in Korean Association REsource (KARE) females. Two of the three SNPs belonged to the ASCC1 gene and one to the FAM50B gene. We carried out a minor allele frequency (MAF) analysis of the rs7097028 and rs11000205 SNPs in the ASCC1 gene with a geographic genome variant browser. Both rs7097028 and rs11000205 in the ASCC1 gene were seen mostly in African and Southeast Asian populations.

CONCLUSIONS

Our results suggest that the ASCC1 gene is a significant genetic factor for determining the risk for both osteoporosis and obesity in KARE postmenopausal females.

Secondary Prevention of Osteoporosis Through Assessment of Individual and Multiple Risk Factors

Introduction

Osteoporosis is a chronic progressive bone disease where the bone tissue resorption exceeds its regenerative capacities. Such a process leads to the reduction of bone mineral density (BMD), and distortion of trabecular microarchitectonics, which creates the basis for an increased fracture risk on a "low trauma" for osteoporosis patients. The notion of low trauma implies a stressor that will not cause a fracture in a healthy person under normal circumstances. BMD is a strong predictor of future fractures. However, many fractures occur in persons with BMD values beyond the defined osteoporosis threshold, and BMD measurement only partially identifies the part of the population with increased fracture risk. Also, it is known that risk factors are influencing the bone mass reduction as predictors of future fractures, and their association may lead to an increased fracture risk irrespective of the bone mass and T-score.

Aim

The 10-year individual risk assessment for osteoporotic fracture and the analysis of impact of individual and multiple osteoporosis risk factors on the degree of osteoporotic fracture risk.

Methods

The research is a retrospective-prospective study which analyzed 120 patients divided into two groups: 1) asymptomatic patients with known risk factors for osteoporosis in the age group of 40-65 (n=60), 2) asymptomatic patients with known risk factors for osteoporosis in the age group of 65-90 (n=60). FRAX® algorithm was used as a tool for the 10-year hip fracture risk assessment, with prior approval of the Centre for Metabolic Bone Diseases, University of Sheffield from the United Kingdom. Fracture risk assessment was calculated using the online FRAX® calculator. High risk is defined as the hip fracture risk higher than 3% or the risk of a "big" osteoporotic fracture higher than 20%. Results are expressed as mean values with a standard deviation. A comparison between tested patient groups was made applying the student T-test.

Results

32% of patients of average age of 65.8±12.6 years are under high hip fracture risk, 28% of patients are under the hip fracture risk higher than 3%, and the risk for 0.03% patients is higher than 20%. Patients with high fracture risk are of advanced age, female, with lower body weight and height values, lower bone mineral density (BMD) and T score values than patients who are not under a high fracture risk. A positive family anamnesis to osteoporosis and fractures, earlier fractures, smoking, rheumatoid arthritis, and use of glucocorticoids are risk factors that are more represented in patients with high fracture risk and osteoporosis. The impact of the majority of individual risk factors for osteoporosis and fracture is moderate, and their joint effect is significant. The contribution of individual risk factors to the overall 10-year fracture risk depends on the type, number and association of risk factors.

Conclusion

This research is a contribution to the resolution of polemics among authors, i.e. a dilemma whether persons with multiple clinical risk factors for osteoporosis with T score values beyond the defined threshold for osteoporosis are candidates for therapy with bisphosphonates, and a dilemma whether persons without any clinical risk factors for osteoporosis with T score values within the defined osteoporosis threshold require therapy with bisphosphonates, or only monitoring is sufficient.

Two-Thirds of All Fractures Are Not Attributable to Osteoporosis and Advancing Age: Implications for Fracture Prevention

CONTEXT

Although bone mineral density (BMD) is strongly associated with fracture and postfracture mortality, the burden of fractures attributable to low BMD has not been investigated.

OBJECTIVES

We sought to estimate the population attributable fraction of fractures and fracture-related mortality that can be attributed to low BMD.

DESIGN AND SETTING

This study is a part of an ongoing population-based prospective cohort study, the Dubbo Osteoporosis Epidemiology study. In total, 3700 participants aged ≥50 years participated in the study. Low-trauma fracture was ascertained by X-ray reports, and mortality was ascertained from the Birth, Death and Marriage Registry.

RESULTS

Overall, 21% of women and 11% of men had osteoporotic BMD. In univariable analysis, 21% and 16% of total fractures in women and men, respectively, were attributable to osteoporosis. Osteoporosis combined with advancing age (>70 years) accounted for 34% and 35% of fractures in women and men, respectively. However, these two factors accounted for ∼60% of hip fractures. About 99% and 66% of postfracture mortality in women and men, respectively, were attributable to advancing age, osteoporosis, and fracture; however, most of the attributable proportion was accounted for by advancing age.

CONCLUSIONS

A substantial health care burden of fracture is on people aged <70 years or nonosteoporosis, suggesting that treatment of people with osteoporosis is unlikely to reduce a large number of fractures in the general population.

