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Osteoporosis in women: Epidemiological and diagnostic perspectives
Linköping University, Department of Biomedicine and Surgery. Linköping University, Faculty of Health Sciences.
2002 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

An epidemiological study of 15.462 hip fractures in Östergötland 1940-86 showed a large incidence increase mainly due to an increase in age-specific incidence of trochanteric fractures. A trendforecast assuming the same increase in incidence as over the study period and a population forecast according to the official prognosis, predicted 70% more hip fractures in the year 2000 compared to 1985. The different forecasts models were validated for the year 1995 and showed a good correlation between estimated and observed number of fractures, but varied dependent on which fracture and prognosis model that were evaluated.

A follow-up investigation of 11.517 hip fractures 1982-96 showed a downturn in incidence of female fractures and a continous increase for males, particularly of trochanteric fractures. A trend brake was thus seen and this continues up to 2010 according to our trendforecasts but may be counteracted by the increasing number of elderly after 2020. Gender ratio changed over time with increasing number of male fractures, more trochanteric fractures relative to cervical (c/t-ratio) and an increasing mean age of the fracture patient.

Age specific reference values were established for bone mineral density (BMD) in forearm, lumbar spine and hip after investigation of 429 women 20-80 years, randomly sampled from the general population. Bone density was assessed from cross-sectional data for the various skeletal sites over an almost complete adult life period and these were then compared to values obtained from other studies, densitometry technologies and reference materials. Large discordances were found between the different technologies and reference materials.

The outcome of using the T-score proposed by a WHO study group 1994 as a diagnostic cutoff principle for the diagnosis of osteoporosis (T<-2.5) and osteopenia (T<-1 - -2.5) was evaluated by calculating the resulting prevalence in a cohort of 210 women, 70 years of age. The use of different approaches in calculation of T -score and different reference samples, yielded unacceptable disparities in disease prevalence of between 9 and 72%. The differences were also heavely dependent of which and how many sites that were included in the diagnostic decision.

We studied biochemical markers of bone turnover (alkaline phosphatase, osteocalcin, hydroxyproline and calcium excretion in the urine) in relation to age, menopause and BMD, and their ability to predict bone loss in a 5-year follow-up perspective. Markers varied inversely to BMD, increased markedly at menopause and predicted bone loss over the next 5 years up to 75% at individual level, (AUC of an ROC analysis).

A case. finding strategy using low-energy index fractures in forearm, spine, hip or humerus was performed to detect subjects with osteoporosis. 303 consecutive women 55-75 years with a recent fracture were examined with densitometry and a risk profile questionnaire. The lowest BMD was found in spine and hip fracture patients. Odds ratio for osteoporosis was at least 8 for a patient with a prior hip fracture. The number of previous fractures correlated inversely with bone density (Z-score). Despite 92% of the fracture patients (many with a multiple fracture history) had a low bone mass (t-score<1), only 15% had been treated for osteoporosis before the index fracture.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2002. , 129 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 737
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-25686Local ID: 10062ISBN: 91-7373-531-0 (print)OAI: oai:DiVA.org:liu-25686DiVA: diva2:246234
Public defence
2002-06-05, Folkhälsovetenskapligt Centrums Aula, Universitetssjukhuset, Linköping, 09:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-12Bibliographically approved
List of papers
1. Increased Hip-Fracture Incidence in the County of Östergötland, Sweden, 1940–1986, with Forecasts up to the Year 2000: An Epidemiological Study
Open this publication in new window or tab >>Increased Hip-Fracture Incidence in the County of Östergötland, Sweden, 1940–1986, with Forecasts up to the Year 2000: An Epidemiological Study
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1991 (English)In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 20, no 4, 1018-1024 p.Article in journal (Refereed) Published
Abstract [en]

