The association between obesity and fracture is controversial. We investigated the relationship between body mass index (BMI) and fracture at different skeletal sites in women aged !50 years using data from the Sistema d' Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP) database. SIDIAP contains the computerized medical records of >3400 general practitioners in Catalonia (northeastern Spain), with information on a representative 80% of the population (>5 million people). In 2009, 1,039,878 women aged !50 years were eligible, of whom 832,775 (80.1%) had a BMI measurement. These were categorized into underweight/ normal (302,414 women), overweight (266,798), and obese (263,563). Fractures were ascertained using the International Classification of Diseases, 10th revision (ICD-10) codes. Multivariate Poisson regression models were fitted to adjust for age, smoking, high alcohol intake, type 2 diabetes, and oral corticosteroid use. Hip fractures were significantly less common in overweight and obese women than in normal/underweight women (rate ratio Conversely, obese women were at significantly higher risk of proximal humerus fracture than the normal/ underweight group (RR 1.28 [95% CI 1.04 to 1.58], p ¼ 0.018). Clinical spine, wrist, tibial, and multiple rib fracture rates were not significantly different between groups. An age-related increase in incidence was seen for all BMI groups at all fracture sites; obese women with hip, clinical spine, and pelvis fracture were significantly younger at the time of fracture than normal/underweight women, whereas those with wrist fracture were significantly older. The association between obesity and fracture in postmenopausal women is sitedependent, obesity being protective against hip and pelvis fractures but associated with an almost 30% increase in risk for proximal humerus fractures when compared with normal/underweight women. The reasons for these site-specific variations are unknown but may be related to different patterns of falls and attenuation of their impact by adipose tissue. ß[

Low body mass index (BMI) is a recognized risk factor for fragility fracture, whereas obesity is widely believed to be protective. As part of a clinical audit of guidance from the National Institute of Health and Clinical Excellence (NICE), we have documented the prevalence of obesity and morbid obesity in postmenopausal women younger than 75 years of age presenting to our Fracture Liaison Service (FLS). Between January 2006 and December 2007, 1005 postmenopausal women aged less than 75 years with a low-trauma fracture were seen in the FLS. Of these women, 805 (80%) underwent assessment of bone mineral density (BMD) by dual energy X-ray absorptiometry (DXA), and values for BMI were available in 799. The prevalence of obesity (BMI 30 to 34.9 kg/m 2 ) and morbid obesity (BMI ! 35 kg/m 2 ) in this cohort was 19.3% and 8.4%, respectively. Normal BMD was reported in 59.1% of obese and 73.1% of morbidly obese women, and only 11.7% and 4.5%, respectively, had osteoporosis ( p < .0001). Multiple regression analysis revealed significant negative associations between hip T-score and age ( p < .0001) and significant positive associations with BMI ( p < .0001) and previous fracture ( p ¼ .001). Our results demonstrate a surprisingly high prevalence of obesity in postmenopausal women presenting to the FLS with low-trauma fracture. Most of these women had normal BMD, as measured by DXA. Our findings have important public heath implications in view of the rapidly rising increase in obesity in many populations and emphasize the need for further studies to establish the pathogenesis of fractures in obese individuals and to determine appropriate preventive strategies. ß