Fracture Risk Assessment Tool (FRAX®) Results Calculated With and Without Bone Mineral Density Values for the Evaluation of Fracture Risk in Postmenopausal Women With Osteopenia

The aim of this study was to evaluate the agreement between fracture risk predictions based on calculations made with and without bone mineral density (BMD) values using the Fracture Risk Assessment Tool (FRAX®) in Turkish postmenopausal women with osteopenia and to compare the treatment recommendations. This descriptive, cross-sectional study included postmenopausal women aged 50-79 yr with a diagnosis of osteoporosis who were not receiving any treatment. A questionnaire was administered to the participants face-to-face to obtain sociodemographic characteristics, medical history, and fracture history. Fracture risk was calculated with FRAX® separately with and without BMD. The study included 230 postmenopausal patients with osteopenia. The mean age of the patients was determined as 63.16 ± 7.59 yr, and the mean body mass index was 30.61 ± 5.02. The intraclass correlation coefficient values of the 10-yr major osteoporotic (MO) fracture and hip fracture score agreement with FRAX® with and without BMD were mean 0.486 and 0.462, respectively. The risk of MO fracture with an intervention threshold of ≥20 was determined in 227/230 patients (98.7%), and the risk of hip fracture with treatment recommendations of ≥3 was determined in 204/230 patients (88.7%). Treatment recommendations in patients with no fracture history and secondary osteoporosis were 100% for MO fracture and 94.7% (123/130) for hip fracture risk. The treatment recommendation rates of FRAX® with and without BMD were similar for the majority of postmenopausal women with osteopenia. The agreement between the values was of a moderate level. When patients with a fracture history and secondary osteoporosis were excluded, the agreement increased. Even though values with BMD are of basic importance for medical treatment in postmenopausal women, the use of measurements evaluating fracture risk, such as FRAX® without BMD, could be useful in postmenopausal women with osteopenia.

High dairy products intake reduces osteoporosis risk in Korean postmenopausal women: A 4 year follow-up study

BACKGROUND/OBJECTIVES

The aim of this study was to identify the effect of dairy products, milk and yogurt on osteoporosis incidence among Korean postmenopausal women using prospective cohort data.

MATERIALS/METHODS

Between 2001 and 2003, 10,038 participants were recruited in rural and urban areas for a baseline examination of a community-based cohort study. Of those, 1,573 postmenopausal women (aged 40–69 years at baseline) were eligible for the present study. Intakes of dairy products, milk, and yogurt were assessed using a validated semi-quantitative food frequency questionnaire. The speed of sound at the radius and tibia were measured using a quantitative ultrasound device and osteoporosis was defined based on the WHO criteria (T-score ≤ −2.5).

RESULTS

During the 4-years follow-up study, the cumulative incidence of osteoporosis was 18.4% (273 cases) in the radius and 33.6% (407 cases) in the tibia. The subjects with higher frequency of dairy product consumption showed a decreased risk of radius osteoporosis after adjusting for potential confounders [hazard ratio (HR) = 0.51, 95% confidence interval (CI): 0.33–0.80 for >1 time/day vs. non consumer; P for trend = 0.0027]. Similarly, high frequency of milk and yogurt consumption had a protective effect on radius osteoporosis risk [milk: HR = 0.60, 95% CI: 0.42–0.87 for > 5–6 times/week vs. non consumer (P for trend = 0.0130), yogurt: HR = 0.51, 95% CI: 0.30–0.85 for > 5–6 times/week vs. non consumer (P for trend = 0.0167)]. However, high dairy products consumption was not related with tibia osteoporosis.

CONCLUSIONS

This study suggests that daily intake of dairy products could potentially reduce radius osteoporosis incidence among Korean postmenopausal women.

Assessment of osteoporotic fracture risk in urban Indian population using quantitative ultrasonography & FRAX tool

Background & objectives

There have been studies around the world on the prevalence of osteoporosis and its related risk factors, but there have been limited studies on risk factors and osteoporosis in the Indian population. In this study, the incidence of osteoporosis and the associated clinical risk factors (CRFs) were studied in the urban Indian population.

Methods

Bone mineral density of 445 individuals >38 yr of age using qualitative ultrasound (QUS) was assessed. The patients were also questioned regarding the presence of the various CRFs as per the FRAX tool. The patients were categorized into normal, osteopenia and osteoporosis groups on the basis of T-score from QUS.

Results

There were 223 males and 222 females in this study. Sex was significantly associated with T-score (P<0.001). Forty (8.99%) patients were osteoporotic, 265 (59.55%) were osteopenic and the remaining 140 (31.46%) were normal. A significant association of T-score was found with parent history of fracture (P<0.05), rheumatoid arthritis (P<0.05) and secondary osteoporosis (P<0.05). Previous history of fracture's association was not found to be significant. Smoking, alcohol intake and steroid intake were not found to be significantly associated with T-scores.

Interpretation & conclusions

The incidence of osteoporosis was found to be high in the urban Indian population. More care and attention should be targeted towards elderly, especially the ones with the risk factors to prevent osteoporosis in future.

Risk factor analysis for re-collapse of cemented vertebrae after percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP)

PURPOSE

Re-collapse of cemented vertebrae occasionally occurs after percutaneous augmentation. However, the potential risks still remain unclear. Several articles have reported some possible risk factors which were not consistent or comprehensive. This study aimed to make a retrospective review on patients with osteoporotic vertebral compression fracture (OVCF) after percutaneous vertebroplasty (PVP) or percutaneous kyphoplasty (PKP) and to further analyse the risk factors for treated vertebral refracture.

METHODS

All patients receiving the PKP/PVP with bilateral approach were retrospectively reviewed from January 2014 to January 2016, among whom 230 patients with single level augmentation (30 in refracture group and 200 in the non-refracture group) were enrolled according to inclusion criteria. The following covariates were reviewed: gender, age, height, weight, body mass index (BMI), bone mineral density (BMD), serum bone turnover markers, surgical parameters including approach, cement volume, anterior height, and Cobb angle restoration. Binary logistic regression analysis was used to determine the relative risk of re-collapse of cemented vertebrae.

