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Abstract

The incidence of osteoporosis and related fractures in African American women is half that of Caucasian women. African American women who sustain osteoporosis-related fractures have increased disability and decreased survival. Given the exponential increase in hip fracture rate among African American women over the age of 70 years, the risk of osteoporosis among this population may be underestimated. This review focuses on racial differences in women's bone mineral density (BMD) and bone metabolism and on various explanations for these observed differences. Environmental risk factors for osteoporosis and related fractures among African American women and modalities for prevention and treatment of osteoporosis are discussed. African American women begin menopause with higher BMD and have lower rates of women's bone loss after menopause, which account for their decreased incidence of osteoporosis and related fractures. The risk factors for osteoporosis among African American women are similar to those found in Caucasian women. Lifestyle interventions, such as calcium and vitamin D supplementation, smoking cessation, and increased physical activity, should be encouraged to enhance peak bone mass and to decrease bone loss. These interventions and other treatment modalities, such as hormone replacement therapy, bisphosphonates, and selective estrogen receptor modulators, should be studied further in African American women.

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... This study has generated normative data for different UK resident ethnic groups, enabling subsequent scans to be more appropriate. As found by other studies [14] a significant difference was found between African-Caribbean and Caucasian groups. The NORA program using SXA of the heel also showed African-American women to have the highest BMD and Asian the lowest [11]. ...
... The Indian-Asian and Chinese normative BUA data are not significantly different from that of the Caucasian population, but BUA of the African-Caribbean group is H J Hinkley, I P Drysdale, N J Walters and D Bird significantly higher than the Caucasian. These findings are in line with published data, which show that bone mass is greatest and fracture rate is lowest in those of African heritage [14]. It therefore seems logical that when measuring African-Caribbean women, the results should be interpreted against an appropriate normative data line. ...
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The purpose of this study was to generate normative broadband ultrasound attenuation data for UK resident Indian-Asian, African-Caribbean and Chinese women, aged 20-80 years, using the McCue Cubaclinical II device. Additionally, comparisons were made against available Caucasian data previously collected by the authors. Exclusions were: use of hormone replacement therapy, corticosteroids or thyroxine for more than 6 months; menopause before the age of 45 years; oophrectomy; lactation within the preceding year; rheumatoid arthritis or a previous osteoporotic fracture. 977 women were recruited from various community centres, from a local GP surgery and from university colleges in the London area. Broadband ultrasound attenuation and velocity of sound were determined for the left and right os calces. Repeat measures on each side after re-positioning, to allow for anatomical variation, were averaged. Significance was set at a minimum level of 0.05. There were significant differences in non-dominant and dominant measures in all ethnic groups except African-Caribbean. For comparison purposes the means of the non-dominant measurements were plotted against age using a polynomial model to give the best data fit. No significant difference was found between non-dominant broadband ultrasound attenuation measurements for either Asian or Chinese when compared with the Caucasian sample populations. A significant difference in broadband ultrasound attenuation was found between African-Caribbean and Caucasian, with African-Caribbean between 10% (age group 20-30 years) and 29% (age group 70-80 years) higher. There was no significant difference in body mass index between Caucasian and Chinese groups, but significant differences were found between Caucasian and Asian, and between Caucasian and African-Caribbean groups.
... For example, polymorphisms in several genes have been correlated with peak bone mass and the incidence of osteoporosis, including the gene for transforming growth factor beta, the vitamin D receptor, and the estrogen receptor alpha (2)(3)(4)(5)(6)(7). Further, compared with Caucasian women, the higher bone-mineral density (BMD) at skeletal maturity measured in African American women combined with their lower rates of postmenopausal bone loss result in an approximately 50% lower incidence of osteoporosis in this cohort (8)(9)(10). Despite the clear impact of subtle genotypic variations on achieving and retaining bone quantity and quality, it is not yet clear whether the genome also influences how an individual may respond to treatment of the disease. ...
... This study also suggests that some people who benefit from a genetically predetermined higher bone mass, as well as slower rates of bone turnover (and thus slower rates of bone loss), may also have a differential sensitivity to increases or decreases in exogenous stimuli, thus reducing the effect of age, disuse, or menopause induced uncoupling of bone formation and resorption. African American women who have a higher bone mineral density also have a slower rate of postmenopausal bone loss than do Caucasian women (8), attributes that result in osteoporotic fracture rates one-half that of Caucasian women (9). It has been proposed that the higher levels of BMD in young adult African Americans is a result not only of a genetically predetermined higher baseline, but also of an adaptive response to increased force magnitudes associated with a larger body mass (29). ...
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The structure of the adult skeleton is determined, in large part, by its genome. Whether genetic variations may influence the effectiveness of interventions to combat skeletal diseases remains unknown. The differential response of trabecular bone to an anabolic (low-level mechanical vibration) and a catabolic (disuse) mechanical stimulus were evaluated in three strains of adult mice. In low bone-mineral-density C57BL/6J mice, the low-level mechanical signal caused significantly larger bone formation rates (BFR) in the proximal tibia, but the removal of functional weight bearing did not significantly alter BFR. In mid-density BALB/cByJ mice, mechanical stimulation also increased BFR, whereas disuse significantly decreased BFR. In contrast, neither anabolic nor catabolic mechanical signals influenced any index of bone formation in high-density C3H/HeJ mice. Together, data from this study indicate that the sensitivity of trabecular tissue to both anabolic and catabolic stimuli is influenced by the genome. Extrapolated to humans, these results may explain in part why prophylaxes for low bone mass are not universally effective, yet also indicate that there may be a genotypic indication of people who are at reduced risk of suffering from bone loss.
... African Americans exhibit lower urinary Ca 2+ excretion than Caucasians (Braun et al. 2007;Pratt et al. 1996;Taylor and Curhan 2007), and the risk of kidney stone in African Americans is lower than that in Caucasians (Sarmina et al. 1987;Stamatelou et al. 2003). In addition, African Americans have higher bone mass (Bell et al. 1991) and lower incidence of osteoporosis-related fractures than whites (Bohannon 1999). Because of the high allele frequencies of TRPV5 and TRPV6 SNPs in African populations, these SNPs may contribute to the Ca 2+ conservation mechanisms in African populations. ...
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TRPV5 is one of the two channels in the TRPV family that exhibit high selectivity to Ca(2+) ions. TRPV5 mediates Ca(2+) influx into cells as the first step to transport Ca(2+) across epithelia. The specialized distribution in the distal tubule of the kidney positions TRPV5 as a key player in Ca(2+) reabsorption. The responsiveness in expression and/or activity of TRPV5 to hormones such as 1,25-dihydroxyvitamin D3, parathyroid hormone, estrogen, and testosterone makes TRPV5 suitable for its role in the fine-tuning of Ca(2+) reabsorption. This role is further optimized by the modulation of TRPV5 trafficking and activity via its binding partners; co-expressed proteins; tubular factors such as calbindin-D28k, calmodulin, klotho, uromodulin, and plasmin; extracellular and intracellular factors such as proton, Mg(2+), Ca(2+), and phosphatidylinositol-4,5-bisphosphate; and fluid flow. These regulations allow TRPV5 to adjust its overall activity in response to the body's demand for Ca(2+) and to prevent kidney stone formation. A point mutation in mouse Trpv5 gene leads to hypercalciuria similar to Trpv5 knockout mice, suggesting a possible role of TRPV5 in hypercalciuric disorders in humans. In addition, the single nucleotide polymorphisms in Trpv5 gene prevalently present in African descents may contribute to the efficient renal Ca(2+) reabsorption among African descendants. TRPV5 represents a potential therapeutic target for disorders with altered Ca(2+) homeostasis.
... Our results for 7784 black women are consistent with these and other smaller published studies, showing that black females, both children and pre-and postmenopausal adults, have higher BMD than whites. (2,4,18,28) Although risk factors for osteoporosis in blacks are similar to those reported for whites, (29) black women in the NORA cohort were significantly less likely to have a personal or maternal history of fracture. This information was not added to the main analyses reported here to avoid potential overadjustment for a race-related characteristic. ...
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Osteoporosis and 1-year fracture risk were studied in 197,848 postmenopausal American women from five ethnic groups. Weight explained differences in BMD, except among blacks, who had the highest BMD. One SD decrease in BMD predicted a 50% increased fracture risk in each group. Despite similar relative risks, absolute fracture rates differed. Most information about osteoporosis comes from studies of white women. This study describes the frequency of osteoporosis and the association between BMD and fracture in women from five ethnic groups. This study was made up of a cohort of 197,848 community-dwelling postmenopausal women (7784 blacks, 1912 Asians, 6973 Hispanics, and 1708 Native Americans) from the United States, without known osteoporosis or a recent BMD test. Heel, forearm, or finger BMD was measured, and risk factor information was obtained; 82% were followed for 1 year for new fractures. BMD and fracture rates were compared, adjusting for differences in covariates. By age 80, more than one-fifth of women in each ethnic group had peripheral BMD T scores <-2.5. Black women had the highest BMD; Asian women had the lowest. Only the BMD differences for blacks were not explained by differences in weight. After 1 year, 2414 new fractures of the spine, hip, forearm, wrist, or rib were reported. BMD at each site predicted fractures equally well within each ethnic group. After adjusting for BMD, weight, and other covariates, white and Hispanic women had the highest risk for fracture (relative risk [RR] 1.0 [referent group] and 0.95, 95% CI, 0.76, 1.20, respectively), followed by Native Americans (RR, 0.87; 95% CI, 0.57, 1.32), blacks (RR, 0.52; 95% CI, 0.38, 0.70), and Asian Americans (RR, 0.32; 95% CI, 0.15, 0.66). In age- and weight-adjusted models, each SD decrease in peripheral BMD predicted a 1.54 times increased risk of fracture in each ethnic group (95% CI, 1.48-1.61). Excluding wrist fractures, the most common fracture, did not materially change associations. Ethnic differences in BMD are strongly influenced by body weight; fracture risk is strongly influenced by BMD in each group. Ethnic differences in absolute fracture risk remain, which may warrant ethnic-specific clinical recommendations.
... Because of the strong site-specific effects of the genome on bone morphology observed in our accompanying paper, here we hypothesized that the response of bone to a catabolic stimulus would exhibit a similar interdependence on genetics and the specific anatomical location. Given that both genetically distinct human (13)(14)(15) and mouse (6) populations with high skeletal mass seem to be less susceptible to catabolic pressure, we further hypothesized that regions within a bone displaying a genetically defined large amount of bone will have a lower propensity to lose bone mineral. ...
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The genetic influence on bone loss in response to mechanical unloading was investigated within diaphyseal and distal femoral regions in three genetically distinct strains of mice. One mouse strain failed to lose bone after removal of function, whereas osteopenia was evident in multiple regions of the remaining two strains but in different areas of the bone. It is well recognized that susceptibility to osteoporosis is, in large measure, determined by the genome, but whether this influence is systemic or site-specific is not yet known. Here, the extent to which genetic variations influence regional bone loss caused by disuse was studied in the femora of adult female mice from three inbred strains. Adult C57BL/6J (B6), C3H/HeJ (C3H), and BALB/cByJ (BALB) mice were subjected to 15-21 days of disuse, achieved by hindlimb suspension, and six distinct anatomical regions of the femur were analyzed by high-resolution microCT. In B6 mice, the amount of disuse stimulated bone loss was relatively uniform across all regions, with 20% loss of trabecular bone and 10% loss of cortical bone. The degree of bone loss in BALB mice varied greatly, ranging from 59% in the metaphysis to 3% in the proximal diaphysis. In this strain, the nonuniformity of bone loss was directly related to the nonuniform distribution of baseline bone morphology (r2 = 0.94). In direct contrast with BALB and B6, disuse failed to produce significant losses of bone in any of the analyzed regions of the C3H mice. Instead, these animals displayed a unique compensatory mechanism to disuse, where the large loss of calcified tissue from the endocortical surface (-24%) was compensated for by an expansion of the periosteal envelope (10%). These data indicate a strong, yet complex, genetic dependence of the site-specific regulation of bone remodeling in response to a powerful catabolic signal. Consequently, the skeletal region of interest and the genetic make-up of the individual may have to be considered interdependently when considering the pathogenesis of osteoporosis or the efficacy of an intervention to prevent or recover bone loss.
... The situation however is quite unique, in that South African Blacks have among the lowest hip fracture rate in the world. The age-adjusted hip fracture incidence is 50% lower in African American women than in Caucasian women (32) and what limited information there is, suggests that South African Blacks also have markedly lower hip fracture rates than South African White adults (253; 274). Very few of the factors influencing osteoporosis have been well studied between race groups. ...
... To further clarify the beneficial effects of an increasing BMI on BMD, we evaluated the race-dependent effect of BMI on BMD by comparing postmenopausal women from three different racial backgrounds: African American , Hispanic and Caucasian. We hypothesized that, given their inherent advantage of having denser bones compared to Caucasian women, African American or Hispanic women, should have further reduction in osteoporosis risk in the presence of an increasing BMI242526. ...