Introduction Greater awareness of the relationship between co-morbidities and fracture risk may improve fracture-prediction algorithms such as FRAX. Materials and methods We used a large, multinational cohort study (GLOW) to investigate the effect of co-morbidities on fracture risk. Women completed a baseline questionnaire detailing past medical history, including co-morbidity history and fracture. They were re-contacted annually to determine incident clinical fractures. A co-morbidity index, defined as number of baseline co-morbidities, was derived. The effect of adding the co-morbidity index to FRAX risk factors on fracture prevention was examined using chi-squared tests, the May-Hosmer test, c index and comparison of predicted versus observed fracture rates. Results Of 52,960 women with follow-up data, enrolled between October 2006 and February 2008, 3224 (6.1%) sustained an incident fracture over 2 years. All recorded co-morbidities were significantly associated with fracture, except for high cholesterol, hypertension, celiac disease, and cancer. The strongest association was seen with Parkinson’s disease (age-adjusted hazard ratio [HR]: 2.2; 95% CI: 1.6–3.1; P<0.001). Co-morbidities that contributed most to fracture prediction in a Cox regression model with FRAX risk factors as additional predictors were: Parkinson’s disease, multiple sclerosis, chronic obstructive pulmonary disease, osteoarthritis, and heart disease. Conclusion Co-morbidities, as captured in a co-morbidity index, contributed significantly to fracture risk in this study population. Parkinson’s disease carried a particularly high risk of fracture; and increasing co-morbidity index was associated with increasing fracture risk. Addition of co-morbidity index to FRAX risk factors improved fracture prediction.

A site-dependent association between obesity and fracture has been reported in postmenopausal women. In this study we investigated the relationship between body mass index (BMI) and fracture at different skeletal sites in older men (≥65 years). We carried out a population-based cohort study using data from the Sistema d'Informació per al Desenvolupament de l'Investigació en Atenció Primària (SIDIAP(Q) ) database. SIDIAP(Q) contains the primary care and hospital admission computerized medical records of >1300 general practitioners (GPs) in Catalonia (Northeast Spain), with information on a representative 30% of the population (>2 million people). In 2007, 186,171 men ≥65 years were eligible, of whom 139,419 (74.9%) had an available BMI measurement. For this analysis men were categorized as underweight/normal (BMI < 25 kg/m(2) , n = 26,298), overweight (25 ≤ BMI < 30 kg/m(2) , n = 70,851), and obese (BMI ≥ 30 kg/m(2) , n = 42,270). Incident fractures in the period 2007 to 2009 were ascertained using International Classification of Diseases, 10th edition (ICD-10) codes. A statistically significant reduction in clinical spine and hip fractures was observed in obese (relative risk [RR], 0.65; 95% confidence interval [CI], 0.53-0.80 and RR, 0.63; 95% CI, 0.54-0.74, respectively), and overweight men (RR, 0.77; 95% CI, 0.64-0.92 and RR, 0.63; 95% CI 0.55-0.72, respectively) when compared with underweight/normal men. Additionally, obese men had significantly fewer wrist/forearm (RR, 0.77; 95% CI, 0.61-0.97) and pelvic (RR, 0.44; 95% CI, 0.28-0.70) fractures than underweight/normal men. Conversely, multiple rib fractures were more frequent in overweight (RR, 3.42; 95% CI, 1.03-11.37) and obese (RR, 3.96; 95% CI, 1.16-13.52) men. In this population-based cohort of older men, obesity was associated with a reduced risk of clinical spine, hip, pelvis, and wrist/forearm fracture and increased risk of multiple rib fractures when compared to normal or underweight men. Further work is needed to identify the mechanisms underlying these associations.

