Comparison of Bone Mineral Density between Urban and Rural Areas: Systematic Review and Meta-Analysis

Prevalence and predictors of osteosarcopenia and relationship with physical functionality in rural and urban Indian women

Age-related bone and muscle impairments lead to osteoporosis and sarcopenia, and their coexistence, osteosarcopenia, causes functional decline but is less studied. We found higher prevalence of osteosarcopenia in rural (13.9%) vs urban women (1.6%), with risk factors including older age, low BMI, tobacco use, low protein, and low socioeconomic status.

BACKGROUND

With ageing, bone and muscle impairment leading to osteoporosis and sarcopenia often co-exist, increasing risk of falls/fractures, physical disability, and premature mortality. Osteosarcopenia, where osteoporosis and sarcopenia co-exist, and its relationship with physical functionality in older adults is relatively less explored. Hence, we aimed to assess the prevalence, predictors, and physical functionality in urban and rural women with osteosarcopenia.

METHODS

We included 397 women > 40 years (182 urban, 215 rural, mean age 52 ± 7) from Pune and nearby villages. Height, weight, BMI, bone density (lumbar spine, femur via DXA), grip strength (JAMAR dynamometer), and muscle function (SPPB) were assessed. Sarcopenia and osteoporosis were diagnosed using AWGS and WHO guidelines, with osteosarcopenia defined as both conditions. Lifestyle factors (diet, physical activity, tobacco use, socioeconomic status) were evaluated by validated questionnaire.

RESULTS

Rural women had higher rates of osteoporosis (42%), sarcopenia (19%), and osteosarcopenia (13.9%) compared to urban women (18%, 3.8%, and 1.6%, respectively). Sarcopenic women had nearly 6 times higher risk (OR = 6.2, 95%CI = 3.2-11.9, p = 0.001) of developing osteoporosis, with the risk remaining significant after adjusting for age and location. Osteosarcopenic women showed impaired physical function and lower bone density, with older age and low BMI as key risk factors.

CONCLUSION

Rural Indian women showed high rates of osteosarcopenia, osteoporosis, and sarcopenia, with older, low-BMI, postmenopausal women at higher risk. Contributing factors included low socioeconomic status, tobacco use, and poor protein intake. Addressing modifiable risks is important to reduce frailty-related outcomes in rural population.

Fracture risk prediction & kidney function at different stages of chronic kidney disease: A correlation study

Background & objectives Mineral bone disease commonly occurs in individuals with chronic kidney disease (CKD) and increases fracture risk due to deficiency in bone quality and quantity. The FRAX score attempts to estimate fracture risk better. The primary aim of this study was to evaluate the prediction and correlation of fracture risk with different stages of CKD. Methods This was a correlational study. Data were collected from 95 individuals at different stages of CKD using non-probability consecutive sampling. The clinical and laboratory parameters were compared with the FRAX score in all CKD patients. Results A total of 95 CKD patients with a mean age of 51.42±9.95 yr were selected. Of these, 66.3 per cent between 40-55 yr, 25.3 per cent were 56-70 yr, and 8.4 per cent were ≥70 yr. There were 62 (65.3%) males and 33 (34.7%) females, and more than half (60%) were from rural areas. Age (P<0.001), occupation (P<0.005), and area of residence (P<0.003) showed a significant association with the FRAX score for major osteoporotic fracture risk. The FRAX score for predicting hip fracture risk showed a significant association with factors such as age, occupation, and area of residence, with P values of <0.001, 0.003, and 0.031, respectively. Additionally, the FRAX score for assessing the risk of major osteoporotic fractures demonstrated a significant association with various stages of CKD (P=0.018). Similarly, for hip fracture, there was a significant increase in the risk between stage III and V CKD patients (P=0.038). Interpretation & conclusions Based on the study findings it was found that the FRAX score was significantly associated with different stages of CKD, both for major osteoporotic as well as hip fracture risk.