Article
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Osteoporosis is a major public health problem with low bone mass affecting nearly half the women aged 50 years or older. Evidence from various studies has shown that higher body mass index (BMI) is a protective factor for bone mineral density (BMD). Most of the evidence, however, is from studies with Caucasian women and it is unclear to what extent ethnicity plays a role in modifying the effect of BMI on BMD. A cross sectional study was performed in which records of postmenopausal women who presented for screening for osteoporosis at 2 urban medical centres were reviewed. Using logistic regression, we examined the interaction of race and BMI after adjusting for age, family history of osteoporosis, maternal fracture, smoking, and sedentary lifestyle on BMD. Low BMD was defined as T-score at the lumbar spine < -1. Among 3,206 patients identified, the mean age of the study population was 58.3 ± 0.24 (Years ± SEM) and the BMI was 30.6 kg/m2. 2,417 (75.4%) were African Americans (AA), 441(13.6%) were Whites and 348 (10.9%) were Hispanics. The AA women had lower odds of having low BMD compared to Whites [Odds ratio (OR) = 0.079 (0.03–0.24) (95% CI), p < 0.01]. The odds ratio of low BMD was not statistically significant between White and Hispanic women. We examined the interaction between race and BMD. For White women; as the BMI increases by unity, the odds of low BMD decreases [OR = 0.9 (0.87–0.94), p < 0.01; for every unit increase in BMI]. AA women had slightly but significantly higher odds of low BMD compared to Whites [OR 1.015 (1.007–1.14), p <0.01 for every unit increase in BMI]. This effect was not observed when Hispanic women were compared to Whites. There is thus a race-dependent effect of BMI on BMD. With each unit increase in BMI, BMD increases for White women, while a slight but significant decrease in BMD occurs in African American women.
... Interestingly, African Americans exhibit lower urinary Ca 2ϩ excretion than whites (8,25,29,34,35,40,45), and the risk of kidney stones in African American is lower than that in whites (32,36,38). Furthermore, African Americans have higher bone mass (5,41) and lower incidence of osteoporosis-related fractures than whites (4,6,7). The mechanism underlying the lowered urinary Ca 2ϩ in African Americans is not well understood. ...
Article
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The transient receptor potential cation channel, subfamily V, member 5 (TRPV5) gene, which encodes the Ca(2+) channel in the apical membrane of distal convoluted tubule and connecting tubule of the kidney, exhibits an unusually high frequency of nonsynonymous single nucleotide polymorphisms (SNPs) among African Americans. To assess the functional impacts of the nonsynonymous SNP variations in TRPV5, these variants were analyzed with radiotracer (45)Ca(2+) influx assay and the voltage-clamp technique using Xenopus laevis oocytes. Among the variations tested, including A8V, R154H, A563T, and L712F, the latter two significantly increased TRPV5-mediated Ca(2+) influx. The A563T variant, which exists in African Americans with relative high frequency, exhibited increased Ca(2+) influx at extracellular Ca(2+) from 0.01 to 2 mM despite a lower expression level at the plasma membrane. This variant also exhibited a reduction in Na(+) current as a result of increased sensitivity to extracellular Mg(2+). By substituting threonine-563 (Thr(563)) with serine or valine residue, the bulky side chain of Thr(563) was shown to facilitate Ca(2+) transport, whereas the hydroxyl group of Thr(563) is likely related to Mg(2+) sensitivity. The A563T variant was capable of increasing TRPV5-mediated Ca(2+) influx, even when it was expressed under conditions mimicking heterozygous or compound state with other variants. In conclusion, the A563T variant of TRPV5 significantly increased Ca(2+) influx by affecting the Ca(2+) permeation pathway. Thus the A563T variation in TRPV5 may contribute to the superior ability of renal Ca(2+) conservation in African Americans.
... A more recent example of a nontraditional HBCU president selection is Julianne Malveaux, most recently at Bennett College for Women. Prior to assuming her position at Bennett, she served as a news commentator on issues related to economics and diversity (Hawkins, 2008). In the midst of varying challenges, presidents of HBCUs whose pathways to the presidency have been traditional or nontraditional have been able to maintain and grow their institutions. ...
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Background/Context Although research on college and university presidents has grown in recent decades, historically Black college and university (HBCU) presidents have rarely been included in this research. We know almost nothing about the pathways to the HBCU presidency or the role that current presidents play in grooming future presidents. More literature is needed in order to deepen our understanding of the HBCU presidency. Purpose With this study, we sought to capture the background characteristics of HBCU leaders, to lay the ground work for future studies on HBCU presidents, and to understand the role these leaders play in grooming and mentoring the next generation of HBCU leaders. Research Design In order to answer our research questions, we used a combination a surveys, document analysis, and qualitative interviews. Conclusions and Recommendations Our conclusions and recommendations point to a recycling of presidents at HBCUs as well as the disproportionate presence of long-term presidencies. Moreover, although grooming of future presidents is taking place, it is not systematic and would benefit from deeper thought and commitment.
... A third causal structure (model C, figure 2) addresses whether current tibia lead level is an adequate surrogate for cumulative lead dose when the majority of the lifetime dose was received decades ago. It is known that ambient exposures to lead in the air and soil were much higher prior to 1975, and clearance of lead from bone could differ by race/ethnicity because race/ethnicity is a known risk factor for bone mineral loss with aging (43). Remote exposures, bone demineralization, and individual variation in rates of clearance of lead from bone could all result in measurement error in current tibia lead with respect to estimating lifetime dose. ...
Article
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Few studies have compared associations of blood lead and tibia lead with blood pressure and hypertension, and associations have differed in samples with occupational exposure compared with those with mainly environmental lead exposure. African Americans have been underrepresented in prior studies. The authors performed a cross-sectional analysis of 2001–2002 data from a community-based cohort in Baltimore, Maryland, of 964 men and women aged 50–70 years (40% African American, 55% White, 5% other race/ethnicity) to evaluate associations of blood lead and tibia lead with systolic and diastolic blood pressure and hypertension while adjusting for a large set of potential confounding variables. Blood lead was a strong and consistent predictor of both systolic and diastolic blood pressure in models adjusted and not adjusted for race/ethnicity and socioeconomic status. Tibia lead was associated with hypertension status before adjustment for race/ethnicity and socioeconomic status (p = 0.01); after such adjustment, the association was borderline significant (p = 0.09). Propensity score analysis suggested that standard regression analysis may have exaggerated the attenuation. These findings are discussed in the context of complex causal pathways. The data suggest that lead has an acute effect on blood pressure via recent dose and a chronic effect on hypertension risk via cumulative dose.
... 194 White and Asian American women develop osteoporosis more often than black women. 195,199 The risk of osteoporosis also increases with age as bone mass decreases from peak bone mass. However, it is important to note that risk factors can be identified but account for only 30% of the prevalence of the disease. ...
... 194 White and Asian American women develop osteoporosis more often than black women. 195,199 The risk of osteoporosis also increases with age as bone mass decreases from peak bone mass. However, it is important to note that risk factors can be identified but account for only 30% of the prevalence of the disease. ...
... There have been a number of studies that have confirmed that African Americans and South African blacks have greater BMD at the proximal femur and that African Americans have greater BMD at the lumbar spine as well as an increased cortical thickness than whites (2, 7). The age-adjusted hip fracture incidence is 50% lower in African American women than in Caucasian women (5), and what limited information there is suggests that South African blacks also have markedly lower hip fracture rates than South African white adults (32,38). Very few of the factors influencing osteoporosis have been well studied between ethnic groups. ...
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We investigated differences in physical activity (PA) levels between black and white South African 9-yr-old children and their association with bone mineral content (BMC) and density (BMD) by using dual-energy X-ray absorptiometry. PA was analyzed in terms of a metabolic (METPA; weighted metabolic score of intensity, frequency, and duration) and a mechanical (MECHPA; sum of all ground reaction forces multiplied by duration) component. There were significant ethnic differences in patterns of activity. White children expended a significantly greater energy score (METPA of 21.7 +/- 2.9) than black children (METPA of 9.5 +/- 0.5) (P < 0.001). When children were divided into quartiles according to the amount and intensity of sport played, the most active white children (using METPA scores) had significantly higher whole body BMD and higher hip and spine BMC and BMD than less active children. White children in the highest MECHPA quartile also showed significantly higher whole body, hip, and spine BMC and BMD than those children in the lowest quartile. No association between exercise and bone mass of black children was found. In this population, PA has an osteogenic association with white children, but not black children, which may be explained by the lower levels of PA in the black children. Despite this, black children had significantly greater bone mass at the hip and spine (girls only) (P < 0.001) even after adjustment for body size. The role of exercise in increasing bone mass may become increasingly critical as a protective mechanism against osteoporosis in both ethnic groups, especially because the genetic benefit exhibited by black children to higher bone mass may be weakened with time, as environmental influences become stronger.
Article
The present study examined levels and correlates of knowledge about osteoporosis among 176 Israeli-Jewish (mean age = 55) and 80 Israeli-Arab (mean age = 51) women. Levels of knowledge about the disease were low among all women, especially regarding some of the risk factors. Knowledge and awareness about the disease were especially deficient among Arab women. Younger age and lower education were the main vulnerability factors among Jewish women, and lower desire to seek information from the medical establishment, higher religiosity, and the lack of extended medical insurance among Arab women. Educational programs, geared to the needs and capabilities of the different ethnic populations, should be encouraged.
Article
While African-American women tend to have greater bone mineral density (BMD) than caucasian women, they are still at risk of developing osteoporosis later in life. Clinical decision rules (i.e., algorithms) have been developed to assist clinicians identify women at greatest risk of low BMD. However, such tools have only been validated in caucasian and Asian populations. Accordingly, the objective of this study was to compare the performance of five clinical decision rules in identifying postmenopausal African-American women at greatest risk for low femoral BMD. One hundred-seventy-four (n=174) postmenopausal African-American women completed a valid and reliable oral questionnaire to assess lifestyle characteristics, and completed height and weight measures. BMD at the femoral neck was measured via dual energy x-ray absorptiometry (DXA). We calculated sensitivity, specificity, positive predictive value, and negative predictive value for identifying African-American women with low BMD (T-Score < or = -2.0 SD) using five clinical decision rules: Age, Body Size, No Estrogen (ABONE), Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Self-Assessment Tool (OST), Simple Calculated Osteoporosis Risk Estimation (SCORE), and body weight less than 70 kg. Approximately 30% of African-American women had low BMD, half of whom had osteoporosis (BMD T-Score < or = -2.5 SD). Sensitivity for identifying women with a low BMD (T-Score < or = -2.0 SD) ranged from 65.57-83.61%, while specificity ranged from 53.85-78.85%. Positive predictive values ranged from 80.95-87.91%, while negative predictive values ranged from 48.44-58.33%. Our data suggest that the clinical decision rules analyzed in this study have some usefulness for identifying postmenopausal African-American women with low BMD. However, there is a need to establish cut-points for these clinical decision rules in a larger, more diverse sample of African-American women.
Article
Osteoporosis in black women may result in increased disability, longer hospital stays, and higher mortality compared with white women. However, it is unknown whether osteoporosis treatment or bone mineral density (BMD) measurement is different in these women, particularly in those at highest risk. To examine differences and determinants of osteoporosis preventive interventions among white and black women in a large regional health maintenance organization, women 50 years of age and older were surveyed (n = 8,909) to determine their receipt of BMD testing and medical therapies for osteoporosis prevention. After adjusting for potential confounders, black women had two- to threefold lower odds of BMD test or osteoporosis prescription treatment. Even among women with a previous fracture, blacks still had a significantly lower likelihood of both BMD testing and prescription therapy. Compared with whites, black women reported significantly less BMD testing and prescription and nonprescription osteoporosis therapy. This disparity was not fully explained by other demographic or risk factor differences.
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More than one million Americans suffer osteoporotic fractures yearly, resulting in a marked increase in morbidity and mortality. Despite a decrease in bone mineral density with increasing age in all ethnic groups and both genders, preventative and therapeutics efforts in osteoporosis have been focused on caucasian and Asian women. This study assesses the osteoporosis screening practices and the frequency of low bone density in a primarily African-American population of older women. Medical records of 252 women at risk for osteoporosis were reviewed for the diagnosis of osteoporosis, prior osteoporosis screening, prior breast cancer screening, and the use of calcium, vitamin D or estrogen. Subsequently, 128 women were assessed for risk factors for osteoporosis, and their bone mineral density was measured using a peripheral bone densitometer. Osteoporosis screening had been performed in 11.5% of the subjects. Of the women evaluated by peripheral bone densitometry, 44.5% of all women, 40.4% of African-American women, and 53.3% of caucasian women had abnormally low bone density measurements. The frequency of abnormal bone density increased with both increasing age and decreasing body mass index. Although few women in this population were previously screened for osteoporosis, low bone density occurred in African-American women at substantial rates. Increasing age and low body mass are important risk factors for low bone density in African-American women. Ethnicity should not be used as an exclusion criterion for screening for osteoporosis.
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To analyze the association between recreational and occupational physical activity and forearm bone mineral density (BMD) in healthy premenopausal women. During 1984-1986, a population-based health survey (HUNT 1) was conducted among women and men aged >19 years in Nord-Trøndelag county in Norway. The second, follow-up survey (HUNT 2) was conducted during 1995-1997. The subjects in this study consist of healthy premenopausal women (n = 1396) < 45 years old in the year of participation of HUNT 2 who had undergone distal and ultradistal radius densitometry in 1995-1997, performed with single-energy x-ray absorptiometry. Women with the highest scores of estimated combined recreational and occupational physical activity (PA) in 1984 and 1995 had significantly higher BMD in the distal radius (mean BMD 0.487 compared with mean BMD 0.480 among those with a low combined PA score) (p for trend = 0.04). At the ultradistal site of the radius, women with a high combined PA score had mean a BMD = 0.403 compared with women with low PA scores (mean BMD = 0.384) (p for trend = 0.017). After adjusting for age, marital status, smoking, amenorrhea, body mass index (BMI), and daily milk consumption, the associations remained the same or got even stronger. The small group of women in the highest category of PA had a significantly higher forearm BMD and the smallest risk of low BMD. Important unanswered questions remain about the optimal relationship between intensity, amount and type of PA, and BMD and later risk of osteoporosis. Further research on BMD as a surrogate measure of structural and architectural bone quality and the sensitivity of different measuring sites for estimation of the effect of PA on bone is warranted.
