Hormone therapy and risk of non-vertebral fracture : Geelong Osteoporosis Study

In this population-based study, we evaluated the association between exposure to hormone therapy (HT), bone mineral density (BMD) and the prevalence of non-vertebral fractures. The study was set in a region located in southeastern Australia where complete fracture ascertainment was determined from radiological reports. Current HT use for at least 6 months was ascertained in women with non-vertebral fractures [median age 70.9 years; inter-quartile range (IQR) 66.5–75.9 years] and randomly selected controls (median age 70.8 years; IQR 65.2–75.0 years). Current HT use was documented in 20 of 262 cases and 49 of 364 controls. The odds ratio (OR) for non-vertebral fracture associated with HT use was 0.53 (95% CI 0.31–0.92). HT use was associated with 2.6–7.5% higher BMD at axial and appendicular sites. HT use is associated with a halving of risk for non-vertebral fractures and higher BMD.

The population burden of fractures originates in women with osteopenia, not osteoporosis

Introduction : Osteoporosis is associated with increased risk for fracture. However, most postmenopausal women have bone mineral density (BMD) within the normal or osteopenic range. The aim of this study was to determine the proportion of the population burden of fragility fractures arising from women at modest risk for fracture.

Methods : We measured baseline BMD in a population-based random sample of 616 postmenopausal women aged 60–94 years and followed these individuals for a median of 5.6 years (IQR 3.9–6.5) to determine the incidence of fractures according to age, BMD and the presence of a prior fracture.

Results : Based on WHO criteria, 37.6% of the women had normal total hip BMD, 48.0% had osteopenia and 14.5% had osteoporosis. The incidence of fracture during follow-up was highest in women with osteoporosis, but only 26.9% of all fractures arose from this group; 73.1% occurred in women without osteoporosis (56.5% in women with osteopenia, 16.6% in women with normal BMD). Decreasing BMD, increasing age and prior fracture contributed independently to increased fracture risk; in a multivariate model, the relative risk for fracture increased 65% for each SD decrease in BMD (RR=1.65, 95%CI 1.32–2.05), increased 3% for every year of age (RR=1.03, 95%CI 1.01–1.06) and doubled with prevalent fracture (RR=2.01, 95% CI 1.40–2.88). A prevalent fracture increased the risk for fractures such that women with osteopenia and prevalent fracture had the same, if not greater, risk as women with osteoporosis alone.

Half the burden of fragility fractures in the community occur in women without osteoporosis. When is fracture prevention cost-effective?

To determine the age- and BMD-specific burden of fractures in the community and the cost-effectiveness of targeted drug therapy, we studied a demographically well-categorized population with a single main health provider. Of 1224 women over 50 years of age sustaining fractures during 2 years, the distribution of all fractures was 11%, 20%, 33%, and 36% in those aged 50–59, 60–69, 70–79, and 80+ years, respectively. Osteoporosis (T score < −2.5) was present in 20%, 46%, 59%, and 69% in the respective age groups. Based on this sample and census data for the whole country, treating all women over 50 years of age in Australia with a drug that halves fracture risk in osteoporotic women and reduces fractures in those without osteoporosis by 20%, was estimated to prevent 18,000 or 36% of the 50,000 fractures per year at a total cost of $573 million (AUD). Screening using a bone mineral density of T score of −2.5 as a cutoff, misses 80%, 54%, 41%, and 31% of fractures in women in the respective age groups. An analysis of cost per averted fracture by age group suggests that treating women in the 50- to 59-year age group with osteoporosis alone costs $156,400 per averted fracture. However, in women aged over 80 years, the cost per averted fracture is $28,500. We infer that treating all women over 50 years of age is not feasible. Using osteoporosis and age (>60 years) as criteria for intervention reduces the population burden of fractures by 28% and is cost-effective but solutions to the prevention of the remaining 72% of fragility fractures remain unavailable.

Anthropometric profiling of elite junior and senior Australian football players

Purpose: Body structure and physical development must be addressed when preparing junior athletes for their first season in a senior competition. The aim of this preliminary study was to measure the extent of the assumption that final year junior Australian Football (AF) athletes are at a physical mismatch to their senior counterparts.