Geographical variation in osteoporosis in Australian women: a longitudinal analysis over 23 years

Osteoporosis affects over half of older women, whether urban compared to rural residents have different risk of osteoporosis is unclear. This 23-year longitudinal study of Australian women found lower risk of osteoporosis and fractures among women living in rural compared with urban areas, which may relate to distribution of risk factors and/or screening opportunities.

PURPOSE

To determine whether the prevalence of osteoporosis, fractures, and dual-X-ray absorptiometry (DXA) differs between Australian women living in rural compared with urban areas.

METHODS

The Australian Longitudinal Study on Women's Health, a prospective longitudinal study of Australian women, includes a cohort of women born 1946-1951, surveyed nine times from 1996-2019. Data from administrative health records were linked to survey data. Geographic area was classified as major city, inner regional, outer regional, or remote. Generalised estimating equations (GEE) explored outcomes of osteoporosis, fracture, and DXA rates. Univariable and multivariable regression were performed and bootstrapping with 100 repetitions at 95% sampling of the original dataset to ensure robust results.

RESULTS

A total of 13,712 women were included: 5000 (36.5%) living in major cities, 5214 (38.0%) inner regional, 2798 (20.41%) outer regional, and 700 (5.1%) remote areas. Baseline age, 47.6 (1.46) years (mean (SD)), was similar; but education, marital status, country of birth, smoking, BMI, and comorbidities varied between areas. Over 23 years, 2956 (21.6%) were diagnosed with osteoporosis, 3185 (23.2%) had an incident fracture, and 8151 (59.4%) had a DXA. On univariable analysis, women living outside major cities had lower risk of osteoporosis (inner regional OR 0.92; 95% CI 0.84, 0.99; outer regional 0.70; 0.63, 0.79; remote 0.43; 0.34, 0.53), and lower risk of fractures (inner regional area OR 0.92, 95% CI 0.84, 0.99; outer regional 0.81; 0.73, 0.90; remote 0.54; 0.42, 0.67), than women living in major cities. These differences were no longer significant on multivariable analysis, suggesting differences might be related to the distribution of risk factors. Women living in inner regional and outer regional areas were significantly less likely to have a DXA, than those living in a major city (OR 0.75, 95% CI 0.70, 0.81; OR 0.72; 95% CI 0.64, 0.77, respectively), and this remained significant on multivariable analysis.

CONCLUSION(S)

Osteoporosis or fracture affected one-third of older Australian women, and women living outside major cities had lower rates of osteoporosis, fractures, and DXA completion.

Urban-rural differences in outcomes and management of vertebral fractures: A real-world observational study

BACKGROUND

A fracture liaison services (FLSs) and its modified services reduce refractures and mortality and can be cost-effective. Limited studies have addressed whether urban-rural differences exist in vertebral fracture outcomes and management. Therefore, the aims of the study were to investigate any urban-rural differences in refracture, mortality, prescription pattern, and associated factors of vertebral fractures after receiving assistance from an FLSs.

METHODS

Baseline characteristics and osteoporosis medication prescription patterns of participants were collected. After 1-year follow-up, mortality, refracture rate, and osteoporosis medication switching and adherence were evaluated. Multivariate logistic regressions were performed to identify baseline correlates on one-year mortality.

RESULTS

There was higher mortality rate in the rural group but no urban-rural difference in the 1-year refracture rate after implementation of FLSs and medication management services (MMSs). The types of osteoporosis medications prescribed for both groups were similar, but participants in the rural group were less likely to change their osteoporosis medications during the 1-year follow-up timeframe and with lower adherence rate. The likelihood of being older and having chronic kidney disease, osteoarthritis, and neurological disease was higher in the rural group.

CONCLUSIONS

Our multicomponent services have similar effectiveness in osteoporosis treatment between urban and rural areas. The overall adherence rate was lower in the rural group with higher mortality but no difference in the refracture rate in one year.