Article
Osteoporosis is a skeletal disease characterized by low bone density and poor bone quality that weakens bones and increases the risk of fractures. Serious consequences of fractures include disability, loss of independence, and death. Despite the availability of clinical tools to evaluate fracture risk and medications to reduce fracture risk, many or most patients at risk, even those with a recent fracture, are not being treated. This represents a large osteoporosis treatment gap that has reached a crisis level. Importantly, the treatment gap is not evenly distributed among populations of different race/ethnicity. Black women are less likely to have bone density testing when indicated, are less likely to be treated, and have worse outcomes after a fracture than White women. This is a review and update of race-based disparities and inequalities, with suggestions for interventions to optimize patient care.
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Admixture is an important evolutionary force that can and should be used in efforts to apply genomic data and technology to the study of complex disease genetics. Admixture linkage disequilibrium (ALD) is created by the process of admixture and, in recently admixed populations, extends for substantial distances (of the order of 10 to 20 cM). The amount of ALD generated depends on the level of admixture, ancestry information content of markers and the admixture dynamics of the population, and thus influences admixture mapping (AM). The authors discuss different models of admixture and how these can have an impact on the success of AM studies. Selection of markers is important, since markers informative for parental population ancestry are required and these are uncommon. Rarely does the process of admixture result in a population that is uniform for individual admixture levels, but instead there is substantial population stratification. This stratification can be understood as variation in individual admixtures and can be both a source of statistical power for ancestry--phenotype correlation studies as well as a confounder in causing false-positives in gene association studies. Methods to detect and control for stratification in case/control and AM studies are reviewed, along with recent studies showing individual ancestry--phenotype correlations. Using skin pigmentation as a model phenotype, implications of AM in complex disease gene mapping studies are discussed. Finally, the article discusses some limitations of this approach that should be considered when designing an effective AM study.
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To determine the frequency of diagnosing and treating osteoporosis in patients with fragility fractures. Retrospective review of medical records from January 1992 to December 2002 at Howard University Hospital, an urban tertiary care teaching hospital with a predominantly African-American population. Men 50 years old and women 45 years old with fractures caused by low impact falls (fragility fractures) were included. The diagnosis of osteoporosis was based on history, x-rays and pathology reports as indicated by ICD-9 codes (733.00-733.09) and review of medical records. Of 58,841 patients who were admitted during the study period, 1,248 patients (2.1%) had fractures. There were 323 patients (65%) who had fractures secondary to low-impact falls. However, only 29 (8.9%) of these had a diagnosis of osteoporosis. Of these, only five (19%) patients were discharged on antiosteoporotic medications, and only one patient was discharged with a bisphosphonate therapy. No patient had DXA scans. In the population studied, osteoporosis was missed in the majority of the patients as an underlying cause for fragility fractures in African Americans. These results strongly suggest that physicians should be more aware of osteoporosis as an essential cause of fragility fractures. Early recognition and treatment in African Americans and other ethnic groups can significantly decrease the morbidity, mortality and the healthcare costs.
Article
Osteoporotic fractures are not rare in men or non-Caucasian women. However, for these groups, there is no consensus densitometric definition of osteoporosis. As is the case in Caucasian women, low bone mineral density (BMD) is associated with increased fracture risk among men and non-Caucasian women; thus, a densitometric definition of osteoporosis seems feasible. Reaching agreement on criteria for diagnosing osteoporosis in men and non-Caucasians was among the goals of the International Society for Clinical Densitometry Position Development Conference held in July 2001. To this end, the conference recommendation for males is that osteoporosis be defined as a BMD T-score of -2.5 or below the young normal mean for men. Since the relationship between BMD and fracture risk may differ between men and women, it is recommended that T scores in men continue to be derived using a male normative database. Similarly, for non-Caucasians, the recommendation is to diagnose osteoporosis at or below a T-score of -2.5. However, given the difficulty in defining race or ethnic groups, a dearth of data, and their conflicting nature correlating BMD with fracture risk in different ethnicities, it is recommended that a uniform normative database (not adjusted for race) be utilized in the United States for T-score derivation in non-Caucasians. Note that these are current clinical recommendations, which may change as additional data accumulate. Furthermore, there was agreement that the following individuals should have their bone density measured: anyone (male or female, regardless of race) with prior fragility fractures or with conditions widely recognized to increase the risk of bone loss and fracture (such as hypogonadism, corticosteroid treatment, hyperparathyroidism, alcohol abuse, anticonvulsant use, and prior gastrectomy); women on long-term hormone replacement therapy; and in the absence of these conditions, women age 65 and older (regardless of race) and men age 70 and older.
Article
Mapping by admixture linkage disequilibrium (MALD) is a theoretically powerful, although unproven, approach to mapping genetic variants that are involved in human disease. MALD takes advantage of long-range haplotypes that are generated by gene flow among recently admixed ethnic groups, such as African-Americans and Latinos. Under ideal circumstances, MALD will have more power to detect some genetic variants than other types of genome-wide association study that are carried out among more ethnically homogeneous populations. It will also require 200-500 times fewer markers, providing a significant economic advantage. The MALD approach is now being applied, with results expected in the near future.
Article
Osteoporosis is a systemic disease in which bone density is reduced, leading to weakness of the skeleton and increased vulnerability to fractures. The purpose of this study was to compare known or suspected risk factors (medical, gynecological, and lifestyle characteristics) related to bone loss between 60 matched pairs of black and white postmenopausal women. The two racial groups were matched one for one on selective anthropometric variables [age (years), standing height (cm), and body weight (kg)] in order to equate age and body size between groups. Information on risk factors was obtained from an orally administered questionnaire and body composition variables (in addition to those used for matching) assessed by anthropometry and total body dual energy X-ray absorptiometry (DXA). Four skinfold sites (chest, triceps, mid-axillary, and abdomen) were measured with Harpendon calipers and four body circumferences (chest, forearm contracted, waist, and gluteal) were assessed with a Gulick tape. DXA radius, spine, femur, and whole body measurements were obtained on a Hologic QDR-2000 with software version 7.20. White women reported significantly higher proportions of alcohol use, family history of broken bones, and a greater utilization of hormones, calcium and vitamins than did black women. Black women reported a greater numbers who had other diseases (i.e., overactive thyroid, diabetes, rheumatoid arthritis, or kidney stones). Although age and body weight were similar in both groups, black women had greater lean tissue and less body fat than white women. Blacks had significantly higher bone mineral density across all body sites with the exception of the mid- and ultra-distal radius. On the basis of these data, it was concluded that part of the difference often observed in bone density between black and white postmenopausal women might be due to lifestyle factors.
Article
Despite a lower prevalence of osteoporosis in African-American women, they remain at risk and experience a greater mortality than white women after sustaining a hip fracture. Lack of recognition of risk factors may occur in African-American women, raising the possibility that disparities in screening practices may exist. To determine whether there is a difference in physician screening for osteoporosis in postmenopausal, at-risk African-American and white women. We conducted a retrospective chart review at an urban academic hospital and a suburban community hospital. Subjects included 205 African-American and white women, age > or = 65 years and weight < or = 127 pounds, who were seen in Internal Medicine clinics. The main outcome was dual-energy x-ray absorptiometry (DXA) scan referral. We investigated physician and patient factors associated with referral. Secondary outcomes included evidence of discussion of osteoporosis and prescription of medications to prevent osteoporosis. Significantly fewer African-American than white women were referred for a DXA scan (OR 0.39%, 95% confidence interval (CI): 0.22 to 0.68). Physicians were also less likely to mention consideration of osteoporosis in medical records (0.27, 0.15 to 0.48) and to recommend calcium and vitamin D supplementation for this population (0.21, 0.11 to 0.37). If referred, African-American women had comparable DXA completion rates when compared with white women. No physician characteristics were significantly associated with DXA referral patterns. Our study found a significant disparity in the recommendation for osteoporosis screening for African-American versus white women of similar risk, as well as evidence of disparate osteoporosis prevention and treatment, confirming results of other studies. Future educational and research initiatives should target this inequality.
Article
A reliable procedure for identifying persons at risk for osteoporosis and subsequent fracture is needed so that preventive measures may be initiated. Participants included 7,532 women, ages 20 and older, surveyed in the National Health and Nutrition Examination Survey III (NHANES, 1988-1994). Influences of race, body composition, exercise, alcohol intake, smoking status, as well as the effect of nutritional intake of calcium, phosphorus, magnesium, iron, zinc, sodium, and potassium on bone mineral density (BMD) were assessed. Advancing age, low body weight, low exercise expenditure, and smoking were significant predictors for low BMD. Nutritional variables examined were not significant in the predictive models. The absence of calcium from the predictive models indicates the need for re-evaluation of the current recommended intake levels of this nutrient. A greater emphasis on factors such as exercise and achieving adequate weight is recommended. Providing women with the knowledge of their risk for low BMD may influence lifestyle behaviors, which may ultimately result in the prevention of bone injury.
Article
To investigate whether polymorphisms in the estrogen receptor alpha (ERalpha) gene are associated with an increased risk of uterine leiomyomas (ULMs). Genomic DNA was isolated from normal myometrium samples collected at the time of the hysterectomy. Volunteers in an academic research environment. One hundred ninety-eight women with surgically confirmed ULMs and 229 matched controls with nonfibroid uteri. Hysterectomy samples were collected from volunteers. The two PvuII and XbaI intronic polymorphisms in the ERalpha gene using polymerase chain reaction and restriction fragment length polymorphism. The ERalpha PP genotype was associated with a significantly increased risk of ULM in black and white women, but not in Hispanic women. Women with the ERalpha PP genotype were 6.42 times (confidence limits 2.04-20.16) more likely to have ULMs than other genotypes. The ERalpha PP genotype was also significantly associated with larger tumor burden (>400 g). The overall prevalence of the PP genotype was significantly higher in black women (35%) than white (13%) or Hispanic (16%) women. Myometrial cell lines expressing the PP genotype exhibited enhanced proliferative response to estrogen in vitro compared with their pp counterparts. The ERalpha PP genotype is a genetic risk factor for ULM development among surgically treated women. The higher prevalence of this genotype in blacks might explain the increased occurrence of this tumor among black women.
Article
The purpose of this work was to develop and conduct a needs and risk instrument to assess knowledge of osteoporosis risk factors, identify beliefs and attitudes about this disease, and delineate the presence and/or absence of healthy behaviors associated with osteoporosis among African American and Hispanic women. The survey findings suggest that African-American and Hispanic women are not well-versed in behaviors that would promote and maintain optimal bone mass. Consequently, they are not practicing appropriate lifestyle and dietary habits to decrease their risk of osteoporosis. Such behaviors include inadequate physical activity, inadequate calcium intake, cigarette smoking, and long-term steroid use. Less than 10% of women in the study were getting adequate daily dietary calcium intake, with only 13% taking daily calcium supplements to augment this deficit and less than one-half of women exercising at a minimal level (20 minutes/3 times a week). Women in this study also had limited knowledge about osteoporosis, perceived this condition to be less of a health threat as compared to breast cancer, heart disease, diabetes, and Alzheimer's disease, and very few had the perception that being Hispanic or African American was a factor to consider in assessing their risk of osteoporosis. Our findings suggest that osteoporosis education and prevention initiatives are needed, specifically for African-American and Hispanic women, to promote healthy behaviors, identify women at-risk, and encourage early diagnosis and treatment.
Article
A longitudinal study of 386 healthy Black and White women aged 35-60 years was conducted to determine the effects of physical activity and other related factors on lumbar bone mineral density over 24 months. Bone mineral density of the lumbar spine, L2-L4, was measured using dual energy x-ray (Hologic 1000). Physical activity levels in three dimensions (leisure, household, and occupational) from both a lifelong and current perspective were obtained by questionnaire. Body mass index was calculated from measured weight in kilograms divided by measured height in meters squared. Calcium, caffeine, and alcohol intake was estimated using a food frequency questionnaire. Age, race, and smoking were determined by self-report. Radioimmunoassays of follicle stimulating hormone (FSH) and estradiol were used to validate self-reports of menopausal status. Multiple regression analysis revealed that race, age, weight, FSH, calcium, and years of tobacco intake formed the best model at baseline (r(2) = 0.32) and at 24 months (r(2) = 0.303). Physical activity was not a significant predictor for bone mineral density at either time point. There were cross-sectional changes of bone mineral density with race, age, and menopausal status. Black women had significantly higher bone mineral density than White women. However, an age-related decline in bone mineral density was exhibited in both Black and White women. Perimenopausal women had significantly lower bone mineral density as compared with premenopausal women. Furthermore 37 (9.6%) women at baseline and 34 (11%) at 24 months were designated at risk for fracture.