Methods: Twenty-one male participants (17.71 ± 0.27 y) were recruited from one state based elite junior AF competition and forty-one male participants (22.80 ± 4.24 y) were recruited from one club competing in the senior elite Australian Football League (AFL), who were subsequently divided into two groups; professional rookies aged 18-20 y (19.44 ± 0.70 y; n = 18) and professional seniors aged 21+ y (25.43 ± 3.98 y; n = 23). Dual energy X-ray absorptiometry (DEXA) scans of all participants were completed.

Results: Despite being an average 6.0% and 6.1% lighter in total weight and lean mass respectively, no significant difference was found between the elite junior athletes and their professional AFL rookie counterparts. However, significant differences were demonstrated in comparison with the professional AFL senior athletes (P < .01). Both professional AFL groups demonstrated greater than 0.3 kg total bone mineral content (BMC) than the elite junior athletes (P < .01) and significantly greater segmental BMC and bone mineral density (BMD) results (P < .05).

Conclusion: While the results identify the differences in body composition of the elite junior athletes, development in a linear fashion is noted, providing useful information for the creation of age appropriate expectations and training programs.

Osteo-cise : Strong bones for life': protocol for a community-based randomised controlled trial of a multi-modal exercise and osteoporosis education program for older adults at risk of falls and fractures

Background : Osteoporosis affects over 220 million people worldwide, and currently there is no 'cure' for the disease. Thus, there is a need to develop evidence-based, safe and acceptable prevention strategies at the population level that target multiple risk factors for fragility fractures to reduce the health and economic burden of the condition.

Methods : The 'Osteo-cise: Strong Bones for Life' study will investigate the effectiveness and feasibility of a multi-component targeted exercise, osteoporosis education/awareness and behavioural change program for improving bone health and muscle function, and reducing falls risk in community-dwelling older adults at an increased risk of fracture. Men and women aged 60 years or above will participate in an 18-month randomised controlled trial comprising a 12-month structured and supervised community-based program and a 6-month 'research to practise' translational phase. Participants will be randomly assigned to either the 'Osteo-cise' intervention or a self-management control group. The intervention will comprise a multi-modal exercise program incorporating high velocity progressive resistance training, moderate impact weight-bearing exercise and high challenging balance exercises performed three times weekly at local community-based fitness centres. A behavioural change program will be used to enhance exercise adoption and adherence to the program. Community-based osteoporosis education seminars will be conducted to improve participant knowledge and understanding of the risk factors and preventative measures for osteoporosis, falls and fractures. The primary outcomes measures, to be collected at baseline, 6, 12, and 18 months, will include DXA-derived hip and spine bone mineral density measurements and functional muscle power (timed stair-climb test). Secondary outcomes measures include: MRI-assessed distal femur and proximal tibia trabecular bone micro-architecture, lower limb and back maximal muscle strength, balance and function (four square step test, functional reach test, timed up-and-go test and 30-second sit-to-stand), falls incidence and health-related quality of life. Cost-effectiveness will also be assessed.

Discussion : The findings from the Osteo-cise: Strong Bones for Life study will provide new information on the efficacy of a targeted multi-modal community-based exercise program incorporating high velocity resistance training, together with an osteoporosis education and behavioural change program for improving multiple risk factors for falls and fracture in older adults at risk of fragility fracture. Trial Registration: Australian New Zealand Clinical Trials Registry reference ACTRN12609000100291

Direct comparison of eight national FRAX® tools for fracture prediction and treatment qualification in Canadian women

The authors compared the calibration of FRAX tools from Canada, the US (white), UK, Sweden, France, Australia, New Zealand, and China when used to assess fracture risk in 36,730 Canadian women. Their data underscores the importance of applying country-specific FRAX tools that are based upon high-quality national fracture epidemiology.

Is lower income associated with an increased likelihood of qualification for treatment for osteoporosis in Canadian women?

The authors examined whether low income was associated with an increased likelihood of treatment qualification for osteoporotic fracture probability determined by Canada FRAX in women aged ≥50 years. A significant negative linear association was observed between income and treatment qualification when FRAX included bone mineral density (BMD), which may have implications for clinical practice.