Effects of sex, tobacco smoking, and alcohol consumption osteoporosis development: Evidence from Taiwan biobank participants

INTRODUCTION

Osteoporosis is major public health concern, but the long-term impacts of tobacco and alcohol consumption on its development are unclear. This study analyzed the relationship between tobacco and alcohol use and osteoporosis by using data from the Taiwan Biobank (TWB), established in 2012.

METHODS

Participants in TWB were included in our study, with a total of 18394 respondents included for analysis. To investigate the relationship between tobacco and alcohol use and osteoporosis, we surveyed their bone mineral density (BMD), consumption of tobacco and alcohol and other covariate data.

RESULTS

We found that participants in the tobacco smoking only group (OR=1.24; 95% CI: 1.08–1.42, p=0.003) and the group that both smoked and consumed alcohol (OR=1.39; 95% CI: 1.09–1.77, p=0.008) were more likely to develop osteoporosis than were participants who neither drank alcohol nor smoked. Menopause is strongly associated with osteoporosis in women, and we found that women who used alcohol or tobacco were not at a significantly higher risk than those in the reference group (tobacco only, OR=1.15; 95% CI: 0.86–1.53, p=0.345; both tobacco and alcohol, OR=0.61; 95% CI: 0.14–2.60, p=0.5040). However, men in these groups were at a significantly higher risk than the reference group (tobacco only, OR=1.26; 95% CI: 1.07–1.48, p=0.006; both tobacco and alcohol, OR=1.32; 95% CI: 1.03–1.70, p=0.030). Menopause was a significant risk factor for osteoporosis (OR=2.46; 95% CI: 1.77–3.41, p<0.001).

CONCLUSIONS

The influence of tobacco use on osteoporosis was significant, particularly in men, but the effects of alcohol consumption were equivocal in our study. The interactions between tobacco use, alcohol use, and menopausal status on osteoporosis should be considered in future studies.

Molecular and cellular mechanisms linking air pollution and bone damage

Air pollution is the second most important risk factor associated with noncommunicable diseases after smoking. The effects of pollution on health are commonly attributable to particulate matter (PM), a complex mixture of particles suspended in the air. PM can penetrate the lower respiratory tract and has harmful direct and indirect effects on different organs and tissues. Direct effects are caused by the ability of PM components to cross the respiratory membrane and enter the bloodstream; indirect effects are systemic consequences of the local airway response. Recent work suggests that PM is an independent risk factor for low bone mineral density and osteoporosis-related fractures. Osteoporosis is a common age-related disease closely linked to bone fractures, with severe clinical consequences affecting quality of life, morbidity, and mortality. In this review, we discuss potential mechanisms behind the association between outdoor air pollution, especially PM, and bone damage. The discussion features four main mechanisms: 1) several different atmospheric pollutants can induce low-grade systemic inflammation, which affects bone metabolism through a specific effect of cytokines such as TNFα, IL-1β, IL-6, and IL-17 on osteoblast and osteoclast differentiation and function; 2) some pollutants, particularly certain gas and metal compounds, can cause oxidative damage in the airway and bone cells; 3) different groups of pollutants can act as endocrine disruptors when binding to the receptors in bone cells, changing their functioning; and 4) air pollution can directly and indirectly cause vitamin D deficiency. Characterizing these mechanisms will better define the physiopathology of bone damage, and recognizing air pollution as a modifiable risk factor for osteoporosis will inform environmental policies. Such knowledge will also guide the prevention of fractures due to fragility and help reduce health-related costs.

Association of Ambient and Household Air Pollution With Bone Mineral Content Among Adults in Peri-urban South India

IMPORTANCE

Air pollution is a major threat to global health. Osteoporosis is responsible for a substantial burden of disease globally and is expected to increase in prevalence because of population aging. Few studies have investigated the association between air pollution and bone health, and their findings were inconclusive.

OBJECTIVE

To quantify the association between ambient and household air pollution and bone mass in a sample of the general population in peri-urban India.

