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The Newcastle Thousand Families birth cohort dates from 1947; assessments have included height measurement at 22 and 50 years, when height loss was also assessed by self-report. A total of 388 attended for 50-year review of bone health, of whom 57 reported a median height loss of 2.5 cm, and 8 reported height loss of >3.5 cm. However, of 24 subjects for whom true height loss could be calculated, 7 had gained height, 9 were unchanged and only 8 had lost height since age 22 years. Self-report leads to over-reporting of height loss, and therefore should not be the sole measure of height loss. In clinical practice, objective confirmation of reported height loss should be undertaken, wherever possible, prior to further investigation.
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ORIGINAL ARTICLE
Fraser Birrell Æ Mark S. Pearce
Roger M. Francis Æ Louise Parker
Self-report overestimates true height loss:
implications for diagnosis of osteoporosis
Received: 5 November 2004 / Revised: 6 January 2005 / Accepted: 6 January 2005 / Published online: 2 June 2005
Ó Clinical Rheumatology 2005
Abstract The Newcastle Thousand Families birth co-
hort dates from 1947; assessments have included height
measurement at 22 and 50 years, when height loss was
also assessed by self-report. A total of 388 attended for
50-year review of bone health, of whom 57 reported a
median height loss of 2.5 cm, and 8 reported height loss
of >3.5 cm. However, of 24 subjects for whom true
height loss could be calculated, 7 had gained height, 9
were unchanged and only 8 had lost height since age
22 years. Self-report leads to over-reporting of height
loss, and therefore should not be the sole measure of
height loss. In clinical practice, objective confirmation of
reported height loss should be undertaken, wherever
possible, prior to further investigation.
Keywords Cohort Æ Height loss Æ Osteoporosis Æ
Self-report
Introduction
Previous epidemiological studies have consistently
shown that self-report of height is biased towards over-
reporting, in contrast to weight which is under-reported
[13]: people therefore appear to believe themselves both
taller and slimmer than objective measurements allow.
We hypothesised that individuals asked about he ight
loss for a prospective birth cohort study of osteoporosis
would therefore minimise self-report of height loss.
Methods
The Newcastle Thousand Families study was init iated in
1947 by Sir James Spence, when all 1142 children born
between May and June that year to mothers resident
within the city of Newcastle upon Tyne were recruited
and followed to age 22 years, when full adult height was
likely to have been achieved. The survivors were traced
when they reached the age of 50 years and invited to fill
in a questionnaire including self-report height and height
loss and to attend for further bone health assessment
including height measured using comparable methodol-
ogy to that used at age 22 years [4]. Height at 22 years
was measured and height loss at 50 years was reported
in inches, then converted to centimetres (1 in.=2.54 cm)
prior to analysis.
Results
Eight hundred and thirty-two of the ori ginal cohort were
successfully traced and 388 agreed to attend (171 men
and 217 women). The median height change from 22 to
50 years, available for 81 men and 102 women, was
0.1 cm for men (interquartile range: 0.8 to +0.9 cm,
Wilcoxon matched pairs p=0.7) and 0.5 cm for wo-
men (interquartile range: 1.2 to +1.2 cm, p=0.1). As
other studies have shown, both men and women signif-
icantly overestimated their heights (median overestima-
tion 1.9 and 1.0 cm, respectively, p<0.0001) and men
overestimated their heights significantly more than wo-
men (p<0.001). Height loss was reported by 57 study
members (15%, median height loss: 2.5 cm), with nine
reporting height loss of >3.5 cm. However, of the 24
subjects reporting height loss for whom true height loss
from age 22 could be calculated , assuming equivalence
of heights within 0.5 cm, 7 had gained height, 9 were
unchanged and only 8 had lost height . There was a poor
correlation between self-reported and true height loss
(r=0.28) (Fig. 1).
F. Birrell (& ) Æ M. S. Pearce Æ R. M. Francis Æ L. Parker
Department of Rheumatology,
University of Newcastle upon Tyne,
4th Floor, Cookson Building, Framlington Place,
NE2 4HH, UK
E-mail: Fraser.Birrell@ncl.ac.uk
Tel.: +44-191-2225548
Fax: +44-191-2225455
Clin Rheumatol (2005) 24: 590–592
DOI 10.1007/s10067-005-1112-y
Discussion
This prospective cohort study has shown there was no
evidence of general height loss in middle-aged men and
women at age 50 years, compared to measured height at
age 22 years. When asked directly about height loss,
15% reported that this had taken place, although
objective measurement showed two-thirds were mis-
taken. In contrast to our hypothesis, there was over-
reporting of height loss, rather than a minimisation due
to overestimation of current height.
