Elsevier

Bone

Volume 50, Issue 3, March 2012, Pages 713-722
Bone

Original Full Length Article
Independent predictors of all osteoporosis-related fractures among healthy Saudi postmenopausal women: The CEOR Study

https://doi.org/10.1016/j.bone.2011.11.024Get rights and content

Abstract

This study was designed to identify independent predictors of all osteoporosis-related fractures (ORFs) among healthy Saudi postmenopausal women. We prospectively followed a cohort of 707 healthy postmenopausal women (mean age, 61.3 ± 7.2 years) for 5.2 ± 1.3 years. Data were collected on demographic characteristics, medical history, personal and family history of fractures, lifestyle factors, daily calcium intake, vitamin D supplementation, and physical activity score. Anthropometric parameters, total fractures (30.01 per 1000 women/year), special physical performance tests, bone turnover markers, hormone levels, and bone mineral density (BMD) measurements were performed. The final model consisted of seven independent predictors of ORFs: [lowest quartile (Q1) vs highest quartile (Q4)] physical activity score (Q1 vs Q4: ≤ 12.61 vs ≥ 15.38); relative risk estimate [RR], 2.87; (95% confidence interval [CI]: 1.88–4.38); age  60 years vs age < 60 years (RR = 2.43; 95% CI: 1.49–3.95); hand grip strength (Q1 vs Q4: ≤ 13.88 vs ≥ 17.28 kg) (RR = 1.88; 95% CI: 1.15–3.05); BMD total hip (Q1 vs Q4: ≤ 0.784 vs 0.973 g/cm2) (RR = 1.86; 95% CI: 1.26–2.75); dietary calcium intake (Q1 vs Q4: ≤ 391 vs ≥ 648 mg/day) (RR = 1.66; 95% CI: 1.08–2.53); serum 25(OH)D (Q1 vs Q4: ≤ 17.9 vs ≥ 45.1 nmol/L) (RR = 1.63; 95% CI: 1.06–2.51); and past year history of falls (RR = 1.61; 95% CI: 1.06–2.48). Compared with having none (41.9% of women), having three or more clinical risk factors (4.8% of women) increased fracture risk by more than 4-fold, independent of BMD. Having three or more risk factors and being in the lowest tertile of T-score of [total hip/lumbar spine (L1–L4)] was associated with a 14.2-fold greater risk than having no risk factors and being in the highest T-score tertile. Several clinical risk factors were independently associated with all ORFs in healthy Saudi postmenopausal women. The combination of multiple clinical risk factors and low BMD is a very powerful indicator of fracture risk.

Highlights

► The clinical risk factors for fractures in postmenopausal women were studied. ► Risk factors include: lowest quartiles of physical activity score, hand grip strength, and BMD of total hip.

Introduction

Osteoporosis is a multi-factorial disorder characterized by low bone mineral density (BMD) and microarchitectural deterioration of bone, resulting in loss of bone strength and thus increased fracture risk [1]. Fragility fractures are the most important and disabling consequences of osteoporosis and result in a loss of functional ability, serious morbidity, elevated mortality, and high socio-economic burden [2]. Due to increased life expectancy, the incidence of fractures is increasing over time, thereby increasing the population burden of fractures [3]. Both vertebral and non-vertebral fractures are associated with significant pain, disability, and impaired quality of life. Identification of determinants of all fragility fractures is of critical importance; thus, a better understanding of the mechanisms that result in fractures is considered an essential step in the early recognition and identification of patients at highest risk of future fracture(s) to better target candidates for preventive measures and therapeutic interventions. Several studies of different populations have confirmed the importance of clinical risk factors as determinants for low bone mass [4], [5], [6], and fragility fractures [7], [8], [9], [10]; no one risk factor alone is able to predict bone mass or risk of fractures on its own individual merits [11], [12], [13]. Therefore, the early identification of individuals at risk is fundamental to the implementation of effective strategies for the screening, diagnosis, prevention, and/or treatment of osteoporosis [14]. In several populations examined, a number of clinical risk factors, including old age, previous fracture(s), low body weight, use of glucocorticoids, low physical activity, dietary habits, falls, current smoking, and family history of fractures, were found to contribute significantly to osteoporosis-related fractures (ORFs) [7], [15], [16], [17], [18]. The need for an assessment of risk factor prevalence in varied populations is underscored by the enormous global variation in fracture incidence [19], [20]. Moreover, there is no information on the possible risk factors for all ORFs among Saudi postmenopausal women.

Thus, the main objectives of the present study are to identify risk factors (i.e., familial, personal history of fracture, medical, gynecological history, physical activity, anthropometric parameters, and lifestyle factors) and, together with BMD, predict the occurrence of all ORFs in a prospective cohort of Saudi postmenopausal women at least 50 years of age followed annually for a period of approximately 5.2 years. We also examined the associations of a number of clinical risk factors with fracture risk that were independent of BMD values.

Section snippets

Study design and subjects

Women were prospectively recruited between January and December 2004, and 3015 women were identified randomly during a health survey from 40 primary health care centers (PHCCs) scattered around the city of Jeddah (divided into seven geographical sectors). A representative sample size was calculated using the sample-size determination option in the Epi-Info Statistical Package, version 6 (USD, West Park Place, Stone Mountain, GA, USA). A multi-stage sampling technique was adopted as described

Results

Of the 912 women initially recruited, 148 were lost to follow-up, and 20 had died by the second (n = 5), third (n = 9), and fourth (n = 6) visits. Furthermore, 37 women who were treated with antiresorptives or hormonal replacement therapy after recruitment were excluded from the final analysis. The main anthropometric and clinical characteristics of all women who completed the study period according to fracture status are presented in Table 1. There were no significant differences at baseline between

Discussion

In the present study, we observed that some but not all of the previously described risk factors for ORFs were independent predictors of such fractures among a Saudi cohort of postmenopausal women followed for a period of 5.2 ± 1.3 years. The most important risk factors for ORFs were advancing age, sedentary lifestyle, poor grip strength, low BMD of total hip, low dietary calcium intake, poor vitamin D status, and a past history of falls. These factors reflect the contribution of certain bone

Conclusions

The public health implications of the findings of the present study are obvious and compelling. The present study has identified a set of clinical risk factors specific to Saudi and possibly other postmenopausal women living the Middle East that effectively predict fracture risk with or without the inclusion of BMD data. Such information will be useful for appropriate risk assessment to identify and select women who will benefit from therapeutic intervention or distinguish women at high risk

Acknowledgments

We are grateful to the Ministry of Higher Education for financial support to the CEOR at KAU, Jeddah, Saudi Arabia. We thank all the women who participated in the present study, and we thank all the staff and colleagues at CEOR, KAUH, and the Primary Care Health Centers for their invaluable assistance during the execution of the present study. We thank also the colleagues at the Departments of Diagnostic Radiology and Orthopedics at New Jeddah Clinic Hospital and Al-Khandara Clinic Hospital for

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