Osteoporotic fractures are a major worldwide epidemic. Here, we review global variability, ethnic differences and secular changes in osteoporotic fractures. Worldwide, age-standardized incidence rates of hip fracture vary >200-fold in women and >140-fold in men when comparing the country in which incidence rates are the highest with that in which they are the lowest. Median age-standardized rates are highest in North America and Europe, followed by Asia, Middle East, Oceania, Latin America and Africa. Globally, rates of hip fracture are greater in women than in men, with an average ratio of ∼2:1. The incidence of radiographic vertebral fractures is much higher than that of hip fractures, whereas the incidence rates of clinical vertebral fractures mirror hip fracture rates in most countries. Methodological challenges of defining and ascertaining vertebral fractures limit the interpretation of these data. Secular declines in hip fracture rates have been reported in populations from North America, Europe and Oceania. These declines are especially notable in women, suggesting that reproductive factors might contribute to this reduction. By contrast, hip fracture rates are increasing in parts of Asia and Latin America. Global indicators of health, education and socioeconomic status are positively correlated with fracture rates suggesting that lifestyles in developed countries might contribute to hip fracture. Improvements in fracture assessment, in particular for nonhip fractures, and identification of factors that contribute to this variability might substantially influence our understanding of osteoporotic fracture aetiology and provide new avenues for prevention.
Objectives To test the hypothesis that men and women with both low bone mineral density and sarcopenia have a higher risk of fracture than those with only one or neither conditions. Design The Osteoporotic Fractures in Men study and the Study of Osteoporotic Fractures in women are prospective observational studies with a mean follow up of 9 years (2000–2012) and 8years (1997–2009) respectively. Setting US clinical centers Participants 5,544 men (mean age=73.7 years) and 1,114 women (mean age=77.6 years); all ≥age 65; able to walk without assistance, and without bilateral hip replacement. Measurements Sarcopenia was defined as low appendicular lean mass plus either slowness or weakness; and low bone mineral density, by the World Health Organization definition of T-score<−1.0. Participants were classified as normal bone mineral density and no sarcopenia (N=3367 men, 308 women); sarcopenic only (N=79 men; 48 women); low bone mineral density only (N=1986 men; 626 women), and low bone mineral density and sarcopenic (N=112 men; 132 women). Results Compared to men with normal bone mineral density and no sarcopenia, the Hazard ratio [HR] for fracture was 3.79 (95% confidence interval [CI], 2.65–5.41) among men with low bone mineral density and sarcopenia, 1.67 (95% CI, 1.45–1.93) among men with low bone mineral density only, and 1.14 (95% CI, 0.62–2.09) among men with sarcopenia only. Women with low bone mineral density and sarcopenia (HR, 2.27; 95% CI, 1.37–3.76), and women with low bone mineral density alone (HR, 2.62; 95% CI, 1.74–3.95), but not women with only sarcopenia had increased risk of fracture compared to normal women. Conclusion Men with both low bone mineral density and sarcopenia are at especially high risk of fracture.
Frailty is a risk factor for cardiovascular diseases (CVD), but the studies available have not considered the presence of subclinical atherosclerotic disease as potential confounders. We investigated the association between frailty and the onset of CVD independently of subclinical atherosclerotic disease. For this reason, a sample of 3818 older participants participating in the Age, Gene/Environment Susceptibility—Reykjavik Study without CVD at baseline was followed for a median of 8.7 years. Frailty was defined as the presence of ≥3 among five Fried's criteria (unintentional weight loss, low physical activity level, weakness, exhaustion, and slow gait speed). Incident CVD was defined as onset of coronary artery disease, heart failure, stroke, and CVD-related mortality identified using hospital, medical, and death records. Subclinical atherosclerotic disease was evaluated as the maximum value of carotid intima media thickness, presence of carotid plaque (moderate or high), and total coronary calcifications (CACs). At baseline, frail participants (n = 300) were more frequently obese, diabetic, and had a greater presence of metabolic syndrome than the nonfrail (n = 3518). Frail participants also showed a higher presence of carotid plaques and CACs. Using a Cox's regression analysis, adjusted for clinical, biochemical, and subclinical atherosclerosis estimates, frailty increased the risk of CVD (hazard ratio [HR] = 1.35; 95% confidence interval [CI]: 1.05–1.74), with results stronger for women than men (HR = 1.51, p = 0.006 and 1.19, p = 0.44, respectively). Among Fried's criteria, exhaustion was the only criterion significantly associated with the onset of new CVD events (HR = 1.30; 95% CI: 1.00–1.73). In conclusion, frailty was associated with the onset of CVD in older people even after adjusting for subclinical atherosclerotic disease.
Although many studies have examined the association between low bone mineral density (BMD) and fracture risk in older men, none have simultaneously studied the relationship between multiple BMD sites and risk of different types of fractures. Using data from the Osteoporotic Fractures in Men study, we evaluated the association between areal BMD (aBMD) by dual-energy X-ray absorptiometry (DXA) and volumetric BMD (vBMD) by quantitative computed tomography (QCT) measurements, and different types of fractures during an average of 9.7 years of follow up. Men answered questionnaires about fractures every 4 months (>97% completions). Fractures were confirmed by centralized review of radiographic reports; pathological fractures were excluded. Risk of fractures was assessed at the hip, spine, wrist, shoulder, rib/chest/sternum, ankle/foot/toe, arm, hand/finger, leg, pelvis/coccyx, skull/face and any non-spine fracture. Age and race adjusted Cox proportional-hazards modeling was used to assess the risk of fracture in 3301 older men with both aBMD (at the femoral neck (FN) and lumbar spine) and vBMD (at the trabecular spine and FN, and cortical FN) measurements, with hazard ratios (HRs) expressed per standard deviation (SD) decrease. Lower FN and spine aBMD were associated with an increased risk of fracture at the hip, spine, wrist, shoulder, rib/chest/sternum, arm, and any non-spine fracture (statistically significant HRs per SD decrease ranged from 1.24 - 3.57). Lower trabecular spine and FN vBMD were associated with increased risk of most fractures with statistically significant HRs ranging between 1.27 and 3.69. There was a statistically significant association between FN cortical vBMD and fracture risk at the hip (HR=1.55) and spine sites (HR=1.26), but no association at other fracture sites. In summary, both lower aBMD and vBMD were associated with increased fracture risk. The stronger associations observed for trabecular vBMD than cortical vBMD may reflect the greater metabolic activity of the trabecular compartment.
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