The global burden of musculoskeletal conditions for 2010: an overview of methods.

The objective of this paper is to provide an overview of methods used for estimating the burden from musculoskeletal (MSK) conditions in the Global Burden of Diseases 2010 study. It should be read in conjunction with the disease-specific MSK papers published in Annals of Rheumatic Diseases. Burden estimates (disability-adjusted life years (DALYs)) were made for five specific MSK conditions: hip and/or knee osteoarthritis (OA), low back pain (LBP), rheumatoid arthritis (RA), gout and neck pain, and an 'other MSK conditions' category. For each condition, the main disabling sequelae were identified and disability weights (DW) were derived based on short lay descriptions. Mortality (years of life lost (YLLs)) was estimated for RA and the rest category of 'other MSK', which includes a wide range of conditions such as systemic lupus erythematosus, other autoimmune diseases and osteomyelitis. A series of systematic reviews were conducted to determine the prevalence, incidence, remission, duration and mortality risk of each condition. A Bayesian meta-regression method was used to pool available data and to predict prevalence values for regions with no or scarce data. The DWs were applied to prevalence values for 1990, 2005 and 2010 to derive years lived with disability. These were added to YLLs to quantify overall burden (DALYs) for each condition. To estimate the burden of MSK disease arising from risk factors, population attributable fractions were determined for bone mineral density as a risk factor for fractures, the occupational risk of LBP and elevated body mass index as a risk factor for LBP and OA. Burden of Disease studies provide pivotal guidance for governments when determining health priority areas and allocating resources. Rigorous methods were used to derive the increasing global burden of MSK conditions.

(1)H-NMR analysis of the human urinary metabolome in response to an 18-month multi-component exercise program and calcium-vitamin-D3 supplementation in older men

The musculoskeletal benefits of calcium and vitamin-D3 supplementation and exercise have been extensively studied, but the effect on metabolism remains contentious. Urine samples were analyzed by (1)H-NMR spectroscopy from participants recruited for an 18-month, randomized controlled trial of a multi-component exercise program and calcium and vitamin-D3 fortified milk consumption. It was shown previously that no increase in musculoskeletal composition was observed for participants assigned to the calcium and vitamin-D3 intervention, but exercise resulted in increased bone mineral density, total lean body mass, and muscle strength. Retrospective metabolomics analysis of urine samples from patients involved in this study revealed no distinct changes in the urinary metabolome in response to the calcium and vitamin-D3 intervention, but significant changes followed the exercise intervention, notably a reduction in creatinine and an increase in choline, guanidinoacetate, and hypoxanthine (p < 0.001, fold change > 1.5). These metabolites are intrinsically involved in anaerobic ATP synthesis, intracellular buffering, and methyl-balance regulation. The exercise intervention had a marked effect on the urine metabolome and markers of muscle turnover but none of these metabolites were obvious markers of bone turnover. Measurement of specific urinary exercise biomarkers may provide a basis for monitoring performance and metabolic response to exercise regimes.

Age- and sex-related patterns of first fracture and fracture prevalence

There are few data documenting the pattern of prevalent fracture across the entire adult age range, so we aimed to address this gap by investigating the prevalence of fractures in an Australian cohort. All-cause (ever) fractures were identified for males and females enrolled in the Geelong Osteoporosis Study (Australia) using a combination of radiology-confirmed and self-reported data. First fractures were used to generate age-related frequencies of individuals who had ever sustained a fracture. Of 1,538 males and 1,731 females, 927 males and 856 females had sustained at least one fracture since birth. The proportion of all prevalent fractures in the 0-10 year age group was similar for both sexes (~10 %). In males, the proportion with prevalent fracture increased to 34.1 % for age 11-20 year. Smaller increases were observed into mid-life, reaching a plateau at ~50 % from mid to late life. The age-related prevalence of fracture for females showed a more gradual increase until mid-life. For adulthood prevalent fractures, approximately 20 % of males had sustained a first adulthood fracture in the 20-30 year age group, with a gradual increase up to the oldest age group (49.1 %), while females showed an exponential pattern of increase from the 20-30 year age group (6.8 %) to the oldest age group (60.4 %). In both sexes, those who had not sustained a fracture in childhood or early adulthood generally appeared to remain fracture-free until at least the sixth decade. When considering the prevalence of adulthood fractures across the age groups, males showed a gradual increase while females showed an exponential increase.

