Objective: To determine the ability of measurements of bone density in women to predict later fractures. Design: Meta-analysis of prospective cohort studies published between 1985 and end of 1994 with a baseline measurement of bone density in women and subsequent follow up for fractures. For comparative purposes, we also reviewed case control studies of hip fractures published between 1990 and 1994. Subjects: Eleven separate study populations with about 90000 person years of observation time and over 2000 fractures. Main outcome measures: Relative risk of fracture for a decrease in bone mineral density of one standard deviation below age adjusted mean. Results: All measuring sites had similar predictive abilities (relative risk 1.5 (95% confidence interval 1.4 to 1.6)) for decrease in bone mineral density except for measurement at spine for predicting vertebral fractures (relative risk 2.3 (1.9 to 2.8)) and measurement at hip for hip fractures (2.6 (2.0 to 3.5)). These results are in accordance with results of case-control studies. Predictive ability of decrease in bone mass was roughly similar to (or, for hip or spine measurements, better than) that of a 1 SD increase in blood pressure for stroke and better than a 1 SD increase in serum cholesterol concentration for cardiovascular disease. Conclusions: Measurements of bone mineral density can predict fracture risk but cannot identify individuals who will have a fracture. We do not recommend a programme of screening menopausal women for osteoporosis by measuring bone density. Key messages Measuring bone mineral density has been suggested as a method of identifying individuals at high risk of fracture in a preventive context Our meta-analysis of prospective studies showed that all studies measuring bone density at any site had similar predictive ability for a decrease of 1 SD in bone density except for measurements at hip and spine, which have better predictive ability for fractures in hip and spine respectively Predictive ability of decrease in bone mass was roughly similar to (or, for hip or spine measurements, better than) that of a 1 SD increase in blood pressure for stroke and better than a 1 SD increase in serum cholesterol concentration for cardiovascular disease Although bone mineral density measurements can predict fracture risk, they cannot identify individuals who will have a fracture, and a screening programme for osteoporosis cannot be recommended

Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures

The assessment of vertebral fracture by conventional radiography has been refined and improved using either semiquantitative or quantitative criteria. The inter- and intraobserver variability was determined for a semiquantitative visual approach that we routinely use in clinical studies for assessing prevalent and incident vertebral fractures. In addition, the semiquantitative approach was compared with a quantitative morphometric approach. The incidence and prevalence of vertebral fractures were determined in 57 postmenopausal women (age 65-75 years) by three independent observers. The radiographic basis for fracture definitions and the source of interobserver agreement for the semiquantitative technique. We conclude that the semiquantitative approach can be applied reliably in vertebral fracture assessment when performed using well-defined criteria.

Vertebral fracture assessment using a semiquantitative technique

Assessment of fracture risk and its application to screening for postmenopausal osteoporos

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(02)08761-5.pdf

Diagnosis of osteoporosis and assessment of fracture risk

The criteria required for an effective screening strategy for osteoporosis are largely met in Caucasian women. The disease is common and readily diagnosed by the measurement of bone mineral with single- or dual-energy absorptiometry. Such measurements have high specificity but lower sensitivity, so that the value of the technique is greater for those identified as being at higher risk. Against this background there is little evidence that osteoporosis can usefully be tackled by a public health policy to influence risk factors such as smoking, exercise and nutrition. This suggests that it is appropriate to consider targetting of treatment with agents affecting bone metabolism to susceptible individuals. Since the main benefits of the use of hormone replacement therapy (HRT) are probably on cardiovascular morbidity, the major role for selective screening is to direct non-HRT interventions. An appropriate time to consider screening and intervention is at the menopause, but screening at later ages is also worthy of consideration. Since the cost of screening is low and that of bone-active drugs is high, the selective use of screening techniques will improve the cost-benefit ratio of intervention.

Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. WHO Study Group.

The thiazide diuretics are known to cause calcium retention. In order to study the effect of thiazides on bone mineralization, we have measured the mineral content of bone at five sites (the distal radius, the distal ulna, the proximal radius, the proximal ulna, and the os calcis) in 1368 men with a mean age of 68 years, including 323 who were taking thiazides for hypertension. The results were adjusted for age and body-mass index. Thiazide users had significantly more bone mineral content at all five sites than did non-users. Untreated hypertensive patients and persons without hypertension had comparable bone mineral content, indicating that the higher mineral content found among thiazide users is related to the drug and not to the underlying hypertension. These findings suggest the possibility of a preventive or therapeutic role for thiazides in osteoporosis. (N Engl J Med 1983; 309:344–7.)

https://www.nejm.org/doi/pdf/10.1056/NEJM198308113090605?listPDF=true

Thiazide effect on the mineral content of bone.

Predicting vertebral deformity using bone densitometry at various skeletal sites and calcaneus ultrasound

The relationship between diet and bone mineral content of multiple skeletal sites in elderly Japanese-American men and women living in Hawaii

Cross-sectional data of bone mineral content measured at five skeletal sites (distal radius and ulna, proximal radius and ulna, and os calcis) with single photon absorptiometry were obtained from a population of Japanese-Americans living in Hawaii, comprising 1368 men (aged 61-81 years) and 1098 women (aged 43-80 years). Age-specific mean values of bone mineral content for all skeletal sites were much greater for men than for women and decreased steadily with advancing age in both sexes. The decrease in bone mineral content with age across a 15-year age range was two to four times (depending on skeletal site) greater for women than for men. In multiple regression analyses, age, weight, and postmenopausal estrogen use were potent determinants of bone mineral content for all skeletal sites. Weight was more strongly related to bone mineral content of the os calcis than age in both sexes. Height was significantly related only to the forearm bones. Strenuous exercise was significantly related to bone mineral content of the os calcis and the distal ulna only in men. When compared with US Caucasians of comparable sex and age, the Japanese in Hawaii have lower bone mineral content of the radius. This may partly be explained by the difference in body size. Significant correlations were found between bone mineral content of appendicular bones and radiographically determined vertebral osteoporosis.

Bone mineral measurements among middle-aged and elderly japanese residents in hawaii

In a prospective study of 699 women, 39 new spine fracture cases were observed during a mean follow-up of 3.6 yr. Spine fracture incidence was compared to initial bone mineral content (BMC) of the calcaneus, distal radius, proximal radius, and the lumbar spine. BMC at all four sites was significantly related to spine fracture incidence. Women at -1 s.d. for calcaneal BMC had a sevenfold greater probability of spine fracture than women at +1 s.d.; women at -2 s.d. had a 50-fold greater probability than women at +2 s.d., even after adjustment for the effects of age. Combinations of BMC at two sites further strengthened the relationship to spine fracture; the best two-site combination is calcaneus and distal radius BMC. Thus women can be categorized and stratified according to future fracture risk, and the selection of postmenopausal women for preventive treatments can be guided by measurements of BMC.

https://jnm.snmjournals.org/content/jnumed/30/7/1166.full.pdf

Richard D. Wasnich

Papers

Thiazide effect on the mineral content of bone.

Predicting vertebral deformity using bone densitometry at various skeletal sites and calcaneus ultrasound

The relationship between diet and bone mineral content of multiple skeletal sites in elderly Japanese-American men and women living in Hawaii

Bone mineral measurements among middle-aged and elderly japanese residents in hawaii

A comparison of single and multi-site BMC measurements for assessment of spine fracture probability.