Article
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Osteoporosis, one of the critical diseases facing the ageing population and along with cardiovascular disease, diabetes and cancer, is a major concern for public health in western countries. Fractures, the clinical endpoint of osteoporosis, contribute considerably to overall morbidity, mortality and healthcare costs. It has been estimated that the lifetime risk to suffer a fracture is 40% for a 50-year-old white woman and 15% for men. Of those who have suffered a fracture of the hip, 50% are subsequently unable to walk unassisted and 20 % die within the first year after the hip fracture occurred. The total health care expenditures attributable to osteoporotic fractures in the United States was estimated at US$ 13.8 billion in 1995. In the Netherlands direct medical cost of osteoporosis-related fractures was estimated to be over 400 million guilders each year. Due to ageing, fractures from osteoporosis occurring each year are projected to increase world-wide from 1.7 million in 1990 to 6.3 mil1ion in 2050. Osteoporosis is defined as a systemic skeletal disease, characterised by low bone mass and microarchitectural detoriation of bone tissue with a consequent increase in bone fragility and susceptibility to fracture.
Article
Genetic risk of low BMD in African American women remains unclear. Based on SNPs discovered from a predominantly Caucasian sample, genetic profile was summarized and was found to be significantly associated with BMD variation in African American women. Introduction: Osteoporosis is largely under-recognized and undertreated in African-American women, the post-fracture morbidity and mortality rates in this racial group is rather high. Since BMD was proved to be highly heritable, based on a comprehensive genome-wide meta-analysis that reported 63 BMD-related single nucleotide polymorphisms (SNPs), we aim to unravel the overall genetic risk for decreased BMD and osteoporosis in African-American women. Methods: Genotype data of 842 African American women in a Women's Health Initiative cohort were analyzed. Comprehensive genotype imputation was conducted at the Sanger Imputation Server. Multi-locus genetic risk scores (GRSs) based on 62 BMD-related single-nucleotide polymorphisms (SNPs) were calculated. The association between GRS and BMD was assessed by regression analysis. Longitudinal data was further analyzed using a generalized estimating equation, which helps achieve more efficient and unbiased regression parameters by accounting for the within-subject correlation of responses on dependent variables. Results: After adjusting for age, body weight, hormone use, and previous fracture, for every unit increase of GRS.FN and GRS.LS, BMD at hip and lumbar spine decreased 0.124 g/cm2 and 0.086 g/cm2, respectively. Collectively, the model accounted for 34.95% of the femoral neck BMD variation and 25.79% of lumbar spine BMD variation. Notably, GRS.FN and GRS.LS accounted for 2.03% and 2.39% of the total explained variance, respectively. The proportion of BMD variation can be explained by GRSs increasing as participants aged. Conclusions: Genetic risk score was significantly associated with lower BMD in the current study, suggesting that SNPs discovered from prior meta-analysis based on primarily Caucasian population can also explain a considerable proportion of BMD variation in African Americans.
Article
Background: Near-falls are a frequent, but not commonly studied, occurrence in the elderly Black population and may be related to prospective falls. Objectives: The purpose of this paper is to examine the relationship of near-falls to demographic characteristics, use of assistive devices, gait, and physical activity levels in elderly Blacks. Methods: Community-dwelling, elderly Black patients aging 65 and older and attending two clinics of the Mount Sinai Hospital in Harlem in New York City were recruited. The number of near-falls during the past year was self-reported using the Elderly Falls Screening Test. The Rapid Assessment of Physical Activity was used to assess aerobic and anaerobic activity levels. Backward stepwise logistic regression was used to identify predictors of near-falls. Results: A total of 120 elderly Black adults took part in the study. Prevalence of occasional or frequent near-falls was 52.5%. In the final trimmed model, time of the 5-m observed walk (OR = 1.41, p = .001) and being male (OR = 3.68, p = .02) were significant predictors of near-fall experiences. Discussion: Future research needs to be done in elderly Black populations to determine what factors may contribute to men experiencing more near-falls and on the relation between near-falls and falls.
Article
Purpose: To determine the frequency of diagnosing and treating osteoporosis in patients with fragility fractures. Methodology: Retrospective review of medical records from January 1992 to December 2002 at Howard University Hospital, an urban tertiary care teaching hospital with a predominantly African-American population. Men 50 years old and women 45 years old with fractures caused by low impact falls (fragility fractures) were included. The diagnosis of osteoporosis was based on history, x-rays and pathology reports as indicated by ICD-9 codes (733.00-733.09) and review of medical records. Main Findings: Of 58,841 patients who were admitted during the study period, 1,248 patients (2.1%) had fractures. There were 323 patients (65%) who had fractures secondary to low-impact falls. However, only 29 (8.9%) of these had a diagnosis of osteoporosis. Of these, only five (19%) patients, were discharged on antiosteoporotic medications, and only one patient was discharged with a bisphosphonate therapy. No patient had DXA scans. Conclusions: In the population studied, osteoporosis was missed in the majority of the patients as an underlying cause for fragility fractures in African Americans. These results strongly suggest that physicians should be more aware of osteoporosis as an essential cause of fragility fractures. Early recognition and treatment in African Americans and other ethnic groups can significantly decrease the morbidity, mortality and the healthcare costs.
Working Paper
Full-text available
Article
The aim of this mini-review was to address the question of whether there are differences between Asian and Caucasian women in the incidence of osteoporotic fractures. The online PubMed web site was used to search for papers on epidemiologic studies designed to compare ethnic differences between Asians and Caucasians in osteoporotic fractures, and nine original papers regarding this issue were retrieved. There is a body of evidence that the incidence of hip fractures in Asians, including Japanese, is lower than in Caucasians. By contrast, no Asian-Caucasian difference in incidence of vertebral fractures has been found, although Japanese living in Japan seem to have a higher incidence of vertebral fractures than Caucasians. More epidemiologic studies comparing vertebral fractures in Asians and Caucasians are needed.
Article
Soluble CD14 (sCD14) is an inflammatory marker associated with osteoclasts. Using Cox proportional hazards models, we found a positive association between plasma levels of sCD14 and risk of incident fracture among participants in the Cardiovascular Health Study. sCD14 may be useful in identifying those at risk for fracture. Introduction Soluble CD14, a proinflammatory cytokine, is primarily derived from macrophages/monocytes that can differentiate into osteoclasts. The purpose of this study was to examine the relationship between sCD14 levels and osteoporotic fractures. Methods In the Cardiovascular Health Study, 5462 men and women had sCD14 levels measured at baseline. Incident hip fractures (median follow-up time 12.5 years) and incident composite fractures (defined as the first hip, pelvis, humerus, or distal radius fracture, median follow-up 8.6 years) were identified from hospital discharge summaries and/or Medicare claims data. Cox proportional hazards models were used to model the association between sCD14 levels and time to incident hip or composite fracture, overall and as a function of race and gender. Results In unadjusted models, there was a positive association between sCD14 levels (per 1 standard deviation increase, i.e., 361.6 ng/mL) and incident hip (HR, 1.26; 95 % CI, 1.17, 1.36) and composite (HR, 1.20; 95 % CI, 1.12, 1.28) fractures. When models were fully adjusted for demographics, lifestyle factors, and medication use, these associations were no longer significant. However, in whites, the association of sCD14 levels with hip fractures remained significant in fully adjusted models (HR, 1.11; 95 % CI, 1.01–1.23). Associations of sCD14 levels with hip and composite fracture did not differ between men and women. Conclusions In this large cohort of community-dwelling older adults, higher sCD14 levels were associated with an increased risk of incident hip fractures in whites.
Article
Background: Although postmenopausal African–American women are at lower risk for osteoporosis-related fractures compared with white women, fractures in African–American women are associated with significantly higher morbidity and mortality. Therefore, early diagnosis and treatment of osteoporosis in this population is just as important as it is for other ethnic groups and worthy of the attention of physicians and healthcare organizations. Objective: The purpose of this study was to evaluate risk factors for osteoporosis in postmenopausal African–American women. Design: This was a retrospective, case-control study in 201 postmenopausal African–American women at a community-based osteoporosis center. Spine and hip bone mineral density measurements were obtained by dual-energy x-ray absorptiometry. Patient and family medical history, past and present pharmaceutical use, and dietary and exercise habits were collected using a patient self-administered questionnaire. Results: Using the manufacturer's African–American referent database, 56 women had osteoporosis, 99 had osteopenia, and 46 had normal bone mineral density. Risk factors more common in the osteoporotic group compared with the normal group included sedentary lifestyle (P < 0.03), family history of osteoporosis (P < 0.03), low body mass index (P < 0.05), and history of bilateral oophorectomy (P < 0.03). Polyarthritis was more prevalent in the normal versus the osteoporotic group (P < 0.001). In addition, premenopausal use of oral contraceptives (P < 0.005) and postmenopausal use of estrogen therapy (P < 0.05) were more common in the normal compared with the osteoporotic group. Conclusions: Many risk factors for osteoporosis in African–American women are similar to those in white women and can aid in the selection of patients in need of bone density testing.
Article
Summary The prevalence and awareness of postmenopausal osteoporosis was assessed among 569 postmenopausal women randomly selected from the population. Osteoporosis was assessed based on bone mineral density (BMD) values at three indicative sites. The results indicate a significant prevalence of the disease among this fraction of the population with a poor knowledge of its risk factors. Introduction Postmenopausal osteoporosis is a major health problem at the individual and population levels. Assessment of its prevalence and awareness of risk factors provide the basis for health plans to control the disease. No previous studies have been done in our population. A cross-sectional study including 569 postmenopausal women showed a significant prevalence of osteoporosis with a poor awareness of risk factors. Methods Included in the study were 569 randomly selected postmenopausal women (≥49 years of age). BMD was measured in 505 subjects at the lumbar spine, femoral neck and total hip using dual energy x-ray absorptiometry. Awareness was evaluated using a special questionnaire. Results Osteoporosis affected the lumbar spine, femoral neck and total hip in 24%, 14% and 29.7% of subjects, respectively. There was a significant negative correlation (pp p=0.05 at the lumbar spine). BMD was higher at the lumbar spine and femoral neck among subjects aware of the disease (0.893 and 0.746 g/cm2, respectively) than among subjects unaware of the disease (0.835 and 0.712 g/cm2, respectively). This investigation is the first among Palestinian women in this region. It indicates the urgent need for a comprehensive national programme to reduce the incidence of osteoporosis. Conclusion Postmenopausal osteoporosis is significant among the Palestinian population and there is a poor awareness of the risk factors.
Article
We reviewed the epidemiology, diagnosis, and treatment of vertebral fractures due to osteoporosis in the elderly. Vertebral fractures are underdiagnosed despite their high prevalence in both men and women. Clinical consequences of vertebral fractures include increased risk of future vertebral and hip fracture, acute and chronic back pain, decreased quality of life, and increased mortality. Patients with vertebral fractures have functional impairment and increased mortality similar to those with hip fractures. Asymptomatic fractures identified on radiograph also affect quality of life and mortality. A vertebral fracture is a clinical marker for a subsequent fracture and should trigger assessment and diagnosis of osteoporosis. The care of patients with vertebral fractures includes pain management, rehabilitation, and prevention of further fractures. There is evidence from randomized controlled trials that pharmacologic therapy can reduce the risk of future fractures by 40% to 50%. Vertebroplasty may be effective in the control of pain and in obtaining stability of the spine.
Article
TRPV5 and TRPV6 are unique members of the TRP super family. They are highly selective for Ca(2+) ions with multiple layers of Ca(2+)-dependent inactivation mechanisms, expressed at the apical membrane of Ca(2+) transporting epithelia, and robustly responsive to 1,25-dihydroxivitamin D(3). These features are well suited for their roles as Ca(2+) entry channels in the first step of transcellular Ca(2+) transport pathways, which are involved in intestinal absorption, renal reabsorption of Ca(2+), placental transfer of Ca(2+) to fetus, and many other processes. While TRPV6 is more broadly expressed in a variety of tissues such as esophagus, stomach, small intestine, colon, kidney, placenta, pancreas, prostate, uterus, salivary gland, and sweat gland, TRPV5 expression is relatively restricted to the distal convoluted tubule and connecting tubule of the kidney. There is only one TRPV6-like gene in fish and birds in comparison to both TRPV5 and TRPV6 genes in mammals, indicating TRPV5 gene was likely generated from duplication of TRPV6 gene during the evolution of mammals to meet the needs of complex renal function. TRPV5 and TRPV6 are subjected to vigorous regulations under physiological, pathological, and therapeutic conditions. The elevated TRPV6 level in malignant tumors such as prostate and breast cancers makes it a potential therapeutic target. TRPV6, and to a lesser extent TRPV5, exhibit unusually high levels of single nucleotide polymorphisms (SNPs) in African populations as compared to other populations, indicating TRPV6 gene was under selective pressure during or after humans migrated out of Africa. The SNPs of TRPV6 and TRPV5 likely contribute to the Ca(2+) conservation mechanisms in African populations.