RESULTS

Regarding the patient data, weight, BMI, and BMD were of statistical significance in refracture group (P < 0.01), among which only low BMD was a risk factor to cemented vertebral re-collapse (P = 0.022, OR = 4.197). In respect of surgical variables, the better restoration of anterior height and Cobb angle was found in refracture group (P < 0.05), both of which might increase the refracture risk but not be risk factors (P = 0.065, OR = 0.891, and P = 0.937, OR = 0.996, respectively). Besides, less injected cement (3.30 ± 0.84 ml vs 4.46 ± 1.10 ml, P = 0.000, OR = 19.433) and PKP (P = 0.007, OR = 13.332) significantly boosted the potential risk of refracture (P < 0.001).

CONCLUSION

Patients with low BMD, or undergoing PKP, or receiving a low volume of injected cement might have a high risk of re-collapse in surgical vertebrae.

Delayed Neurological Deficits after Osteoporotic Vertebral Fractures: Clinical Outcomes after Surgery

Study Design

Retrospective cohort.

Purpose

To review the clinical presentation of operated patients with delayed neurological deficits after osteoporotic vertebral fractures (OVFs).

Overview of Literature

Delayed neurological deficits can occur from 1 week to 5.7 months after OVFs. Baba has reported 78% good-to-excellent improvement (i.e., ≥50%) after 20 posterior (Cotrel-Dubousset) and 7 anterior (Kaneda in 4, Zielke ventral derotational spondylodesis in 2, and un-instrumented anterior fusion in 1) fusions. Predictive factors for neurological deficits include burst type, vacuum sign, kyphosis, angular instability, and retropulsion.

Methods

Patients with neurological deficits after OVF who received spinal operations between 2000 and 2016 were included.

Results

Totally, 28 patients with a mean age of 77 years underwent surgery. Neurological deficits occurred at an average of 5.4 weeks after the onset of back pain. The most common site was L1. Burst fracture was present in 14 patients and vacuum sign in seven. Surgery was performed within an average of 3.9 days of the onset of neurological deficit. Baba's score improved significantly from 5.96 to 9.81, with good-to-excellent improvement in 18 (64%) patients. Better outcomes based on Baba's scores (improvement>60% [median]) were associated with compression fractures, preoperative retropulsion of <41%, and correction of >16%. Poor improvement in Baba's scores (<25%) was associated with surgical complications and burst fracture type. Twenty-two patients (79%) regained walking ability, and seven of 15 (47%) patients demonstrated improved sphincter control at the latest follow-up. Six Frankel grade B patients did not achieve neurological recovery, four of whom exhibited postoperative surgical complications and died at 2 years because of medical problems. Implant migration occurred in six patients, albeit this was of no clinical significance.

Conclusions

Although OVFs are commonly considered benign, delayed neurological deficits can occur. The significant improvement in clinical function after surgery for neurological deficits is associated with compression (and not burst) fractures, lack of surgical complications, and optimal restoration of retropulsion.

Fracture Risk Assessment in Clinical Practice: Why Do It? What to Do It With?

Fracture is the outcome of concern in osteoporosis, and fracture reduction is the primary goal of osteoporosis treatment. Fracture risk assessment is a critical component in osteoporosis management. The earlier approach of deciding on whether to treat solely based on bone mineral density (BMD) T-scores has been supplanted by employing the concept of absolute risk over medium time periods and more encompassing integration of clinical risk factors with or without BMD into robust fracture risk assessment tools. Fracture risk estimation allows for identifying high-risk patient groups not only at a health system and population-based level and thereby allowing allocation of financial resources to the people most at risk, but also at an individual level for the clinician to involve the patient in shared decision-making processes for treatment. The process of fracture risk assessment involves several steps including performing a thorough history and physical examination, assessing BMD, doing radiological assessment for vertebral fractures, and laboratory evaluation to rule out secondary contributors to osteoporosis. The data thus obtained can be input into any one of several fracture risk assessment tools that are now available. The decision on which tool to use can be made on the background of country-specific guidelines, although it is imperative that the physician be aware of the limitations inherent to whichever tool is chosen. This article aims to provide a brief overview of why fracture risk estimation is important and the methods that can be employed for it by the physician in clinical practice.

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.

Predictors of non-vertebral fracture in older Chinese males and females: Mr. OS and Ms. OS (Hong Kong)

Clinical risk factors to predict fracture are useful in guiding management of patients with osteoporosis or falls. Clinical predictors may however be population specific because of differences in lifestyle, environment and ethnicity. Four thousand community-dwelling Chinese males and females with average ages of 72.4 and 72.6 years were followed up for incident fractures, with an average of 6.5 and 8.8 years, respectively. Clinical information was collected, and bone mineral density (BMD) measurements were carried out at baseline. Stepwise Cox regression models were used to identify risk factors of nonvertebral fractures, with BMD as covariate. Areas under the receiver-operating characteristic (ROC) curve (AUC) were compared among different risk models. The incidence rates of nonvertebral fractures were 10.3 and 20.5 per 1000 person years in males and females, respectively. In males, age ≥80, history of a fall in the past year, fracture history, chronic obstructive pulmonary disease, impaired visual depth perception and low physical health-related quality of life were significant fracture risk factors, independent of BMD. In females, the significant factors were fracture history, low visual acuity and slow narrow walking speed. The clinical risk factors had a significant influence on fracture risk irrespective of osteoporosis status, even having a better risk discrimination than BMD alone, especially in males. The best risk prediction model consisted both BMD and clinical risk factors. Clinical risk factors have additive value to hip BMD in predicting nonvertebral fractures in older Chinese people and may predict them better than BMD alone in older Chinese males.