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Until recently obesity was believed to be protective against fractures. However, a report from a Fracture Liaison Clinic in the UK (2010) reported a surprisingly high proportion of obese postmenopausal women attending the clinic with fractures, and in the GLOW study (2011), a similar prevalence and incidence of fractures in obese and non-obese postmenopausal women was observed. Subsequently, other studies have demonstrated the importance of obesity in the epidemiology of fractures. Obese women are at increased risk of fracture in ankle, leg, humerus, and vertebral column and at lower risk of wrist, hip and pelvis fracture when compared to non-obese women. In men, it has been reported that multiple rib fractures are associated with obesity. Furthermore, falls appear to play an important role in the pathogenesis of fractures in obese subjects. Regarding hip fracture and major fractures, the FRAX algorithm has proven to be a useful predictor in obese individuals. Obese people are less likely to receive bone protective treatment; they have a longer hospital stay and a lower quality of life both before and after fracture. Moreover, the efficacy of antiresorptive therapies is not well established in obese people. The latter is a field for future research. Arq Bras Endocrinol Metab. 2014;58(5):470-7 Keywords Obesity; fractures; osteoporosis; osteopenia ReSumo Acreditava-se que pessoas obesas estavam protegidas contra fraturas. No entanto, um estudo realizado no Reino Unido (2010) encontrou uma proporção surpreendentemente alta de obesidade entre as mulheres na pós-menopausa que se consultaram em uma Clínica de Fraturas Ósseas. Da mesma maneira, o estudo GLOW (2011) observou prevalência e incidência semelhantes de fraturas em mulheres na pós-menopausa obesas e não obesas. Posteriormente, vários outros estudos têm demonstrado a importância da obesidade na epidemiologia de fraturas. Mulheres obesas têm maior risco de fratura no tornozelo, na perna, no úmero e na coluna vertebral e têm menor risco de fratura de punho, quadril e pelve quando comparadas às mulheres não obesas. A associação entre fraturas múltiplas de costelas e obesidade foi descrita em homens. Além disso, as quedas parecem desempenhar um papel importante na patogênese de fraturas em pacientes obesos. O algoritmo FRAX parece ser uma ferramenta útil na predição do risco de fraturas em indivíduos obesos. Indivíduos obesos são menos propensos a receber tratamento preventivo para as fraturas ósseas e, quando sofrem uma fratura óssea, sua internação costuma ser mais longa do que a internação de indivíduos magros. A qualidade de vida dos indivíduos obesos é menor antes e depois da fratura. Não obstante, a eficácia de terapias antirreabsorção não está bem estabelecida em pessoas obesas. Este último é um campo para pesquisas futuras. Arq Bras Endocrinol Metab. 2014;58(5):470-7 Descritores Obesidade; fraturas ósseas; osteoporose, osteopenia

Fractures in obese older individuals contribute significantly to the overall burden on primary health care, but data on their impact on mortality are lacking. We studied the association between obesity and mortality following hip and nonhip clinical fractures in a retrospective, population-based cohort study. The Sistema d'Informacio pel Desenvolupament de la Investigacio en Atencio Primària (SIDIAP Q ) database contains primary care computerized medical records of a representative sample of >2.1 million people (35% of the population) in Catalonia (Spain), linked to hospital admissions data. We included in this analysis anyone aged 40 years and older suffering a hip or nonhip clinical fracture in 2007 to 2009 in the SIDIAP Q database. The main exposure was the most recent body mass index (BMI) measured before fracture, categorized as underweight (<18.5 kg/m 2 ), normal (18.5 to <25 kg/m 2 ), overweight (25 to <30 kg/m 2 ), and obese (!30 kg/m 2 ). Furthermore, the study outcome was all-cause mortality in 2007 to 2009 as provided to SIDIAP Q by the National Office of Statistics. Time to death after fracture was modeled using Cox regression. Multivariate models were adjusted for age, gender, smoking, alcohol intake, oral glucocorticoid use, and Charlson comorbidity index. Within the study period, 6988 and 29,372 subjects with a hip or nonhip clinical fracture were identified and followed for a median (interquartile range) of 1.17 (0.53-2.02) and 1.36 (0.65-2.15) years, respectively. Compared to subjects of normal weight, adjusted hazard ratios (HRs) for mortality in overweight and obese subjects were 0.74 (95% CI, 0.62-0.88; p ¼ 0.001) and 0.74 (95% CI, 0.60-0.91; p ¼ 0.004) after hip and 0.50 (95% CI, p ¼ 0.002), 0.56 (95% CI,; p ¼ 0.010) after nonhip fracture. In conclusion, the highest mortality was observed in individuals with low BMI, but compared to subjects of normal weight, obese and overweight individuals survived longer following fracture. The latter observation is consistent with data reported in other chronic conditions, but the reasons for reduced mortality in obese and overweight subjects when compared to those of normal weight require further research.

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