Article
Adequate calcium and vitamin D are needed to maintain calcium balance. Our objective was to examine the influence of calcium intake and vitamin D exposure separately and their interaction on biomarkers of calcium sufficiency. Healthy men and women, age 20-80 yr, were randomly allocated to four groups: 1) double placebo, 2) calcium (1200 mg daily) plus placebo, 3) vitamin D(3) (100 microg) plus placebo, and 4) vitamin D(3) and calcium. Fasting serum and urine as well as serum and urine 2 h after a calcium load (600 mg of calcium carbonate) were obtained at baseline and 3 months. Ninety-nine participants were randomized; 78 completed the study. Baseline demographics, protein intake and laboratory studies did not differ among the four groups. Study medication compliance was 90%. Fasting bone turnover markers declined after 3 months only in the two groups given calcium supplements and increased in the vitamin D(3) plus placebo calcium group. The calcium load resulted in a decrease in PTH and in bone turnover markers that did not differ among groups. Urinary calcium excretion increased in the combined group. Mean serum 25-hydroxyvitamin D increased from a baseline of 67 (18 sd) nmol/liter to 111 (30 sd) nmol/liter after vitamin D supplementation. Increased habitual calcium intake lowered markers of bone turnover. Acute ingestion of a calcium load lowered PTH and bone turnover markers. Additional intake of 100 microg/d vitamin D(3) did not lower PTH or markers of bone turnover.
Article
Osteoporosis is a serious national public health problem, and is expected to increase significantly over the next few decades, especially in women. A limitation of bone health research exists since few studies have involved Hispanic women, and even fewer, Hispanic immigrant women. For this study we examined the effects of anthropometric, behavioral, and health history variables on bone mineral density (BMD) in 84 immigrant Hispanic women, age 40 and above. BMD was assessed at the spine, femur, and forearm using dual energy x-ray absorptiometry (DXA). Demographic information, health histories, and behavioral risk factors were obtained from a questionnaire. In the younger group (mean age = 44.1 years) 61% had spinal osteopenia, and in the postmenopausal group (mean age = 53.0 years) 59% had osteopenia and 13% had osteoporosis. Femur sites were free of osteoporosis. Mean body mass index (BMI) was 31.8 ± 6.1 and mean waist girth was 95.6 ± 12.5 cm, indicating overall and abdominal obesity. Partial correlations indicated a significant positive relationship between body fat variables and total femur BMD values. ANOVAs revealed no differences in BMD values at any bone site across tertile levels for calcium intake or for physical activity. However, supplemental and dietary calcium intakes were very low and few participants engaged in regular physical activity outside of work and activities of daily living (ADL). In light of the expected increase in osteoporosis in this population and the prevalence of spinal osteopenia in the younger participants, education about the health risks of osteoporosis should be made available to this group.
Article
To review current literature regarding the etiology, diagnosis, and conservative treatment of spondylolysis and spondylolytic spondylolisthesis. The PubMed database was searched for articles on spondylolysis and/or spondylolisthesis and their incidence, diagnosis, imaging, treatment, and prognosis. The bibliographies of articles determined to be relevant were also reviewed. A PubMed search of spondylolysis or spondylolis-thesis yielded over 800 citations. Sixty-eight articles were selected based on an opinion of perceived relevance to the subjects of spondylolysis and spondylolisthesis. Spondylolysis affects approximately 6% of the population. The lesion likely represents a stress fracture and the typical age of onset is early childhood and adolescence. Most individuals are asymptomatic. Adolescents with low back pain may have an impending or new pars defect. A high index of suspicion for a new pars defect should prompt utilization of physiologic imaging to determine the likelihood of pars union in young patients. Restrictive bracing may lead to healing of the fracture and cessation of pain. Spondylolisthesis is a common complication of spondylolysis. Spondylolisthesis progression is typically small and most likely in young individuals. Significant progression in adults is rare. The finding of spondylolysis and spondylolisthesis in an adult patient is usually incidental and not likely to be a direct source of pain unless there is concurrent instability.
Article
Inadequate calcium intake is more common among women belonging to racial and ethnic minorities. This study examined the patterns and characteristics associated with calcium supplement use or nonuse among African American women, and the potential impact of physician recommendation on calcium supplementation. African American women aged 19 to 65, attending community outreach activities sponsored by a multispecialty academic medical center in northeastern Ohio, completed a calcium supplement survey. Survey items included demographic and bone health-related information, and rationale for calcium supplement use or nonuse. Of 160 respondents, 14% of women regularly took calcium supplements, 16% were former users, and 70% never used calcium supplements. Characteristics associated with calcium use status included age, multivitamin use, and marital status. Few African American women recall discussions with their doctors about calcium intake. Most who formerly took calcium supplements and most who had never taken them were willing to do so if recommended by their physician. Calcium supplement use among African American women in this study was low. However, many of the barriers to calcium supplement use by African American women appear remediable through brief calcium intake counseling by their physician.
Article
To develop and implement a protocol that improves recognition of osteoporosis in patients with fragility fractures. The awareness protocol included 6 meetings with the clinical staff of the emergency department (ED) and the orthopedic department to discuss osteoporosis awareness, a poster placed in the ED triage and orthopedic residents' rooms, monthly verbal awareness reminders, and distribution of pocket-sized poster copies to the residents. Two hundred ninety-one patients with fractures were admitted to Howard University Hospital from June 2005 - December 2005. Fractures were evident in 11% (n = 32). All were admitted from the ED. Of the patients with fractures, 81% were African American--62.5% were women with a mean age of 73.3 +/- 15.8 years; the mean age of the men, 59.3 +/- 14.9 years. The orthopedists requested an endocrine consult for 8 patients. Osteoporosis was evident in 25% of the fracture patients (n = 8). One of these patients was diagnosed on the basis of risk factors, thus 22% were diagnosed on the basis of dual-energy x-ray absorptiometry and pathological findings. As compared with a prior study, this is a significant increase (13%, p = .02) in the diagnostic rate at this institution. Bisphosphonates were prescribed for 3 of the 32 patients (9%) prior to discharge. This pilot study presents an easy-to-execute awareness protocol that significantly improved the diagnosis of osteoporosis in a predominantly African American population with fractures. The diagnosis of osteoporosis may be enhanced by cooperative efforts among ED, orthopedics, endocrinology, and other disciplines.
Article
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The relationship between lactose maldigestion, lactose intolerance, and calcium intake in premenopausal African American women is unknown. To determine how intolerance of lactose and dairy products affects intake of calcium in lactose maldigesting premenopausal African American women. Dietary intake of calcium was assessed in 50 premenopausal lactose maldigesting African American women as determined by the breath hydrogen test. Twenty-six women were lactose intolerant and 24 were lactose tolerant by self-reports. The average intake of calcium in lactose maldigesting and intolerant women was significantly lower than in lactose tolerant women (388 +/- 150 mg/day vs. 763 +/- 333 mg/day, p < 0.0001, t test). Neither group reached the newly established Dietary Reference Intake (DRI) for calcium (1,000 mg/day). Major source of dietary calcium in lactose tolerant women were milk and dairy products (45%), and mixed foods containing calcium from non-dairy sources (30%). In lactose intolerant women, 46% of calcium was from mixed foods and only 12% was from milk and dairy products. Lactose intolerant women had higher body mass index (BMI) than lactose tolerant women (p = 0.008, t test), and calcium intake was negatively associated with BMI (R2 = 0.470). In African American premenopausal women, lactose tolerance facilitates the dietary intake of calcium when compared with their lactose intolerant counterparts. Low calcium intake is associated with higher BMI.
Article
In a multi-site longitudinal cohort study, decreasing hemoglobin was associated with increased hip fracture risk in men. Anemia was associated with hip fracture in men and in African American women. Decreasing hemoglobin may be a marker of progressing bone fragility, making its serial measurement useful for fracture risk stratification.IntroductionHematopoiesis and bone health are interdependent. Anemia has been associated with risk of fracture in humans. To further elucidate this relationship, we hypothesized that decreasing hemoglobin could indicate defective hematopoiesis and would also predict fracture risk.Methods We performed a prospective analysis from study baseline (1992) of the Cardiovascular Health Study, a multi-site longitudinal cohort study. A total of 4670 men and women, ages >65 years, who were able to consent and not institutionalized or wheelchair bound, had hemoglobin (Hb) measured in 1992. For 4006 subjects, Hb change from 1989 to 1992 was annualized and divided into sex-specific quartiles. Incident hip fractures were verified against Medicare claims data during a median follow-up of 11.8 years.ResultsNested Cox proportional-hazard models estimated association of hip fracture with anemia (men Hb <13 g/dL, women Hb <12 g/dL) and separately, greatest Hb decrease (versus others). Anemia was associated with increased hip fracture risk in all men (HR 1.59; 95% CI 1.01–2.50) and African American women (HR 3.21; 95% CI 1.07–9.63). In men, an annualized Hb loss of >0.36 g/dL/year was associated with a higher risk of hip fracture (HR 1.67; 95% CI 1.10–2.54), which was lessened by anemia at the start of fracture follow-up (HR 1.53; 95% CI 0.99–2.39).Conclusions Decreasing Hb may be an early marker for subsequent hip fracture risk in men, which may be less informative once an anemia threshold is crossed. Only African American women with anemia had increased hip fracture risk, suggesting a race difference in this relationship.
Article
Most studies of risk factors for osteoporosis and nontraumatic fracture involve white women, although more research is being geared toward bone health among various ethnic groups. The purpose of this review is to provide an overview of health disparity in osteoporosis, including assessment of bone mineral density (BMD), bone health screening, lifestyle risk factors, and treatment involving white, black, Hispanic, Asian, and Native American women. This review summarizes evidence that white, Asian, Hispanic, and Native American women are more at risk for osteoporosis than black women. These conclusions are supported by the disparity in BMD between white and black women, although the reason for this biological difference is not well characterized. Additional research is needed to determine if there is a significant difference in BMD among Hispanic, Asian, and Native American women independent of body weight and size. Similarly, there is also disparity in fracture rates, with the causes presumed to be multifactorial. Calcium intake is lower than recommended in all females at all ages; however, it is much lower in black and Native American women and highest in white and Hispanic women. Black women also have a lower vitamin D status than white women, with mean vitamin D status of Hispanic American women lying between that of black and white women. Similarly, although white women are more active than black and Hispanic women at all ages, data are lacking about physical activity habits of women of other ethnic backgrounds and how this impacts bone health. Finally, screening protocols for women of various ethnicities and effectiveness of treatments are not well established and remain a priority in women's health.
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While noninvasive studies of bone mass and turnover in blacks and whites abound, histologic evaluations are very rare. We have performed a comparative bone histomorphometric study of iliac biopsies from 55 healthy, premenopausal women including 21 blacks (mean age 33.4 + 1.2 years) and 34 whites (mean age 32.5 + 0.8 years) of comparable age, weight, body composition, education, and lifestyle. Biochemical indices of mineral metabolism: parathyroid hormone, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, serum ionized calcium, serum phosphorus, and urinary calcium/creatinine were measured in the fasting state. Blacks had lower 25-hydroxyvitamin D (31.5 ± 3.36 vs. 63.21 ± 3.79 nmol/l, p = 0.0001). Histomorphometric indices of bone volume, structure, and connectivity were not different between groups. The following indices of bone remodeling were also similar in both groups: eroded perimeter, osteoid width, mineralizing perimeter, tissue-based bone formation rate, osteoid maturation time, active formation period, and activation frequency. However, osteoid perimeter (black [B] = 15.85 ± 1.30 vs. white [W] = 9.49 ± 0.70%, p = 0.0002), osteoid area (B = 2.55 ± 0.32 vs. W = 1.39 ± 0.12%, p = 0.003), single-labeled perimeter (B = 5.46 ± 0.54 vs. W = 4.04 ± 0.33%, p = 0.03), mineralization lag time (B = 38.18 ± 4.04 vs. W = 21.83 ± 1.60 days, p < 0.009), and total formation period (B = 148.15 ± 19.70 vs. W = 84.04 ± 7.62 days, p = 0.0056) were higher in blacks than in whites. The quiescent perimeter (B = 76.91 ± 1.40 vs. W = 84.25 ± 0.91%, p = 0.0001), mineral apposition rate (B = 0.70 ± 0.02 vs. W = 0.75 ± 0.02 μm/day, p = 0.066), mineralizing osteoid perimeter (B = 0.49 ± 0.04 vs. W = 0.75 ± 0.04%, p = 0.0001) and adjusted apposition rate (B = 0.35 ± 0.04 vs. W = 0.58 ± 0.04 μm3/μm2/day, p = 0.0001) were all lower in blacks than in whites. These results indicate that there are no differences in bone volume, microstructure, or turnover between black and white premenopausal women. However, there are significant differences in the mechanism of bone formation between the two groups, with a lower rate of mineralized matrix apposition within each remodeling unit and a longer total formation period in blacks than in whites. The differences appear to be the result of more frequent and/or longer inactive periods in the life span of the bone formation units in blacks. These differences may allow a greater overall deposition of bone mineral in black women and therefore help explain a higher bone mass and perhaps better bone quality in black than white women.
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This paper describes the all-cause mortality experience, following a fracture of the hip, of 712,027 persons covered by the Medicare program from 1984 through 1987. White women experienced the lowest mortality rate (17.2 per 1000 person-months), followed by Black women (22.9 per 1000 person-months), Black men (33.5 per 1000 person-months), and White men (33.7 per 1000 person-months). The observed race-sex differences in survival were found at all ages and regardless of the number of comorbid conditions listed with the discharge diagnosis. While these data demonstrate marked race-sex differences in survival following hip fracture, the cause of these differences is not immediately apparent and demands further investigation.