Evaluation on the cost-effective threshold of osteoporosis treatment on elderly women in China using discrete event simulation model

This study used a simulation model to determine the cost-effective threshold of fracture risk to treat osteoporosis among elderly Chinese women. Osteoporosis treatment is cost-effective among average-risk women who are at least 75 years old and above-average-risk women who are younger than 75 years old.

INTRODUCTION

Aging of the Chinese population is imposing increasing economic burden of osteoporosis. This study evaluated the cost-effectiveness of osteoporosis treatment among the senior Chinese women population.

METHODS

A discrete event simulation model using age-specific probabilities of hip fracture, clinical vertebral fracture, wrist fracture, humerus fracture, and other fracture; costs (2015 US dollars); and quality-adjusted life years (QALYs) was used to assess the cost-effectiveness of osteoporosis treatment. Incremental cost-effectiveness ratio (ICER) was calculated. The willingness to pay (WTP) for a QALY in China was compared with the calculated ICER to decide the cost-effectiveness. To determine the absolute 10-year hip fracture probability at which the osteoporosis treatment became cost-effective, average age-specific probabilities for all fractures were multiplied by a relative risk (RR) that was systematically varied from 0 to 10 until the WTP threshold was observed for treatment relative to no intervention. Sensitivity analyses were also performed to evaluate the impacts from WTP and annual treatment costs.

RESULTS

In baseline analysis, simulated ICERs were higher than the WTP threshold among Chinese women younger than 75, but much lower than the WTP among the older population. Sensitivity analyses indicated that cost-effectiveness could vary due to a higher WTP threshold or a lower annual treatment cost. A 30 % increase in WTP or a 30 % reduction in annual treatment costs will make osteoporosis treatment cost-effective for Chinese women population from 55 to 85.

CONCLUSIONS

The current study provides evidence that osteoporosis treatment is cost-effective among a subpopulation of Chinese senior women. The results also indicate that the cost-effectiveness of using osteoporosis treatment is sensitive to the WTP threshold and annual treatment costs.

Randomized controlled trial of the effect of phytosterols-enriched low-fat milk on lipid profile in Chinese

Phytosterols found naturally in plants are known to reduce cholesterol absorption in the gut. The traditional southern Chinese diet typically contains many vegetables and not much meat, and there is high prevalence of lactose intolerance in Chinese; we therefore aimed to test if phytosterols-enriched milk is effective in lowering serum LDL-cholesterol in Chinese. Two hundred and twenty-one participants (41 men and 180 women; age 24–79) without cholesterol-lowering drugs or diabetes mellitus were randomized to daily intake of phytosterols-enriched low-fat milk which contained 1.5 g phytosterols per day (N = 110) or a conventional low-fat milk (N = 111) for three weeks. Fasting bloods were taken before and at the end of the study for the measurement of lipid and glucose profile. Physical examination was also performed. Comparing treatment with control, treatment group had significant decrease in serum LDL-cholesterol level (9.5 ± 2.0%; p < 0.0001). Phytosterols intake also decreased total cholesterol (P < 0.0001) and diastolic blood pressure (P = 0.01). Consumption of a phytosterols-enriched low-fat milk led to a significant fall in LDL-cholesterol, total cholesterol, and diastolic blood pressure in Chinese. This can be recommended as part of a healthy diet for people. (ClinicalTrials.gov identifier: NCT02541201; Date of registration: 26 Aug 2015).

Predictors of bone mineral density testing among older women on Medicare

Although dual-energy X-ray absorptiometry (DXA) is recommended for all women ≥65 and is covered by Medicare, 40 % of women on Medicare report never having had a DXA. In a longitudinal cohort of 3492 women followed for two decades, we identified several risk factors that should be targeted to improve DXA testing rates.

INTRODUCTION

DXA is used to measure bone mineral density, screen for osteoporosis, and assess fracture risk. DXA is recommended for all women ≥65 years old. Although Medicare covers DXA every 24 months for women, about 40 % report never having had a DXA test, and little is known from prospective cohort studies about which subgroups of women have low use rates and should be targeted for interventions. Our objective was to identify predictors of DXA use in a nationally representative cohort of women on Medicare.

METHODS

We used baseline and biennial follow-up survey data (1993-2012) for 3492 women ≥70 years old from the nationally representative closed cohort known as the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). The survey data for these women were then linked to their Medicare claims (1991-2012), yielding 17,345 person years of observation. DXA tests were identified from the Medicare claims, and Cox proportional hazard regression models were used with both fixed and time-dependent predictors from the survey interviews including demographic characteristics, socioeconomic factors, health status, health habits, and the living environment.

RESULTS

DXA use was positively associated with being Hispanic American, better cognition, higher income, having arthritis, using other preventative services, and living in Florida or other southern states. DXA use was negatively associated with age, being African-American, being overweight or obese, having mobility limitations, and smoking.

CONCLUSIONS

Interventions to increase DXA use should target the characteristics that were observed here to be negatively associated with such screening.