DESIGN, SETTING, AND PARTICIPANTS

This was a population-based cross-sectional analysis of the Andhra Pradesh Children and Parents Study cohort, which recruited participants from 28 villages near Hyderabad, South India, during 2009 to 2012. Separate linear mixed models were fitted with nested random intercepts (household within villages) for each exposure-outcome pair and were sequentially adjusted for potential confounders. Data analysis was conducted between April 2019 and July 2019.

EXPOSURES

Annual mean ambient particulate matter air pollution less than 2.5 µm in aerodynamic diameter (PM2.5) and black carbon (BC) levels at the residence estimated by land-use regression and self-reported use of biomass cooking fuel.

MAIN OUTCOMES AND MEASURES

The primary outcome was bone mineral content (BMC) measured in grams, corrected by bone area at the lumbar spine and left hip, as measured by dual-energy x-ray absorptiometry. The secondary outcome was bone mineral density measured in grams per centimeters squared.

RESULTS

A total of 3717 participants were analyzed (mean [SD] age, 35.7 [14.0] years; 1711 [46.0%] women). The annual mean (SD) PM2.5 exposure was 32.8 (2.5) μg/m3, and the annual mean (SD) BC exposure was 2.5 (0.2) μg/m3; 57.8% of participants used biomass cooking fuels. In fully adjusted models, PM2.5 was associated with lower BMC in the spine (mean difference, -0.57 g per 3 μg/m3 increase in PM2.5; 95% CI, -1.06 to -0.07 g per 3 μg/m3 increase in PM2.5) and hip (mean difference, -0.13 g per 3 μg/m3 increase in PM2.5; 95% CI, -0.3 to 0.03 g per 3 μg/m3 increase in PM2.5). After confounder adjustment, exposure to PM2.5 was also associated with lower bone mineral density in the spine (mean difference, -0.011 g/cm2 per 3 μg/m3 increase in PM2.5; 95% CI, -0.021 to 0 g/cm2 per 3 μg/m3 increase in PM2.5) and hip (mean difference, -0.004 g/cm2 per 3 μg/m3 increase in PM2.5; 95% CI, -0.008 to 0.001 g/cm2 per 3 μg/m3 increase in PM2.5). Exposure to BC was associated with lower BMC in the spine (mean difference, -1.13 g per 1 μg/m3 increase in BC; 95% CI, -2.81 to 0.54 g per 1 μg/m3 increase in BC) and hip (mean difference, -0.35 g per 1 μg/m3 increase in BC; 95% CI, -0.96 to 0.25 g per 1 μg/m3 increase in BC), although the confidence intervals were wider. There was no association between biomass fuel use and spine BMC (mean difference, 0.12 g; 95% CI, -0.45 to 0.68 g).

CONCLUSIONS AND RELEVANCE

In a cross-sectional analysis of a population-based cohort, ambient air pollution was associated with lower BMC in a young adult population in a peri-urban area of South India.

Association Between Osteoporosis and Age-Related Macular Degeneration: The Korea National Health and Nutrition Examination Survey

Purpose

Previous studies have reported a possible link between low bone mineral density and AMD. The aim of the present study was to investigate the association between osteoporosis and AMD in a South Korean cohort.

Methods

This cross-sectional, nationwide study included 3496 women and 2789 men who had participated in the Korean National Health and Nutrition Examination Survey from 2008 to 2011. All retinal photographs were graded using an international classification and grading system. Osteoporosis was assessed using dual-energy x-ray absorptiometry. Multivariate logistic regression analysis was performed to examine the relationship between osteoporosis and AMD after adjustment for potential confounders, including age, the body mass index, dietary calcium intake, and the serum vitamin D level. The odds ratios (OR) for other aging-related eye diseases, including cataract, open-angle glaucoma, and diabetic retinopathy, were analyzed in accordance with the presence of osteoporosis.