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The prevalence of osteoporosis and the incidence of vertebral fractures are lower in black women than in white women, findings generally attributed to racial differences in adult bone mass. Little is known, however, about the factors that contribute to racial variations in bone mass or the time of life when such differences become manifest. This study was done to characterize the changes in vertebral bone density at various stages of sexual development in black and white females. We measured cancellous vertebral bone density by quantitative computed tomography in 75 black female subjects between 2 and 20 years old and 75 whites matched for age and stage of sexual development. The vertebral bone density did not differ between black girls and white girls before puberty. Bone density increased during puberty in each racial group, but the magnitude of the increase from prepubertal values was substantially greater in black than in white subjects (34 percent vs. 11 percent). The marked difference between black and white females in cancellous vertebral bone density occurs during a relatively brief period late in puberty. Metabolic and hormonal events related to the achievement of sexual maturity during adolescence may be important determinants of racial differences in bone mass in women.
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Although fluoride increases bone mass, the newly formed bone may have reduced strength. To assess the effect of fluoride treatment on the fracture rate in osteoporosis, we conducted a four-year prospective clinical trial in 202 postmenopausal women with osteoporosis and vertebral fractures who were randomly assigned to receive sodium fluoride (75 mg per day) or placebo. All received a calcium supplement (1500 mg per day). Sixty-six women in the fluoride group and 69 women in the placebo group completed the trial. As compared with the placebo group, the treatment group had increases in median bone mineral density of 35 percent (P less than 0.0001) in the lumbar spine (predominantly cancellous bone), 12 percent (P less than 0.0001) in the femoral neck, and 10 percent (P less than 0.0001) in the femoral trochanter (sites of mixed cortical and cancellous bone), but the bone mineral density decreased by 4 percent (P less than 0.02) in the shaft of the radius (predominantly cortical bone). The number of new vertebral fractures was similar in the treatment and placebo groups (163 and 136, respectively; P not significant), but the number of nonvertebral fractures was higher in the treatment group (72 vs. 24; P less than 0.01). Fifty-four women in the fluoride group and 24 in the placebo group had side effects sufficiently severe to warrant dose reduction; the major side effects were gastrointestinal symptoms and lower-extremity pain. We conclude that fluoride therapy increases cancellous but decreases cortical bone mineral density and increases skeletal fragility. Thus, under the conditions of this study, the fluoride-calcium regimen was not effective treatment for postmenopausal osteoporosis.
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The effect of two structured exercise programmes on the bone mass of 48 healthy postmenopausal white women aged 50-62 was studied after one year. Volunteers were randomised to group 1 (control), group 2 (aerobic exercise), or group 3 (aerobic and strengthening exercises). Before and after the training programme each subject had evaluations of bone mass (determined by neutron activation analysis and expressed as calcium bone index) and maximum oxygen uptake attained on a multistage exercise treadmill test. After one year both exercise groups had higher levels of fitness and greater bone mass than controls. Mean values (2 SEM) for changes in the calcium bone index were -0.011 (0.037), 0.039 (0.035), and 0.066 (0.036) for groups 1, 2, and 3, respectively. Analysis of variance on the observed data and analysis of covariance adjusting changes to the initial mean value for the whole group showed significant differences between each exercise group and the controls but no difference between the exercise groups themselves. Both exercise groups showed a significant improvement in maximum oxygen uptake. This study suggests that exercise may modify bone loss in healthy postmenopausal women.
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To study the effect of bone mass on the risk of fracture, we followed 521 Caucasian women over an average of 6.5 yr and took repeated bone mass measurements at the radius. We observed 138 nonspinal fractures in 3,388 person-yr. The person-years of follow-up and the incident fractures were cross-classified by age and bone mass. The incidence of fracture was then fitted to a log-linear model in age and bone mass. It was found that incidence of fracture increased with both increasing age and decreasing radius bone mass. When subsets of fractures were examined it was found that age was a stronger predictor of hip fractures, whereas midshaft radius bone mass was a stronger predictor of fractures at the distal forearm. We concluded that bone mass is a useful predictor of fractures but that other age-related factors associated with fractures need to be identified.
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As compared with values in white subjects, bone mass is known to be increased and urinary calcium to be diminished in black individuals. To evaluate the possibility that these changes are associated with alterations in the vitamin D-endocrine system, an investigation was performed in 12 black subjects, 7 men and 5 women, and 14 white subjects, 8 men and 6 women, ranging in age from 20 to 35 yr. All of them were hospitalized on a metabolic ward and were given a constant daily diet containing 400 mg of calcium, 900 mg of phosphorus, and 110 meq of sodium. Whereas mean serum calcium, ionized calcium, and phosphate were the same in the two groups, mean serum immunoreactive parathyroid hormone (350 +/- 34 vs. 225 +/- 26 pg/ml, P less than 0.01) and mean serum 1,25-dihydroxyvitamin D (1,25(OH)2D) (41 +/- 3 vs. 29 +/- 2 pg/ml, P less than 0.01) were significantly higher, and mean serum 25-hydroxy-vitamin D (25-OHD) was significantly lower in the blacks than in the whites (6 +/- 1 vs. 20 +/- 2 ng/ml, P less than 0.001). Mean urinary sodium and 24-h creatinine clearance were the same in the two groups, whereas mean urinary calcium was significantly lower (101 +/- 14 vs. 166 +/- 13 mg/d, P less than 0.01) and mean urinary cyclic AMP was significantly higher (3.11 +/- 0.47 vs. 1.84 +/- 0.25 nM/dl glomerular filtrate, P less than 0.01) in the blacks. Further, the blacks excreted an intravenous calcium load, 15 mg/kg body weight, as efficiently as the whites (49 +/- 3 vs. 53 +/- 3%, NS). Mean serum Gla protein was lower in blacks than in whites (14 +/- 2 vs. 24 +/- 3 ng/ml, P less than 0.02), and increased significantly in both groups in response to 1,25(OH)2D3, 4 micrograms/d for 4 d. There was a blunted response of urinary calcium to 1,25(OH)2D3 in the blacks, and mean serum calcium did not change. The results indicate that alteration of the vitamin D-endocrine system with enhanced renal tubular reabsorption of calcium and increased circulating 1,25(OH)2D as a result of secondary hyperparathyroidism may contribute to the increased bone mass in blacks. Their low serum 25-OHD is attributed to diminished synthesis of vitamin D in the skin because of increased pigment.
Article
The effects of a supervised 1-y walking program and increased dietary calcium (milk supplement, 831 mg/d, vs placebo drink, 41 mg/d) on bones were examined in 36 postmenopausal women (60.2 ±6.5 y). Trabecular bone-mineral density (BMD) of the lumbar spine (L1−L3), measured by computed tomography, increased by 0.5% in exercising women (n = 18) and decreased by 7.0% in sedentary women (n = 18; P = 0.02). Femoral-neck BMD measured by dual-photon absorptiometry (DPA) increased by 2.0% in women consuming high dietary calcium (n = 18) and decreased by 1.1% in those on moderate calcium intake (n = 18; P = 0.001). Neither exercise nor dietary calcium had an effect on lumbar spine (L2−L4) measured by DPA, distal radius measured by single-photon absorptiometry, or total body calcium measured by in vivo neutron activation. The varying proportions and rates of turnover of trabecular and cortical bone from one site to another suggest that exercise and high dietary calcium may preferentially alter bone density at different skeletal sites.
Article
Objective. —To determine how multiple risk factors for osteoporotic fractures could be modified by high-intensity strength training exercises in postmenopausal women.Design. —Randomized controlled trial of 1-year duration.Setting. —Exercise laboratory at Tufts University, Boston, Mass.Population. —Forty postmenopausal white women, 50 to 70 years of age, participated in the study; 39 women completed the study. The subjects were sedentary and estrogen-deplete.Interventions. —High-intensity strength training exercises 2 days per week using five different exercises (n=20) vs untreated controls (n=19).Main Outcome Measures. —Dual energy x-ray absorptiometry for bone status, one repetition maximum for muscle strength, 24-hour urinary creatinine for muscle mass, and backward tandem walk for dynamic balance.Results. —Femoral neck bone mineral density and lumbar spine bone mineral density increased by 0.005±0.039 g/cm2 (0.9%±4.5%) (mean±SD) and 0.009±0.033 g/cm2 (10%±3.6%), respectively, in the strength-trained women and decreased by -0.022±0.035 g/cm2 (-2.5%±3.8%) and -0.019±0.035 g/cm2 (-1.8%±3.5%), respectively, in the controls (P=.02 and.04). Total body bone mineral content was preserved in the strength-trained women (+2.0±68 g; 0.0%±3.0%) and tended to decrease in the controls (-33+77 g; -1.2%±3.4%, P=.12). Muscle mass, muscle strength, and dynamic balance increased in the strength-trained women and decreased in the controls (P=.03 to <.001).Conclusions. —High-intensity strength training exercises are an effective and feasible means to preserve bone density while improving muscle mass, strength, and balance in postmenopausal women.(JAMA. 1994;272:1909-1914)
Article
Objective. —To determine the risk of breast cancer in relation to the use of combined estrogen and progestin hormone replacement therapy (HRT).Design. —A population-based case-control study.Setting. —The general female population of King County in western Washington State.Participants. —Middle-aged (50 to 64 years) women, including 537 patients with incident primary breast cancer diagnosed between January 1,1988, and June 30, 1990, who were ascertained through the Seattle—Puget Sound Surveillance, Epidemiology, and End Results cancer registry and 492 randomly selected control women without a history of breast cancer.Main Outcome Measure. —Breast cancer risk in relation to use of menopausal hormones.Results. —Menopausal hormones of some type had been used by 57.6% of breast cancer cases and 61.0% of comparison women. The women who had ever taken combined estrogen-progestin HRT, representing 21.5% of cases and 21.3% of controls, were not at increased risk of breast cancer (relative odds [RO]=0.9; 95% confidence interval [CI], 0.7 to 1.3). Compared with nonusers of menopausal hormones, those who used estrogen-progestin HRT for 8 or more years had, if anything, a reduced risk of breast cancer (RO=0.4; 95% CI, 0.2 to 1.0).Conclusions. —On the whole, the use of estrogen with progestin HRT does not appear to be associated with an increased risk of breast cancer in middle-aged women. Nonetheless, since the use of combined estrogen-progestin HRT has only recently become prevalent, future investigations must assess whether breast cancer incidence is altered many years after estrogen-progestin HRT has been initiated, particularly among long-term users.(JAMA. 1995;274:137-142)
Article
Low bone mass predicts future fracture risk as well as high cholesterol or high blood pressure can predict the risk of heart disease or stroke. Prevention of the first fracture should be a clinical goal. In patients without fractures, osteopenia and osteoporosis can be diagnosed based on the extent of reduction in bone mass below mean peak bone mass of young healthy individuals. As bone mass decreases, fracture risk increases exponentially. Clinical situations in which an assessment of bone mass and fracture risk affects therapeutic decisions include estrogen deficiency, vertebral abnormalities, radiographic osteopenia, asymptomatic primary hyperparathyroidism, and long-term corticosteroid therapy. Serial measurements can also be used to monitor the effects of osteoporosis treatments. The appropriate technique and skeletal site for bone mass measurements should be chosen based on the patient's circumstances and the precision of measurement. A clinical interpretation can enhance the value of computer generated bone mass measurement reports and improve decision making.
Article
Compared with white women, Asian women have about a 40%–50% and blacks a 50%–60% lower risk of hip fracture, but the reason for this racial difference is not known. Women with a shorter hip axis have a lower risk of hip fracture. To test the hypothesis that a shorter hip axis length could account for the lower risk of hip fracture among Asian and black women, we measured hip axis length in 135 Caucasian, 74 Asian and 50 black women. The mean hip axis lengths of Asian and black women were significantly shorter (1.2 and 0.7 standard deviations, respectively) than that of the whites (p
Article
Background Previous studies have shown that alendronate can increase bone mineral density (BMD) and prevent radiographically defined (morphometric) vertebral fractures. The Fracture Intervention Trial aimed to investigate the effect of alendronate on the risk of morphometric as well as clinically evident fractures in postmenopausal women with low bone mass. Methods Women aged 55–81 with low femoral-neck BMD were enrolled in two study groups based on presence or absence of an existing vertebral fracture. Results for women with at least one vertebral fracture at baseline are reported here. 2027 women were randomly assigned placebo (1005) or alendronate (1022) and followed up for 36 months. The dose of alendronate (initially 5 mg daily) was increased (to 10 mg daily) at 24 months, with maintenance of the double blind. Lateral spine radiography was done at baseline and at 24 and 36 months. New vertebral fractures, the primary endpoint, were defined by morphometry as a decrease of 20% (and at least 4 mm) in at least one vertebral height between the baseline and latest follow-up radiograph. Non-spine clinical fractures were confirmed by radiographic reports. New symptomatic vertebral fractures were based on self-report and confirmed by radiography. Findings Follow-up radiographs were obtained for 1946 women (98% of surviving participants). 78 (8·0%) of women in the alendronate group had one or more new morphometric vertebral fractures compared with 145 (15·0%) in the placebo group (relative risk 0·53 [95% CI 0·41–0·68]). For clinically apparent vertebral fractures, the corresponding numbers were 23 (2·3%) alendronate and 50 (5·0%) placebo (relative hazard 0·45 [0·27–0·72]). The risk of any clinical fracture, the main secondary endpoint, was lower in the alendronate than in the placebo group (139 [13·6%] vs 183 [18·2%]; relative hazard 0·72 [0·58–0·90]). The relative hazards for hip fracture and wrist fracture for alendronate versus placebo were 0·49 (0·23–0·99) and 0·52 (0·31–0·87). There was no significant difference between the groups in numbers of adverse experiences, including upper-gastrointestinal disorders. Interpretation We conclude that among women with low bone mass and existing vertebral fractures, alendronate is well tolerated and substantially reduces the frequency of morphometric and clinical vertebral fractures, as well as other clinical fractures.