Long-Term Low Intake of Dietary Calcium and Fracture Risk in Older Adults With Plant-Based Diet: A Longitudinal Study From the China Health and Nutrition Survey

The aim of this longitudinal study was to investigate long-term associations between low dietary calcium intake and fracture risk in older adults with plant-based diet. Data of self-reported first fracture events of any type from 6210 Chinese men and women, aged 50 years or older and free from fracture at baseline, in a subcohort based on the China Health and Nutrition Survey (CHNS), were analyzed. Diet was repeatedly assessed by a combination of three consecutive 24-hour individual dietary recalls and a weighing and measuring of household food inventory in each round. The older men and women habitually ingested mean (SD) of 415 (147) mg/d and 373 (140) mg/d of calcium from plant-based diet, respectively. During a median follow-up of 7.0 years, 127 men (4.34%) and 232 women (7.06%) experienced first fracture events. The crude rates were 4.88, 2.55, and 6.83 per 1000 person-years at risk for men, and 6.72, 7.10, and 11.0 per 1000 person-years at risk for women in the lowest, third, and highest quintile of dietary calcium intake. In nonlinear regressions, an increased risk of fracture was associated with dietary calcium intake more than 778 mg/d (multivariable adjusted hazard ratio [HR] 2.10, 95% confidence interval [CI] 1.00-4.41) or lower than 275 mg/d (1.74, 95% CI 1.00-3.01) for men and more than 651 mg/d for women (1.54, 95% CI 1.00-2.38). A nonsignificant trend of increase in fracture risk was found below 248 mg/d (1.00, 95% CI 0.67-1.50) in women using restricted cubic spline Cox regression. A relatively low fracture risk is observed in men with dietary calcium intakes of 275 to 780 mg/d and in women with intakes of 250 to 650 mg/d, and higher intakes may have no further benefit for fracture prevention. The patterns of dietary calcium with fracture risk are U-shaped in men and possibly in women. © 2016 American Society for Bone and Mineral Research.

Expected lifetime numbers, risks, and burden of osteoporotic fractures for 50-year old Chinese women: a discrete event simulation incorporating FRAX

This work was undertaken to provide an estimation of expected lifetime numbers, risks, and burden of fractures for 50-year-old Chinese women. A discrete event simulation model was developed to simulate the lifetime fractures of 50-year-old Chinese women at average risk of osteoporotic fracture. Main events in the model included hip fracture, clinical vertebral fracture, wrist fracture, humerus fracture, and other fracture. Fracture risks were calculated using the FRAX^® tool. Simulations of 50-year-old Chinese women without fracture risks were also carried out as a comparison to determine the burden of fractures. A 50-year-old Chinese woman at average risk of fracture is expected to experience 0.135 (95 % CI: 0.134-0.137) hip fractures, 0.120 (95 % CI: 0.119-0.122) clinical vertebral fractures, 0.095 (95 % CI: 0.094-0.096) wrist fractures, 0.079 (95 % CI: 0.078-0.080) humerus fractures, and 0.407 (95 % CI: 0.404-0.410) other fractures over the remainder of her life. The residual lifetime risk of any fracture, hip fracture, clinical vertebral fracture, wrist fracture, humerus fracture, and other fracture for a 50-year-old Chinese woman is 37.36, 11.77, 10.47, 8.61, 7.30, and 27.80 %, respectively. The fracture-attributable excess quality-adjusted life year (QALY) loss and lifetime costs are estimated at 0.11 QALYs (95 % CI: 0.00-0.22 QALYs) and US $714.61 (95 % CI: US $709.20-720.02), totaling a net monetary benefit loss of US $1,104.43 (95 % CI: US $904.09-1,304.78). Chinese women 50 years of age are at high risk of osteoporotic fracture, and the expected economic and quality-of-life burden attributable to osteoporotic fractures among Chinese women is substantial.

Osteoporosis in East Asia: Current issues in assessment and management

The greatest burden of hip fractures around the world is expected to occur in East Asia, especially China. However, there is a relative paucity of information on the epidemiology and burden of fractures in East Asia. Osteoporosis is greatly under-diagnosed and under-treated, even among the highest-risk subjects who have already suffered fractures. The accessibility to bone densitometry, the awareness of the disease by professionals and the public, and the use and reimbursement of drugs are some of the areas which need improvement especially. Cost-effective analysis on screening strategy and intervention thresholds based on local epidemiology data and economic status are available only in Japan. In addition, clinical risk factor models for the assessment of fracture probability may be ethnic specific. Further research is needed to develop a cost-effective risk assessment strategy to identify high-risk individuals for screening and treatment based on local data. Moreover, inadequate calcium and vitamin D intake is still an issue faced by this region.

Development of a Korean Fracture Risk Score (KFRS) for Predicting Osteoporotic Fracture Risk: Analysis of Data from the Korean National Health Insurance Service

Background

Asian-specific prediction models for estimating individual risk of osteoporotic fractures are rare. We developed a Korean fracture risk prediction model using clinical risk factors and assessed validity of the final model.

Methods

A total of 718,306 Korean men and women aged 50–90 years were followed for 7 years in a national system-based cohort study. In total, 50% of the subjects were assigned randomly to the development dataset and 50% were assigned to the validation dataset. Clinical risk factors for osteoporotic fracture were assessed at the biennial health check. Data on osteoporotic fractures during the follow-up period were identified by ICD-10 codes and the nationwide database of the National Health Insurance Service (NHIS).