The incidence of hip fractures in the county of Östergōtland in Sweden has increased dramatically from 1940 to 1986, mainly due to an increase in age-specific incidence of trochanteric fractures. The increase is most pronounced in people over 80 but is present even in age groups down to 50 years. If the age-specific incidence rates continue to increase, and the population of the elderly grows in accordance with the forecast, there will be 70% more hip fractures in the year 2000 than in 1985.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81307 (URN)10.1093/ije/20.4.1018 (DOI)
Available from: 2012-09-11 Created: 2012-09-11 Last updated: 2017-12-07Bibliographically approved
2. Changes in Hip Fracture Epidemiology: Redistribution Between Ages, Genders and Fracture Types
Open this publication in new window or tab >>Changes in Hip Fracture Epidemiology: Redistribution Between Ages, Genders and Fracture Types
2002 (English)In: Osteoporosis International, ISSN 0937-941X, E-ISSN 1433-2965, Vol. 13, no 1, 18-25 p.Article in journal (Refereed) Published
Abstract [en]

After several reports of increasing hip fracture incidence some studies have suggested a trend-break. In a previous study of hip fractures we forecast a 70% increase in the total number of fractures from 1985 up to year 2000. We therefore studied the incidence trend for the last 15 years and supply a new prognosis up to year 2010. We recorded all incident hip fractures treated in the county of Östergötland, Sweden (≈ 400 000 inhabitants) 1982–96. A total of 11 517 hip fractures in men and women aged 50 years and above were included in the study after cross-validation between a computerized register of radiologic investigations and the hospital records. The projected number of fractures up to year 2010 was estimated by a Poisson regression model, considering both age and year of fracture in every single year 1982–96 for the respective fracture type and gender, and applied to the projected population. The annual number of hip fractures increased by 39% in men and 25% in women during the study period. Amongst men, the age-adjusted incidence of cervical fractures increased from 188 to 220/100 000 and of trochanteric fractures from 138 to 170/100 000. In women the incidence of cervical fractures decreased from 462/100 000 to 418/100 000 and of trochanteric fractures from 407/100 000 to 361/100 000. Cervical/trochanteric fracture incidence rate ratio leveled off, and also the female/male fracture rate ratio declined. A prognosis assuming that the incidence development will continue as during 1982–96, and a population in agreement with the forecast, predicts that the total age- and sex-adjusted number of hip fractures will decrease by 11% up to year 2010 compared with 1996. In women and men, however, a decrease of 19% and an increase of 7% respectively were projected. If the age- and sex-specific incidence remains at the same level as at the end of the study period, no significant change in the total numbers will occur. A trend-break was thus found in hip fracture incidence for women but not for men. Whether this is due to therapeutic and/or preventive measures in women is unknown. According to the most probable scenario a substantial increase in male trochanteric fractures (36%) is expected up to 2010, while all other hip fractures in both genders will decrease by 4–32% resulting in a total reduction of 11%.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25209 (URN)10.1007/s198-002-8333-x (DOI)9648 (Local ID)9648 (Archive number)9648 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2012-09-12Bibliographically approved
3. Bone mineral density in normal Swedish women
Open this publication in new window or tab >>Bone mineral density in normal Swedish women
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1997 (English)In: Bone, ISSN 8756-3282, E-ISSN 1873-2763, Vol. 20, no 2, 167-174 p.Article in journal (Refereed) Published
Abstract [en]