The study methodology is robust: although the
numbers are relatively small, this design is unique in
allowing comparison of self-report changes in height
with prospectively collected objective measurements.
Also, participation rates are high compared to other
similar longitudinal studies [4]. In contrast to many
studies, variation in age is not a factor, with all subjects
having been born within a 2-month period; nor is there
reason to believe that seasonal or cohort effects should
systematically bias self-report. Although a higher pro-
portion of women answered the questionnaire and at-
tended for clinical examination, this would not be
expected to affect these findings. If anything, the greater
overestimation of height by men suggests that the re-
ported height loss would be underestimated. Further-
more, the conversion from inches to centimetres does not
systematically bias the results, although threshold effect s
are seen with clustering of data at fractions of the inch.
Rather, the over-reporting of height loss this study
has demonstrated can be explained in two major ways .
First, there is a tendency towards answering direct
questions in population surveys positively, hence the
need for inversion and careful balance in the ordering of
questionnaires like the short form-36 health status
questionnaire (SF-36) [5]. Second, if there is differ ential
recall between recent height estim ates and those from
early adulthood, this may lead to an greater overesti-
mate of early adult height and therefore the imputation
of height loss in subsequent estimates. Further data from
this cohort at 60-year review will be helpful in clarifying
whether self-report continues to overestimate height loss
in the post-menopausal period when true height loss is
expected to occur more frequently.
In conclusion, height loss was over-reported in this
population at age 50 years; therefore, self-report should
not be used as the only measure of height loss. This has
direct relevance to clinical rheumatology, as patients
with inflammatory arthritis [6, 7] and on oral cortico-
steroid therapy [8] are at increased risk of osteoporosis.
Furthermore, height loss has long been recognised to be
associated with osteoporosis [9] and is recommended by
the Royal College of Physicians of London clinical
guidelines for osteoporosis [10] as a marker of possible
osteoporotic vertebral deformation. Objective confir-
mation of reported height loss should be undertaken in
this setting, wherever possible, prior to further investi-
gation.
Self-report leads to over-reporting of height loss, so
should not be the sole measure of height loss.
In clinical practice, objective confirmation of reported
height loss should be undertaken pri or to further
investigation for osteoporosis.
References
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Fig. 1 Self-reported height loss
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Generalised osteoporosis is a feature of established rheumatoid arthritis but whether this is a consequence of treatment, immobility, or disease activity has been unclear. We estimated bone mineral density by dual energy x-ray absorptiometry on 148 patients with early rheumatoid arthritis before treatment with corticosteroids or disease-modifying drugs and 730 normal controls. Scans were done at 12-month intervals in patients and at 0 and 12 months on 50 of the controls matched for menopausal status. At presentation, bone mineral density of patients did not differ from controls. However, patients with disease for less than 6 months had significantly higher spinal bone mineral density than those of longer duration. Over the next 12 months, bone mineral density loss was greater in patients with rheumatoid arthritis compared with controls; significantly so for early disease (eg, -2.4 [0.8] vs -0.6 [0.4] g/cm2, p < 0.05 in the spine and -4.3 [0.8] vs -0.4 [0.5] g/cm2, p < 0.001 in the trochanter). For the lumbar spine, only disease activity was significantly associated with this bone mineral density loss. For patients with active disease over 2 years, mean bone mineral density loss at each site was between 5.5 and 10% (p < 0.01 compared to patients with inactive disease). Suppression of disease activity stabilised this bone loss. In patients with rheumatoid arthritis significant amounts of generalised skeletal bone were lost early in the disease and the loss was associated with disease activity. These findings have implications for the management of patients with rheumatoid arthritis and possibly other inflammatory diseases.
Article
To assess bone mineral density (BMD) in men with steroid-treated rheumatoid arthritis (RA). Dual-energy x-ray absorptiometry (DXA) was used to measure BMD in 40 men with RA, 20 of whom were receiving low-dose corticosteroids (< or = 10 mg prednisolone daily), and in 20 healthy, age-matched male controls. BMD was significantly reduced at the femoral neck and greater trochanter in both groups of RA patients, and at the spine from the anteroposterior dimension in the steroid-treated group. Low-dose steroid therapy may induce excess axial osteopenia in men with RA.