Results

During the follow-up period, 19,840 osteoporotic fractures were reported (4,889 in men and 14,951 in women) in the development dataset. The assessment tool called the Korean Fracture Risk Score (KFRS) is comprised of a set of nine variables, including age, body mass index, recent fragility fracture, current smoking, high alcohol intake, lack of regular exercise, recent use of oral glucocorticoid, rheumatoid arthritis, and other causes of secondary osteoporosis. The KFRS predicted osteoporotic fractures over the 7 years. This score was validated using an independent dataset. A close relationship with overall fracture rate was observed when we compared the mean predicted scores after applying the KFRS with the observed risks after 7 years within each 10th of predicted risk.

Conclusion

We developed a Korean specific prediction model for osteoporotic fractures. The KFRS was able to predict risk of fracture in the primary population without bone mineral density testing and is therefore suitable for use in both clinical setting and self-assessment. The website is available at http://www.nhis.or.kr.

Calcium intake and risk of fracture: systematic review

OBJECTIVE

To examine the evidence underpinning recommendations to increase calcium intake through dietary sources or calcium supplements to prevent fractures.

DESIGN

Systematic review of randomised controlled trials and observational studies of calcium intake with fracture as an endpoint. Results from trials were pooled with random effects meta-analyses.

DATA SOURCES

Ovid Medline, Embase, PubMed, and references from relevant systematic reviews. Initial searches undertaken in July 2013 and updated in September 2014.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials or cohort studies of dietary calcium, milk or dairy intake, or calcium supplements (with or without vitamin D) with fracture as an outcome and participants aged >50.

RESULTS

There were only two eligible randomised controlled trials of dietary sources of calcium (n=262), but 50 reports from 44 cohort studies of relations between dietary calcium (n=37), milk (n=14), or dairy intake (n=8) and fracture outcomes. For dietary calcium, most studies reported no association between calcium intake and fracture (14/22 for total, 17/21 for hip, 7/8 for vertebral, and 5/7 for forearm fracture). For milk (25/28) and dairy intake (11/13), most studies also reported no associations. In 26 randomised controlled trials, calcium supplements reduced the risk of total fracture (20 studies, n=58,573; relative risk 0.89, 95% confidence interval 0.81 to 0.96) and vertebral fracture (12 studies, n=48,967. 0.86, 0.74 to 1.00) but not hip (13 studies, n=56,648; 0.95, 0.76 to 1.18) or forearm fracture (eight studies, n=51,775; 0.96, 0.85 to 1.09). Funnel plot inspection and Egger's regression suggested bias toward calcium supplements in the published data. In randomised controlled trials at lowest risk of bias (four studies, n=44,505), there was no effect on risk of fracture at any site. Results were similar for trials of calcium monotherapy and co-administered calcium and vitamin D. Only one trial in frail elderly women in residential care with low dietary calcium intake and vitamin D concentrations showed significant reductions in risk of fracture.

CONCLUSIONS

Dietary calcium intake is not associated with risk of fracture, and there is no clinical trial evidence that increasing calcium intake from dietary sources prevents fractures. Evidence that calcium supplements prevent fractures is weak and inconsistent.

Fracture predictive ability of physical performance tests and history of falls in elderly women: a 10-year prospective study

In a large cohort of elderly women followed for 10 years, we found that balance, gait speed, and self-reported history of fall independently predicted fracture. These clinical risk factors are easily evaluated and therefore advantageous in a clinical setting. They would improve fracture risk assessment and thereby also fracture prevention.

INTRODUCTION

The aim of this study was to identify additional risk factors for osteoporosis-related fracture by investigating the fracture predictive ability of physical performance tests and self-reported history of falls.

METHODS

In the population-based Osteoporosis Prospective Risk Assessment study (OPRA), 1044 women were recruited at the age of 75 and followed for 10 years. At inclusion, knee extension force, standing balance, gait speed, and bone mineral density (BMD) were examined. Falls the year before investigation was assessed by questionnaire. Cox proportional hazards regression analysis was used to determine fracture hazard ratios (HR) with BMD, history of fracture, BMI, smoking habits, bisphosphonate, vitamin D, glucocorticoid, and alcohol use as covariates. Continuous variables were standardized and HR shown for each standard deviation change.

RESULTS

Of all women, 427 (41%) sustained at least one fracture during the 10-year follow-up. Failing the balance test had an HR of 1.98 (1.18-3.32) for hip fracture. Each standard deviation decrease in gait speed was associated with an HR of 1.37 (1.14-1.64) for hip fracture. Previous fall had an HR of 1.30 (1.03-1.65) for any fracture; 1.39 (1.08-1.79) for any osteoporosis-related fracture; and 1.60 (1.03-2.48) for distal forearm fracture. Knee extension force did not show fracture predictability.

CONCLUSION

The balance test, gait speed test, and self-reported history of fall all hold independent fracture predictability. Consideration of these clinical risk factors for fracture would improve the fracture risk assessment and subsequently also fracture prevention.

Screening for and treatment of osteoporosis: construction and validation of a state-transition microsimulation cost-effectiveness model

This study aimed to document and validate a new cost-effectiveness model of osteoporosis screening and treatment strategies. The state-transition microsimulation model demonstrates strong internal and external validity. It is an important tool for researchers and policy makers to test the cost-effectiveness of osteoporosis screening and treatment strategies.

INTRODUCTION

The objective of this study was to document and validate a new cost-effectiveness model of screening for and treatment of osteoporosis.