We examined 429 women, aged 20–80 years, randomly selected from the population register to establish normal values for bone mineral density (BMD) in Swedish women. BMD of the spine and hip was measured by dual-energy X-ray absorptiometry (DEXA; Hologic QDR 1000) and in the forearm by single photon absorptiometry (SPA; Molsgaard ND-1100). The recalled age of menarche was negatively correlated to BMD at all ages. There was no significant change in BMD from 20–49 years at any site except a slight decline at Ward's triangle. Bone loss was rapid at all sites during the first decade after menopause. Thereafter, BMD declined slowly in the trochanter and total hip but more rapidly in the forearm, femoral neck, and Ward's triangle. BMD in the spine even increased in the eighth decade probably due to osteoarthritis. The average change in forearm BMD during the 15 perimenopausal years comprising mean age for menopause ± 2 SD (43–57 years) was −0.4% per year in premenopausal females and −1.6% per year in postmenopausal females. The corresponding annual percental change was, for the spine, +0.2 and −1.7; neck, −0.7 and −1.7; trochanter, +0.5 and −1.5; and Ward's triangle, −0.1% and −2.2%, respectively. Our normal values for lumbar spine BMD prior to menopause did not differ from published values or the manufacturer's normal values; however, our spine BMD values for the first decade after menopause were significantly lower (≈10%) than in other studies. Our femoral neck BMD values for younger women were, like those of several other groups, significantly lower than the manufacturer's normal values, but our sample of young women in this study was small. The prevalence of osteoporosis, if defined as t score < −2.5 is highly dependent on the sampling of the reference population of young adult women, and also on the choice of skeletal site. Further studies on bone mineral density in healthy young adult women are needed.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81309 (URN)10.1016/S8756-3282(96)00345-6 (DOI)
Available from: 2012-09-11 Created: 2012-09-11 Last updated: 2017-12-07Bibliographically approved
4. Bone Mineral Density in Diagnosis of Osteoporosis: Reference Population, Definition of Peak Bone Mass, and Measured Site Determine Prevalence
Open this publication in new window or tab >>Bone Mineral Density in Diagnosis of Osteoporosis: Reference Population, Definition of Peak Bone Mass, and Measured Site Determine Prevalence
2000 (English)In: Journal of clinical densitometry, ISSN 1094-6950, Vol. 3, no 2, 177-186 p.Article in journal (Refereed) Published
Abstract [en]

A population-based study was performed in order to compare different definitions of peak bone mass, and to apply the corresponding T-scores for different skeletal sites to a cohort of 70-yr-old women for studying the prevalence of osteoporosis. Bone mineral density (BMD) of the hip, lumbar spine, and forearm was measured by dual X-ray absorptiometry (Hologic 4500) in 296 women ages 16–31 yr and 210 women age 70 yr. Peak bone mass occurred in women in their early 20s at the proximal femur and at 28 and 31 yr at the spine and forearm, respectively. BMD cutoff levels were compared to machine-specific cutoff values for the different sites. When applied to our cohort of 70-yr-old women, the prevalence of osteoporosis at the total hip was 9–25%, depending on which peak bone mass the T-score of – 2.5 was based. The prevalence in the spine was 28–33% and in the forearm 45–67%. Osteoporosis in at least one of the three measured sites was documented in 49–72% of the population sample. Our results show that the use of T-score to define osteoporosis results in a highly different prevalence rate in a given population depending on the reference population and the skeletal sites chosen for measurement.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25205 (URN)10.1385/JCD:3:2:177 (DOI)9644 (Local ID)9644 (Archive number)9644 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2012-09-12Bibliographically approved
5. Bone mineral density instead of T-score?
Open this publication in new window or tab >>Bone mineral density instead of T-score?
2001 (English)In: Journal of clinical densitometry, ISSN 1094-6950, Vol. 4, no 1, 75-77 p.Article in journal, Letter (Refereed) Published
Abstract [en]

No abstract available.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-25208 (URN)10.1016/S1094-6950(06)60152-2 (DOI)9647 (Local ID)9647 (Archive number)9647 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2012-09-12Bibliographically approved
6. Common biochemical markers of bone turnover predict future bone loss: A 5-year follow-up study
Open this publication in new window or tab >>Common biochemical markers of bone turnover predict future bone loss: A 5-year follow-up study
2005 (English)In: Clinica Chimica Acta, ISSN 0009-8981, E-ISSN 1873-3492, Vol. 356, no 1-2, 67-75 p.Article in journal (Refereed) Published
Abstract [en]

Background

Bone mineral density (BMD) is used to follow gain or loss of bone mass but cannot detect changes within a short period of time. Biochemical markers of bone turnover may be of value for prediction of individual bone loss.

Methods

We studied the relation between common inexpensive markers of bone turnover (serum alkaline phosphatase (ALP), osteocalcin (OC), urinary hydroxyproline (OHPr), and calcium (Ca)), BMD, age, and menopause in a combined cross-sectional and longitudinal design comprising 429 pre- and postmenopausal randomly selected women aged 21–79 years (mean 50 years). A follow-up was initiated after 5 years (including 192 of these women), which focused on changes in bone mass and the ability of these four common markers of bone turnover (sampled at baseline) to predict future bone loss.