Article
The objective of this article was to review the recent literature (1990-1995) on drugs and falls in the older population. A computerized literature search identified 19 research articles. The quality of each study was critically evaluated, and a consistent risk relationship between the use of psychotropic drugs and falls was identified. Moreover, polypharmacy and certain cardiovascular agents may be associated with falls. Finally, it is controversial as to whether certain agents (eg, analgesics, hypoglycemics) are associated with falls. Future studies are necessary to better understand the relationship between drugs and falls in the older adult. (C) 1996 Aspen Publishers, Inc.
Article
Bone mineral density (BMD) is under genetic control. Some studies in Caucasian and Asian women suggest that polymorphisms in the vitamin D receptor (VDR) gene are associated with BMD and the rate of postmenopausal bone loss. We determined if similar associations exist in 101 African-American women aged 65 years and older (71 ± 5 years, mean ± SD). We also examined the relation between VDR genotype and fractional45Ca absorption and markers of bone formation (osteocalcin) and resorption (N-telopeptides) in these women. BMD was measured at the proximal femur and whole body at baseline and after 1.9 ± 0.4 years (femur only) on a Hologic QDR-2000 densitometer using dual-energy X-ray absorptiometry. Calcaneal BMD was measured with single x-ray absorptiometry. VDR gene polymorphisms were defined by the endonucleases BsmI, ApaI, and TaqI. These polymorphisms were not associated with BMD at any skeletal site or with markers of bone turnover. There was a significant interaction between age and VDR genotype where the oldest women (>70 years) with the tt genotype experienced greater hip bone loss than women with the TT genotype (−2.1%/year vs. −0.4%/year, respectively), whereas heterozygous women experienced an intermediate rate of bone loss (−1.3%/year). Women homozygous for the B allele had 14% lower fractional45Ca absorption compared with women homozygous for the b allele, although this difference was not statistically significant (p = 0.08). We conclude that VDR gene polymorphisms are not associated with BMD or indices of bone turnover in this population of older African-American women. However, DNA sequence variation in the VDR gene or a nearby locus may influence intestinal calcium transport and the rate of postmenopausal bone loss in African-American women.
Article
Genetic factors play an important role in determining bone mass and several genes probably act as regulators of this process. Interleukin-6 (IL-6) is a candidate gene for regulation of bone density, since it has stimulatory effects on cells of the osteoclast lineage and has been implicated in the pathogenesis of bone loss associated with estrogen deficiency. Here we studied the relationship between bone mineral density (BMD) and a polymorphic AT rich minisatelite repeat in the 3' flank of the IL-6 gene in a cohort of 200 women. Six length variants were identified (designated A−F), but four of these were rare such that the vast majority of individuals fell into one of two common genotypes: (58.5%) and (27.5%). There was a significant relationship between IL-6 genotype and bone mass at the lumbar spine as determined by analysis of variance (p = 0.04) and a similar trend for bone mass at the femoral neck (p = 0.11). When BMD values were compared in the two common genotypes, we found that spine BMD values were significantly higher in the genotype (mean ± SEM = 0.94 ± 0.04 g/cm2) as compared with the genotype (0.81 ± 0.02 g/cm2; p = 0.012). A similar trend was seen for hip BMD values, but here, the difference failed to reach statistical significance (p = 0.06). Further analysis showed that genotype-specific effects on bone mass were observed in both premenopausal and postmenopausal women and did not increase with age, suggesting that the association between IL-6 polymorphisms and bone density may be mediated by an effect on peak bone mass, rather than rate of bone loss. We conclude that bone mass is associated with two common polymorphisms of the IL-6 gene. Although the mechanisms that underlie this association will require further research, our data suggest that polymorphic variation at the IL-6 gene locus may contribute to the genetic regulation of bone mass.
Article
Considerable epidemiological evidence has accumulated regarding the effect of postmenopausal estrogens on coronary heart disease risk. Five hospital-based case-control studies yielded inconsistent but generally null results; however, these are difficult to interpret due to the problems in selecting appropriate controls. Six population-based case-control studies found decreased relative risks among estrogen users, though only 1 was statistically significant. Three cross-sectional studies of women with or without stenosis on coronary angiography each showed markedly less atherosclerosis among estrogen users. Of 16 prospective studies, 15 found decreased relative risks, in most instances, statistically significant. The Framingham study alone observed an elevated risk, which was not statistically significant when angina was omitted. A reanalysis of the data showed a nonsignificant protective effect among younger women and a nonsignificant increase in risk among older women. Overall, the bulk of the evidence strongly supports a protective effect of estrogens that is unlikely to be explained by confounding factors. This benefit is consistent with the effect of estrogens on lipoprotein subfractions (decreasing low-density lipoprotein levels and elevating high-density lipoprotein levels). A quantitative overview of all studies taken together yielded a relative risk of 0.56 (95% confidence interval 0.50–0.61), and taking only the internally controlled prospective and angiographic studies, the relative risk was 0.50 (95% confidence interval 0.43–0.56).
Article
[7-3HA1Androstenedione and [4-14C]estrone or [7-3H]testosterone and [14C]estradiol were infused at constant rates into brachial arm veins of 15 normal men. During the infusions blood samples were obtained from the brachial artery, a deep vein draining primarily muscle, and a superficial vein draining primarily adipose tissue of the arm contralateral to the infusion. In seven men the mean +/- SE value for the fractional conversion of androstene tissue. In eight men the mean +/- SE value for the fractional conversion of testosterone to estradiol was 0.0007 +/- 0.0001 for muscle and 0.0012 +/- 0.0002 for adipose tissue. Both of these values were significantly (P less than 0.01) less than the respective values of androstenedione aromatization to estrone. If constancy of tissue aromatization throughout the body is assumed, the muscle accounts for 25-30% and adipose tissue for 10-15% of the total extragonadal aromatization of androgens to estrogens.
Article
Hip fractures are recognized to be a major public health problem in many Western nations, most notably those in North America, Europe and Oceania. Incidence rates for hip fracture in other parts of the world are generally lower than those reported for these predominantly Caucasian populations, and this has led to the belief that osteoporosis represents less of a problem to the nations of Asia, South American and Africa. Demographic changes in the next 60 years, however, will lead to huge increases in the elderly populations of those countries. We have applied available incidence rates for hip fracture from various parts of the world to projected populations in 1990, 2025 and 2050 in order to estimate the numbers of hip fractures which might occur in each of the major continental regions. The projections indicate that the number of hip fractures occurring in the world each year will rise from 1.66 million in 1990 to 6.26 million by 2050. While Europe and North America account for about half of all hip fractures among elderly people today, this proportion will fall to around one quarter in 2050, by which time steep increases will be observed throughout Asia and Latin America. The results suggest that osteoporosis will truly become a global problem over the next half century, and that preventive strategies will be required in parts of the world where they are not currently felt to be necessary.
Article
To compare the incidence of all nonvertebral fractures between elderly blacks and whites, the authors conducted a retrospective cohort study among Tennessee Medicaid enrollees aged 65 years or more from 1987 through 1989. A previously validated computer algorithm identified 6,802 persons of black or white race with 7,645 new nonvertebral fractures. The incidence of all nonvertebral fractures in blacks was only half of that in whites. This finding persisted after the authors controlled for sex, age, and nursing home residence (relative risk = 0.4, 95% confidence interval 0.4-0.5). Rates were consistently lower among blacks within subgroups defined by these factors and for each of the 13 different fracture sites examined. The magnitude of the difference between blacks and whites in rates of all fractures combined and most site-specific fractures is similar to that previously reported for hip fractures. These consistent racial differences suggest a common underlying factor(s).
Article
OSTEOPOROSIS is one of the most important disorders associated with aging.1 , 2 More than 1.5 million Americans have fractures related to osteoporosis each year, with attendant pain, deformity, and loss of independence. The annual cost to the U.S. health care system is at least $10 billion.1 , 2 Because of the aging of the population and increases over time in the incidence of fractures, these already huge costs will more than double over the next 30 years3 unless a comprehensive program of prevention and treatment is initiated soon. The most important preventable cause of fractures is low bone mass. During the course of . . .
Article
Osteoporosis among older women is a major public health problem. We studied the effects of three approaches to the prevention of osteoporosis in women with low bone density. One hundred twenty postmenopausal women (mean [+/- SD] age, 56 +/- 4) who were selected because they had low forearm bone density were enrolled in a double-blind, placebo-controlled, randomized study comparing the effects of an exercise regimen (exercise group, n = 41), exercise plus dietary calcium supplementation (exercise-calcium group, n = 39), and exercise plus continuous replacement of estrogen and progesterone (exercise-estrogen group, n = 40). Periodically during the two-year study period, we measured the women's bone density at three forearm sites, measured indexes of calcium metabolism, and recorded symptom scores. A comparison group of 42 women (mean age, 55.5 +/- 3.1) with normal bone density was also followed for two years. Significant bone loss in the distal forearm occurred in the group with normal bone density (control group) and the exercise group (change, -2.7 percent and -2.6 percent of the base-line value per year, respectively). Bone loss at the distal forearm site was significantly lower in the exercise-calcium group (-0.5 percent of the base-line value per year), and bone density increased at this site in the exercise-estrogen group (+2.7 percent of the base-line value per year). Bone loss at the median forearm site was significantly lower in the exercise-calcium group (-1.3 percent of the base-line value per year) than in the exercise group (-2.4 percent), and bone density at this site increased significantly in the exercise-estrogen group (+0.8 percent of the base-line value per year). Breast tenderness occurred in 47 percent of the women in the exercise-estrogen group but in only 20 percent in the other two treatment groups. Vaginal bleeding occurred at some time in 52 percent of the women who had not had a hysterectomy in the exercise-estrogen group, as compared with 11 percent and 12.5 percent, respectively, in the exercise and exercise-calcium groups. In postmenopausal women with low bone density, bone loss can be slowed or prevented by exercise plus calcium supplementation or estrogen-progesterone replacement. Although the exercise-estrogen regimen was more effective than exercise and calcium supplementation in increasing bone mass, it also caused more side effects.
Article
Osteoporosis and hip fractures are less common and bone mass is greater in black than in white women. To determine if bone mass is greater in black than in white children, bone mineral density (BMD) of the midradius by single-photon absorptiometry and BMD of the lumbar spine (L1-L4), trochanter, and femoral neck by dual-photon absorptiometry were measured in 20 black boys, 18 black girls, 33 white boys, and 35 white girls between the ages of 7 and 12 years. Mean age (10.4 +/- 0.3 versus 10.2 +/- 0.2 years) and body weight (39 +/- 2 versus 38 +/- 2 kg) in the blacks and whites, respectively, were not different in the two groups, and the ages and weights of the boys and girls were not different from each other. BMD were significantly greater in black than in white children at each site, in the black than in white boys at the trochanter and femoral neck, and in the black than in white girls at each site. In both races, BMD varied directly with age and body weight. Multivariate analysis showed that BMD were greater at the midradius, lumbar spine, trochanter, and femoral neck in the black than in the white children, that BMD of the lumbar spine was greater in the girls than in the boys, and that BMD of the trochanter and femoral neck were greater in the boys than in the girls. There were significant partial correlations between race and BMD and between BMD and body weight at each site, between sex and BMD at the lumbar spine, trochanter, and femoral neck, and between age and BMD at the midradius, trochanter, and femoral neck. Race, sex, age, and body weight together accounted for 49-66% of the variation in bone mass. Thus, BMD of the midradius, spine, and hip are greater in black than in white children, body weight and age are important determinants of bone mass, and some sex differences in bone mass are present at this age.
Article
The etiology of the racial disparity in bone mass and fracture rate is unknown. Since the PTH-vitamin D endocrine system is a major regulator of calcium metabolism and bone turnover, this cross-sectional study examined the relationship of radial and lumbar bone density to vitamin D metabolite and PTH concentrations and to calcium intake and excretion in 67 white and 70 black highly comparable, healthy, premenopausal women. Bone density at both radial and lumbar sites was higher in blacks than in whites. Serum 25-hydroxyvitamin D was slightly but not statistically significantly (P = 0.08), lower in blacks than in whites, but there were no racial differences in 1,25-dihydroxyvitamin D, PTH, or renal tubular maximum for reabsorption of phosphate. The mean 25-hydroxyvitamin D concentration in blacks was well within the normal range and was not associated with evidence of secondary hyperparathyroidism. There were no correlations of bone density to vitamin D or PTH concentrations. Although there were no racial differences in dietary intake of calcium and vitamin D or in sodium excretion, 24-h urinary calcium excretion was significantly lower in blacks than in whites, and calcium excretion was inversely associated with radial bone density. In contrast to previous reports, in healthy, normal weight, premenopausal black women there is no evidence of vitamin D deficiency or secondary hyperparathyroidism, suggesting that factors other than the vitamin D-PTH axis are responsible for racial differences in bone mass.