METHODS

A state-transition microsimulation model using a lifetime horizon was constructed with seven Markov states (no history of fractures, hip fracture, vertebral fracture, wrist fracture, other fracture, postfracture state, and death) describing the most important clinical outcomes of osteoporotic fractures. Tracker variables were used to record patients' history, such as fracture events, duration of treatment, and time since last screening. The model was validated for Chinese postmenopausal women receiving screening and treatment versus no screening. Goodness-of-fit analyses were performed for internal and external validation. External validity was tested by comparing life expectancy, osteoporosis prevalence rate, and lifetime and 10-year fracture risks with published data not used in the model.

RESULTS

The model represents major clinical facets of osteoporosis-related conditions. Age-specific hip, vertebral, and wrist fracture incidence rates were accurately reproduced (the regression line slope was 0.996, R(2) = 0.99). The changes in costs, effectiveness, and cost-effectiveness were consistent with changes in both one-way and probabilistic sensitivity analysis. The model predicted life expectancy and 10-year any major osteoporotic fracture risk at the age of 65 of 19.01 years and 13.7%, respectively. The lifetime hip, clinical vertebral, and wrist fracture risks at age 50 were 7.9, 29.8, and 18.7% respectively, all consistent with reported data.

CONCLUSIONS

Our model demonstrated good internal and external validity, ensuring it can be confidently applied in economic evaluations of osteoporosis screening and treatment strategies.

The global burden attributable to low bone mineral density

INTRODUCTION

The Global Burden of Disease Study 2010 estimated the worldwide health burden of 291 diseases and injuries and 67 risk factors by calculating disability-adjusted life years (DALYs). Osteoporosis was not considered as a disease, and bone mineral density (BMD) was analysed as a risk factor for fractures, which formed part of the health burden due to falls.

OBJECTIVES

To calculate (1) the global distribution of BMD, (2) its population attributable fraction (PAF) for fractures and subsequently for falls, and (3) the number of DALYs due to BMD.

METHODS

A systematic review was performed seeking population-based studies in which BMD was measured by dual-energy X-ray absorptiometry at the femoral neck in people aged 50 years and over. Age- and sex-specific mean ± SD BMD values (g/cm(2)) were extracted from eligible studies. Comparative risk assessment methodology was used to calculate PAFs of BMD for fractures. The theoretical minimum risk exposure distribution was estimated as the age- and sex-specific 90th centile from the Third National Health and Nutrition Examination Survey (NHANES III). Relative risks of fractures were obtained from a previous meta-analysis. Hospital data were used to calculate the fraction of the health burden of falls that was due to fractures.

RESULTS

Global deaths and DALYs attributable to low BMD increased from 103 000 and 3 125 000 in 1990 to 188 000 and 5 216 000 in 2010, respectively. The percentage of low BMD in the total global burden almost doubled from 1990 (0.12%) to 2010 (0.21%). Around one-third of falls-related deaths were attributable to low BMD.

CONCLUSIONS

Low BMD is responsible for a growing global health burden, only partially representative of the real burden of osteoporosis.

How to decide intervention thresholds based on FRAX in central south Chinese postmenopausal women

The FRAX tool has been used to determine possible thresholds for therapeutic intervention; however, there are no FRAX-based intervention thresholds available for China, we proposed that the 10-year probability of major osteoporotic fracture and hip fracture of about 4.0 and 1.3%, respectively, may be acceptable intervention thresholds for central south Chinese postmenopausal women.

A secular increase in BMD in Chinese women

Population-based studies have revealed a decline in the incidence of age-adjusted hip fractures in southern Chinese women during the past decade. To determine whether there was a secular change in population characteristics that accounted for this decline, we compared the bone mineral density (BMD) and lifestyle habits of two cohorts of women who were more than 50 years of age and who were recruited from 1995 to 2000 and 2005 to 2010. The BMD levels in the 2005-2010 cohort were significantly higher at the spine and hip and ranged from 3.6 to 17.8% among the different age groups. Additionally, a significantly lower prevalence of subjects with osteoporosis and osteopenia was observed. Longer reproductive years, higher levels of physical activity, higher estradiol and 25(OH) vitamin D levels, and lower alkaline phosphatase levels were found in the 2005-2010 cohort. After adjusting for bone-determining factors, significant differences were detected in the BMD levels at the lumbar spine, femoral neck, and total hip (4.17, 9.02, and 9.34%, respectively) in women >50 years of age but not in women ≤50 years of age. The secular increase in BMD and healthier lifestyles most likely led to the decline in the incidence of age-adjusted fractures.

Charlson co-morbidity index and albumin significantly associated with fracture risk in peritoneal dialysis patients

Published literature on fracture in dialysis patients seldom addressed the effect of co-morbidity and malnutrition. In this study, we reported the incidence and risk factors for fracture in peritoneal dialysis patients. Peritoneal dialysis patients who had fractures between 2006 and 2011 were recruited. Demographic data, details of fracture, Charlson Co-morbidity Index (CCI) and biochemical parameters were also collected. Non-fracture controls, matched for age, gender and duration of dialysis, were also recruited at ratio 1:1 for fracture risk analysis. The incidence of fracture was 1 in 37 patient-years. The commonest site of fracture was neck of femur (n = 16, 55.2%). Twenty-four patients (82.8%) developed fracture after slip and fall injury. Eight out of 17 self-ambulatory patients (47.1%) became non-ambulatory after fracture. Infection was the commonest complication during hospitalization. Univariant analysis demonstrated high CCI (P = 0.001), hypoalbuminaemia (P < 0.001), loss of self autonomy (P = 0.006) and non-ambulatory state (P = 0.011) significantly associated with increased fracture risk. However, only CCI (odds ratio (OR) 1.373, P = 0.028) and albumin (OR 0.893, P = 0.025) increased fracture risk significantly on multivariant analysis. Bone profile and parathyroid hormone were not significant risk factors. To conclude, fracture associated with adverse outcome in peritoneal dialysis patients. High CCI score and hypoalbuminaemia significantly increase risk of fracture.