Adulthood fracture and quality of life : A population-based study of Australian men

Background: Our objective was to investigate associations between adulthood fracture and quality of life (QOL) in men. Methods: For 448 men aged 50-85 years and enrolled in the Geelong Osteoporosis Study, we measured QOL using the validated (Australian) World Health Organization Quality of Life-Brief Version (WHOQOL-Bref) in the domains of physical health, psychological health, social relationships, and the environment. Self-reported adulthood fractures were categorized as recent or non-recent ( ≤ 10 years or > 10 years pre-QOL assessment, respectively). Lifestyle and health information were self-reported. Results: One hundred seventy four men (38.8%) sustained at least one fracture, 26% of which had occurred within the last 10 years. Compared with men who had never had an adulthood fracture, a non-recent fracture was more likely associated with poorer QOL in the physical health domain (age-adjusted odds ratio [OR] 0.47, 95% confidence interval [95%CI] 0.27-0.83), but not in any other domain. Men who had sustained a recent fracture reported a lower QOL in the domain of psychological health (age-adjusted OR 0.48, 95%CI 0.24-0.97), with a trend observed for lower QOL in the domains of physical health and environment. No further associations were observed. All results were sustained in further models that were adjusted for smoking, alcohol, physical inactivity, and body mass index. Conclusions: We present novel data examining associations between fracture status and QOL in a populationbased sample of Australian men using the WHOQOL-Bref. Recent fractures were associated with poorer QOL in the domain of psychological health while non-recent fractures were more likely associated poorer QOL for physical health. These findings have important implications for healthcare post-fracture.

Knowledge change regarding osteoporosis prevention: translating recommended guidelines into user-friendly messages within a community forum.

Osteoporosis is a skeletal disorder characterised by low bone mineral density and increased fracture risk. Nationally the total costs of this chronic disease are currently estimated at $2.754 billion annually. Effective public health messages providing clear recommendations are vital in supporting prevention efforts. This research aimed to investigate knowledge change associated with the translation of preventive guidelines into accessible messages for the community.

Fracture prediction from repeat BMD measurements in clinical practice

Summary: We investigated whether repeat BMD measurements in clinical populations are useful for fracture risk assessment. We report that repeat BMD measurements are a robust predictor of fracture in clinical populations; this is not affected by preceding BMD change or recent osteoporosis therapy. Introduction: In clinical practice, many patients selectively undergo repeat bone mineral density (BMD) measurements. We investigated whether repeat BMD measurements in clinical populations are useful for fracture risk assessment and whether this is affected by preceding change in BMD or recent osteoporosis therapy. Methods: We identified women and men aged ≥50 years who had a BMD measurement during 1990–2009 from a large clinical BMD database for Manitoba, Canada (n = 50,215). Patient subgroups aged ≥50 years at baseline with repeat BMD measures were identified. Data were linked to an administrative data repository, from which osteoporosis therapy, fracture outcomes, and covariates were extracted. Using Cox proportional hazards models, we assessed covariate-adjusted risk for major osteoporotic fracture (MOF) and hip fracture according to BMD (total hip, lumbar spine, femoral neck) at different time points. Results: Prevalence of osteoporosis therapy increased from 18 % at baseline to 55 % by the fourth measurement. Total hip BMD was predictive of MOF at each time point. In the patient subgroup with two repeat BMD measurements (n = 13,481), MOF prediction with the first and second measurements was similar: adjusted-hazard ratio (HR) per SD 1.45 (95 % CI 1.34–1.56) vs. 1.64 (95 % CI 1.48–1.81), respectively. No differences were seen when the second measurement results were stratified by preceding change in BMD or osteoporosis therapy (both p-interactions >0.2). Similar results were seen for hip fracture prediction and when spine and femoral neck BMD were analyzed. Conclusion: Repeat BMD measurements are a robust predictor of fracture in clinical populations; this is not affected by preceding BMD change or recent osteoporosis therapy.