Results

A marked increase was observed for all markers at the beginning of menopause. During the postmenopausal period ALP and Ca decreased to near premenopausal levels, while OC and OHPr remained high even 15 years after menopause. We also found inverse correlations at baseline between the bone markers and BMD, independent of the selected marker or skeletal site, r=−0.14 to −0.46, P<0.05. The correlations between ALP, OC, OHPr, and subsequent bone loss over 5 years, was significant for arm, r=−0.23 to −0.36, P<0.01. Baseline levels of all bone markers correlated significantly at group level with the 5-year follow-up of BMD for all sites. The ability of markers to predict individual bone loss was estimated by a multivariate regression model, which included baseline BMD, age, and body mass index as independent variables. ROC analysis showed a validity of approximately 76% for the forearm model, but was lower for the hip (55%) and lumbar spine (65%).

Conclusions

These data show that the common inexpensive biochemical markers of bone turnover ALP, OC, OHPr, and Ca were related to the current bone mass and, moreover, provides information about future bone loss at the individual level. Future investigations should include an evaluation of the clinical relevance of markers of bone turnover in relation to fracture risk.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-29375 (URN)10.1016/j.cccn.2004.12.014 (DOI)14707 (Local ID)14707 (Archive number)14707 (OAI)
Note

On the day of the defence day the status of this article was a manuscript.

Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2012-09-12Bibliographically approved
7. Women with low energy fracture: Case for investigation?
Open this publication in new window or tab >>Women with low energy fracture: Case for investigation?
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: The combined use of bone mineral density, fracture history and other risk markers for fracture is advocated for identifying subjects with high fracture risk. An incident fracture is suggested as an accurate indication for osteoporosis investigation, but there are still insufficient data for grading the priority between ages and types of fractures. We therefore decided to examine a consecutive series of 55-75 year old women with an incident fracture for evaluating a standardized clinical routine program and for studying the covariance between fracture history, bone mineral density and other risk markers.

Materila and methods: We invited 600 consecutive women 55-75 years old with an incident newly diagnosed fracture in distal radius forearm, proximal humerus, vertebra or hip. External drop-out was 33%. Of the 400 responders 31 had a high-energy trauma, 62 were on treatment against osteoporosis and 4 were living in other counties and were therefore excluded. The remaining 303 subjects entered the study. A questionnaire on previous fractures and risk factors was enclosed with the invitation to the osteoporosis unit. At a single visit a short history was assessed and physical examination performed as well as a few laboratory investigations. Bone mineral density was measured at the hip, lumbar spine and forearm by DXA (Hologic QDR 4500A).

Results: The fracture spectrum was: distal radius 56.4 %, proximal humerus 12.2%, vertebra 18.2% and hip 13.2%. 49% had had at least one previous fracture, 19% at least two previous and 6.3% three or more previous fractures before the recent one. As few spine X-rays were performed, the true prevalence of vertebral fracture is unknown. Patients with fracture in vertebra or hip had lower BMD and more previous fractures than patients with forearm or humerus fracture. The number of previous fractures was inversely correlated to BMD of the hip and forearm, while BMD of the spine had a biphasic relationship.

The Odds ratio of having either osteopenia and osteoporosis were >20 for patients with hip fracture and 75 for the spine (mean values), whereas the OR of the forearm fracture group was slightly above 10, table 6. The OR were as expected dependent of cut-off limit used. Mean value for the OR was in the hip fracture group 8.2 and 9.2 for !-score -2.5 and -2.0 respectively at the lower end of the confidence interval. For the spine and the forearm, the corresponding odds ratios were 16-17 and 7-9 respectively.

Conclussion: Vertebral fracture was the strongest and distal radius the weakest predictor of low BMD. The number of previous fractures is a helpful information for finding the most osteoporotic patients. Only 15 % had been treated for osteoporosis before the index fracture. Osteoporosis investigation therefore seems warranted in every woman 55-75 years old with a recent low-energy fracture in distal radius, proximal humerus, spine or hip, with highest priority to those in spine or hip and those with multiple previous fractures.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81343 (URN)
Available from: 2012-09-12 Created: 2012-09-12 Last updated: 2012-09-12Bibliographically approved

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