Genetic analysis of recently identified osteoporosis susceptibility genes in southern Chinese

CONTEXT

Fifty-six genomic loci recently were identified as associated with bone mineral density (BMD) in a large meta-analysis study of mainly European-descent subjects. Circulating factors related to calcium and phosphate metabolism, eg, serum levels of calcium, phosphate, vitamin D metabolites, PTH, and alkaline phosphatase (ALP), may affect bone turnover and metabolism.

OBJECTIVE AND DESIGN

We aimed to investigate the effects of these reported variants, as well as their interactions with 5 studied circulating factors, on BMD in a southern Chinese prospective cohort (n = 2670). The identified interactions were further replicated in an independent cohort of 800 Chinese females.

RESULTS

Approximately half (n = 27) of the reported variants were successfully replicated in our sample of southern Chinese individuals. We further demonstrated a significant interaction between MARK3 and serum ALP levels (Pmeta = 9.89 ×10(-6)); the effect of MARK3 rs11623869 on BMD was stronger in the presence of high serum levels of ALP. In addition, several interactions between other genes and circulating factors were suggested.

CONCLUSIONS

Our study has provided an independent replication of associations between several reported loci and BMD in a large sample of southern Chinese individuals. These replicated loci may represent osteoporosis susceptibility genes in both Chinese and European-descent populations. Furthermore, we have shown that serum ALP levels modified the association of MARK3 with BMD. Understanding the mechanisms of the interactions between BMD-related loci and circulating factors may help to determine the pathogenesis of susceptibility to osteoporosis and could have implications for clinical care.

Fracture risk after thiazide-associated hyponatraemia

BACKGROUND/AIM

Although thiazide-type diuretics can promote a positive calcium balance, thiazide can be associated with hyponatraemia, which is recently linked with heightened fracture risk. We examine the chance of developing fracture in patients with and without hyponatraemia after taking thiazide diuretics.

METHODS

In this single-centre retrospective study, we followed up a previously published cohort of patients with (n= 223) and without (n= 216) thiazide-induced hyponatraemia.

RESULTS

A total of 61 osteoporotic fractures was recorded during a mean follow-up period of 82 months. Using univariate regression analysis, the hazard ratio of thiazide-induced hyponatraemia was 1.78 (95% confidence interval (CI), 1.05-3.03; P= 0.033). Cox proportional hazards regression analysis, however, showed that age, body mass index and diabetes mellitus were the only independent predictors of osteoporotic fractures. No association of a history of thiazide-induced hyponatraemia and risk of fracture was evident in the final model.

CONCLUSION

Since a history of thiazide-induced hyponatraemia is associated with osteoporotic fracture in univariate but not multivariate analyses, an alternative explanation is that confounding factors of older age and low body mass index accounted for the apparently increased risk of osteoporotic fracture in patients with thiazide-induced hyponatraemia.

Prevalence and risk factors of radiographic vertebral fractures in elderly Chinese men and women: results of Mr. OS (Hong Kong) and Ms. OS (Hong Kong) studies

This study investigated the prevalence of radiographic vertebral fractures using Genant's semiquantitative (SQ) scoring system in elderly Chinese men (n = 2,000; mean age, 72.4 years) and women (n = 2,000; mean age, 72.6 years). Vertebral deformities had similar prevalence in elderly men (14.9 %) and women (16.5 %). Majority of the deformities in men were mild (9.9 %, grade = 1). The prevalence of vertebral fractures (grade ≥ 2) was 5.0 % among men and 12.1 % among women.

INTRODUCTION

Vertebral fracture is a serious consequence of osteoporosis and is often under-diagnosed. Researches on different ethnicities and territories to estimate the prevalence of vertebral fractures and to identify the risk factors are necessary.

METHODS

Mr. OS (Hong Kong) and Ms. OS (Hong Kong) represent the first large-scale cohort studies ever conducted on bone health in elderly Chinese men (n = 2,000) and women (n = 2,000). The current study investigated the prevalence of radiographic vertebral fractures in these subjects using Genant's SQ scoring system and identified risk factors for vertebral fractures.

RESULTS

The radiographs of all men (mean age, 72.4 years) and women (mean age, 72.6 years) were obtained. Six hundred twenty-seven subjects (15.7 %) had at least one vertebral deformity (SQ grade ≥ 1), including 297 men (14.9 %) and 330 women (16.5 %, p = 0.151). Three hundred forty-two participants (8.6 %) were defined as having at least one vertebra fracture (SQ grade ≥ 2), consisted of 100 men (5.0 %) and 242 women (12.1 %, p < 0.001). Older age, lower bone mineral density, lower physical activity, lower grip strength, fracture history, and low back pain were significantly associated with higher vertebral fracture rate for both men and women.

CONCLUSION

Vertebral deformity had similar prevalence in older men and women, while vertebral fracture was more common in women. Majority of deformities in men was mild. The vertebral deformity prevalence of women from this study is similar to previous reports of other East Asian women and Latin American women.