Article
Although even in the elderly most falls are not associated with fractures, over 90 percent of hip fractures are the result of a fall. Few studies have assessed whether the risk factors for falls are also important risk factors for hip fracture. To examine the importance of risk factors for falls in the epidemiology of hip fracture, we performed a case-control study of 174 women (median age, 80 years) admitted with a first hip fracture to 1 of 30 hospitals in New York and Philadelphia. Controls, matched to the case patients according to age and hospital, were selected from general surgical and orthopedic surgical hospital services. Information was obtained by direct interview. As measured by the odds ratio, increased risks for hip fracture were associated with lower-limb dysfunction (odds ratio = 1.7; 95 percent confidence interval, 1.1 to 2.8), visual impairment (odds ratio = 5.1; 95 percent confidence interval, 1.9 to 13.9), previous stroke (odds ratio = 2.0; 95 percent confidence interval, 1.0 to 4.0), Parkinson's disease (odds ratio = 9.4; 95 percent confidence interval, 1.2 to 76.1), and use of long-acting barbiturates (odds ratio = 5.2; 95 percent confidence interval, 0.6 to 45.0). Of the controls, 44 (25 percent) had had a recent fall. The case patients were more likely than these controls to have fallen from a standing height or higher (odds ratio = 2.4; 95 percent confidence interval, 1.0 to 5.7). Of those with hip fracture the younger patients (less than 75 years old) were more likely than the older ones (greater than or equal to 75 years old) to have fallen on a hard surface (odds ratio = 1.9; 95 percent confidence interval, 1.04 to 3.7). A number of factors that have been identified as risk factors for falls are also associated with hip fracture, including lower-limb dysfunction, neurologic conditions, barbiturate use, and visual impairment. Given the prevalence of these problems among the elderly, who are at highest risk, programs to prevent hip fracture should include measures to prevent falls in addition to measures to slow bone loss.
Article
The effects of a supervised 1-y walking program and increased dietary calcium (milk supplement, 831 mg/d, vs placebo drink, 41 mg/d) on bones were examined in 36 postmenopausal women (60.2 +/- 6.5 y). Trabecular bone-mineral density (BMD) of the lumbar spine (L1-L3), measured by computed tomography, increased by 0.5% in exercising women (n = 18) and decreased by 7.0% in sedentary women (n = 18; P = 0.02). Femoral-neck BMD measured by dual-photon absorptiometry (DPA) increased by 2.0% in women consuming high dietary calcium (n = 18) and decreased by 1.1% in those on moderate calcium intake (n = 18; P = 0.001). Neither exercise nor dietary calcium had an effect on lumbar spine (L2-L4) measured by DPA, distal radius measured by single-photon absorptiometry, or total body calcium measured by in vivo neutron activation. The varying proportions and rates of turnover of trabecular and cortical bone from one site to another suggest that exercise and high dietary calcium may preferentially alter bone density at different skeletal sites.
Article
Sex-, race- and age-specific hip fracture rates were determined using Health Care Financing Administration data for Medicare-reimbursed hip fracture hospitalizations from 1980 to 1982. Rates were highest in White women, lowest in Black men, and intermediate in White men and Black women. Proportions of hip fracture patients dying during hospitalization and those discharged to nursing homes, respectively, were: White men (10.5%; 49%); Black men (9.3%; 32%); White women (5.0%; 54%); and Black women (8.2%; 30%).
Article
Neither age-related osteoporosis nor the increasing incidence of falls with age sufficiently explain the exponential increase in the incidence of hip fracture with aging. We propose that four conditions must be satisfied in order for a fall to cause a hip fracture: (a) the fatter must be oriented to impact near the hip; (b) protective responses must fail; (c) local soft tissues must absorb less energy than necessary to prevent fracture, and (d) the residual energy of the fall applied to the proximal femur must exceed its strength. All of these events become more likely with aging and lead to an exponential rise in the risk of hip fracture with advancing age. This model also suggests that a combination of measurements of neuromuscular function and of bone strength may be the most accurate approach to assessing the risk of hip fracture.
Article
The reasons for a different incidence of osteoporotic fractures in white and black women are unknown. Previous racial comparisons of bone mass have been limited by racial differences in body weight and socioeconomic, health, and nutritional status. This cross-sectional study examined bone density in 105 black and 114 white healthy nonobese women, 24-65 yr old, using dual photon absorptiometry of the lumbar spine and single photon absorptiometry of the distal radius. Bone density at both sites was higher in blacks at all ages than in whites. When adjusted for age and body mass index, mean bone density was 6.5% higher in blacks at both spine and radius (P less than 0.0001). The cross-sectional rate of decline of vertebral bone density was similar between races; however, radial density increased 3.8%/decade (P = 0.03) in premenopausal blacks under age 46 yr, while it declined 3.2%/decade (P = 0.09) in premenopausal whites. The racial difference in slopes in these premenopausal women is significant (P = 0.002). These findings suggest that attainment of higher peak bone mass and delayed onset of bone loss contribute to the lower incidence of osteoporotic fractures in black women.
Article
Although osteoporosis is an age-related disorder, the accelerated bone loss observed in postmenopausal women may be preventable with early diagnosis and adequate estrogen replacement. In a prospective study, we investigated the effect of oral estrogen replacement using conjugated estrogens (Premarin, 0.625 mg) or micronized 17 beta-estradiol (Estrace, 1 mg) versus no estrogen in sequential single-photon bone density measurements over 3-year intervals in 397 postmenopausal women. Estradiol, 1 mg, and conjugated estrogens, 0.625 mg, were equally effective in regarding bone loss. The rate of bone loss was about the same for estrogen users regardless of age (51 to 80 years) and was approximately one third that of nonusers. Among nonusers a uniform accelerated rate of bone loss of 2.5% per year was noted between 56 and 70 years old, whereas between the ages of 51 and 55 years and after age 70 years, the rate of bone loss was significantly less. Ever users over age 65 years showed continued protection from bone loss as long as estrogen therapy was continued. Previous estrogen users who stopped estrogen after age 65 years lost bone more rapidly than women of similar age who had never taken estrogen. Thus to prevent accelerated bone loss in postmenopausal women, we recommend early and continued hormone replacement for life. Estrogen nonusers should be monitored at regular intervals to minimize accelerated bone loss.
Article
Because blacks make up a small proportion of the hip fracture population, little is known about how blacks' experience following hip fracture compares to that of whites. This study, a retrospective review of the medical records of 119 community residing subjects, 60 years of age and older, 37% of whom were black, admitted with a diagnosis of hip fracture to a large urban teaching hospital, investigated differences between black and white patients in factors associated with outcome following hip fracture and outcomes at time of hospital discharge. Blacks were significantly more likely than whites to exhibit a high total number of diagnoses, urinary incontinence following surgery, low admission hemoglobins and mental impairment. Blacks experienced significantly longer hospitalizations than whites, were significantly more likely to be nonambulatory at discharge and showed different patterns of discharge destination. Multiple regression and logistic regression indicated that the greater amount of illness of blacks is a consistent significant predictor of these differences in outcomes, but that race, delays to surgery and non-surgical treatment also make independent significant contributions. These findings indicate the importance of planning for the in-hospital care of black hip fracture patients, and the examination of the financial consequences of DRG's for hospitals serving black or poor populations.
Article
We examined the incidence of hip fracture in Non-Hispanic White, Hispanic, Black, and Asian Americans for the years 1983 and 1984 using a data base which contains a summary of all hospitalizations for the State of California. We found a consistently lower risk for hip fracture after age 60 in Hispanic, Black, and Asian American females than in White females who were not Hispanic. Overall age-adjusted hip fracture rates in Hispanic, Black, and Asian females were 49.7, 57.3, and 85.4, respectively, and 140.7/100,000 in White females who were not Hispanic. These differences were not found in males, although Whites (not Hispanic) had the highest incidence of hip fractures among males.
Article
Blacks have a greater bone mass and a lower incidence of osteoporosis and hip fractures than whites. We performed biopsies of the iliac crest in 12 blacks (6 men and 6 women) and 13 whites (8 men and 5 women) who were matched for age (range, 19 to 46 years) and weight, to determine whether histomorphometric differences between blacks and whites could be identified. The static measurements of cortical and cancellous bone architecture were not significantly different in the two groups. In contrast, the dynamic measurements, determined with tetracycline markers, showed that the mean rate of bone formation in the blacks was only 35 percent of that in the whites (P less than 0.001). We conclude that the rate of bone turnover is lower in blacks than in whites, since bone resorption and bone formation are closely coupled in the steady state. If reconstitution of previously resorbed cavities at remodeling sites is incomplete in osteoporosis, a reduction in the rate of skeletal remodeling could provide a means for maintaining and preserving bone mass in blacks.
Article
The incidence of osteoporosis and fractures of the hip are diminished in blacks and in obese subjects. To determine whether bone mass is increased in them, bone mineral density (BMD) of the lumbar spine, trochanter, and femoral neck was measured by dual photon absorptiometry in 89 nonobese white and 51 nonobese black women, all of whom were within 30% of their ideal body weight and between the ages of 20 and 50 yr, and in 21 obese white women and 21 obese black women, all of whom weighed 30% on more than their ideal body weight and were in the same age range. The BMD of the mid radius was also measured by single photon absorptiometry. The mean BMD of the mid radius was higher in black than in white nonobese women [0.73 +/- 0.01 (+/- SE) vs. 0.70 +/- 0.01 g/cm2; P less than 0.01] and was not altered by obesity in either group. The mean BMD was higher in the black than in the white nonobese women at the lumbar spine (1.23 +/- 0.02 vs. 1.16 +/- 0.01 g/cm2; P less than 0.01), trochanter (0.78 +/- 0.02 vs. 0.72 +/- 0.01 g/cm2; P less than 0.01) and femoral neck (0.96 +/- 0.02 vs 0.90 +/- 0.02 g/cm2; P less than 0.02). The mean body weight was higher in the obese than in the nonobese white women (92 +/- 2 vs. 61 +/- 1 kg; P less than 0.001) and black women (94 +/- 3 vs. 63 +/- 1 kg; P less than 0.001). The mean BMD was higher in the obese than in the nonobese white women at the lumbar spine (1.24 +/- 0.03 g/cm2; P less than 0.05), trochanter (0.89 +/- 0.04; P less than 0.001), and femoral neck (0.99 +/- 0.03; P less than 0.01) and was higher in the obese than in the nonobese black women at the lumbar spine (1.33 +/- 0.03 g/cm2; P less tham 0.01), trochanter (0.88 +/- 0.04 g/cm2; P less than 0.05), and femoral neck (1.04 +/- 0.03 g/cm2; P less than 0.05). Multivariate regression analysis revealed positive correlations between body weight and BMD at each of the 3 weight-bearing sites, but not at the mid radius, in both the black women and white women.(ABSTRACT TRUNCATED AT 400 WORDS)
Article
Osteoporosis and associated fractures are common in Western countries, especially among elderly white women. In the United States alone, the total cost of osteoporosis and osteoporotic fractures was estimated to be 6.1 billion dollars in 1983. In addition to enormous economic costs, these fractures cause considerable disability and many premature deaths. As the number of elderly increases, so will the magnitude of the problem. Consequently, the public, health professionals, and policymakers have become increasingly concerned about prevention of osteoporosis and osteoporotic fractures. Osteoporosis may be defined as a reduction in bone mass that increases susceptibility to fracture. Defining osteoporosis more precisely is difficult since, for a specific age and sex, there is a wide, continuously distributed range of bone mass and no distinctly separate group of people with low bone mass. Average bone mass tends to decrease after the fourth or fifth decade in all populations studied so far, so that bone loss may be considered an almost universal phenomenon of aging. Osteoporosis predisposes to fractures of the hip, vertebrae, distal forearm, humerus, pelvis, and other, less common types of fractures. With sufficient force of injury, these fractures can occur in anoyone, but they are considered to be 'osteoporotic' when they occur in the elderly or as the result of minimal trauma (no more severe than that resulting from falling from a standing height).
Article
The ash weight of the third lumbar vertebral body and the weight of the left psoas muscle from forty-six routine necropsies were significantly correlated (p<0·001) when bodyweight, age, and height were taken into account. It is proposed that the weight of a muscle reflects the forces that it exerts on bones to which it is attached and that muscle weight is an important determinant of bone mass.
Article
Incidence rates for hip fracture in the United States were estimated using non-federal hospital discharges from the National Hospital Discharge Survey for the years 1974-1979. Age-specific incidence curves for women and for men showed similar patterns of increase in risk with age, with risks approximately doubling every five years after age 50. Age-specific rates by five-year age groups were compared among the four race-sex groups. No significant differences were observed between Black females, Black males, and White males. In contrast, rates for White females were one and one-half to four times those for Black females after age 40 and were approximately double those for White males after age 50. Analysis based on an independent data source of non-federal hospital discharges in Washington, DC confirmed these relationships. In the Washington study, White women were at twice the risk for hip fracture (controlled for age) compared with Black women and at 2.7 times the risk for hip fracture (controlled for age) compared to White men. No significant differences were observed between Black women and Black men.
Article
We interviewed 327 women who had been 50 to 74 years of age when treated for fracture of the hip of lower forearm, to determine their use (or lack of use) of estrogen preparations. Their responses were compared with those in a random sample of 567 women who were of similar age and from the same region. The risk of fracture was 50 to 60 per cent lower in women who had used these drugs for six years or longer than in women who hadnot used them (95 per cent confidence interval of relative risk, 0.3 to 0.6); those using them for shorter periods received less benefit, if any. A decreased risk of fracture was clearly evident only in women still taking estrogens and evident at either common daily dose (0.625 and 1.25 mg). In conjunction with the finding that estrogens can retard the development of osteoporosis in postmenopausal women, our data argue that lowering of the risk of hip and forearm fractures must be weighed as a benefit of long-term estrogen use.