Results

Multivariate regression analysis revealed that osteoporosis was significantly associated with all types of AMD (early and late: OR, 1.31; P = 0.017) and early AMD (OR, 1.36; P = 0.007) in women. Late AMD was not associated with osteoporosis (OR, 0.84; P = 0.670). In men, osteoporosis was not associated with any type of AMD. In women, the status of osteoporosis in the femoral neck showed a linear relationship with AMD (P = 0.004). Although osteoporosis was associated with AMD in women, it showed no association with other age-related eye diseases; this suggested a disease-specific association.

Conclusions

Our findings suggest that osteoporosis plays a role in AMD development in postmenopausal women.

Effects of depression and antidepressant medications on hip fracture: A population-based cohort study in Taiwan

This study was conducted to investigate the effects of depression and antidepressant medications on hip fracture. The database of the Taiwan National Health Insurance with medical records of more than 1,000,000 individuals was searched for patients who had hip fracture with or without depression from 1998 to 2009. Patients with the following conditions were excluded: hip fracture due to cancer or traffic accidents, hip fracture that occurred before the diagnosis of depression, and use of antidepressants before the diagnosis of depression. A matched cohort of 139,110 patients was investigated, including 27,822 (17,309 females; 10,513 males) with depression and 111,288 (69,236 females; 42,052 males) without depression (1:4 randomly matched with age, sex, and index date). Among these patients, 232 (158 females and 74 males) had both hip fracture and depression, and 690 (473 females and 217 males) had hip fracture only. The Cox proportional-hazards regression method was used to determine the effect of depression on hip fracture. The hazard ratio (HR) for each clinical parameter was calculated after adjusting for confounders including sex, age, Charlson comorbidity index, urbanization, osteoporosis, and antidepressants. Results showed that patients with major depressive disorder had a 61% higher incidence of hip fracture than those without depression (HR 1.61, 95% confidence interval [CI] 1.19-2.18, P = 0.002). The risk of hip fracture for patients with less severe depressive disorder (dysthymia or depressive disorder, not otherwise specified) was not statistically higher than that of patients with no depression (HR 1.10, 95% CI = 0.91-1.34, P = 0.327). Among the patients with depression, females had a 49% higher incidence for hip fracture than males (HR 1.49, 95% CI 1.30-1.72, P < 0.001). The incidence of hip fracture also increased with age and Charlson comorbidity index scores. Analyses of both all (139,110) patients and only patients (27,822) with depression revealed that antidepressants had no negative impact on the incidence of hip fracture. In conclusion, major depression was found to be a risk factor for hip fracture and that use of antidepressants had no adverse effect on hip fracture in the Taiwanese population.

Urban-Rural Differences in Bone Mineral Density: A Cross Sectional Analysis Based on the Hyderabad Indian Migration Study

Background

Fracture risk is rising in countries undergoing rapid rural to urban migration, but whether this reflects an adverse effect of urbanization on intrinsic bone strength, as reflected by bone mineral density (BMD), is currently unknown.

Methods

Lumbar spine (LS) and total hip (TH) BMD, and total body fat and lean mass, were obtained from DXA scans performed in the Hyderabad arm of the Indian Migration Study (54% male, mean age 49 years). Sib-pair comparisons were performed between rural-urban migrants (RUM) and rural non-migrated (RNM) siblings (N = 185 sib-pairs).

Results

In analyses adjusted for height, gender, age and occupation, rural to urban migration was associated with higher lumbar and hip BMD and greater predicted hip strength; ΔLS BMD 0.030 (0.005, 0.055) g/cm², ΔTH BMD 0.044 (0.024; 0.064) g/cm², Δcross-sectional moment of inertia 0.162 (0.036, 0.289) cm⁴. These differences were largely attenuated after adjusting for body composition, insulin levels and current lifestyle factors ie. years of smoking, alcohol consumption and moderate to vigorous physical activity. Further analyses suggested that differences in lean mass, and to a lesser extent fat mass, largely explained the BMD differences which we observed.

Conclusions

Rural to urban migration as an adult is associated with higher BMD and greater predicted hip strength, reflecting associated alterations in body composition. It remains to be seen how differences in BMD between migration groups will translate into fracture risk in becoming years.