Age as a predictor of osteoporotic fracture compared with current risk-prediction models.

OBJECTIVE: To compare several fracture risk-prediction models and their predictive values. METHODS: Women older than age 49 years were sent for dual-energy X-ray absorptiometry screening between January 2007 and March 2009. Data collection included multiple osteoporosis risk factors. The ability to identify fractures was analyzed and compared using the North American Menopause Society 2006 and 2010 Position Statements, The Fracture Risk Assessment Tool, along with age alone. The area under the curve (AUC) comparison with chance (AUC 0.50) and paired AUC comparisons between models were used to investigate the efficacy of each model in predicting osteoporotic fractures. RESULTS: Among the 615 women studied, with mean (standard deviation) age of 61.4 (8.3) years and 94.5% being white, 15 have experienced a fracture. All screening approaches were significantly better than chance at predicting fractures. Paired comparisons of the detection ability of fracture prediction models showed no significant differences. Age alone was a significant predictor for fracture (AUC 0.79, 95% confidence interval [CI] 0.67-0.91, P<.001) with the optimal cutoff age of 65 years, which was associated with a sensitivity (95% CI) of 80% (77-83%) and specificity (95% CI) of 73% (70-77%). Compared with young postmenopausal women (younger than 65 years), the odds ratio (95% CI) of fractures in older women (65 years or older) is 10.2 (2.32-44.97). In addition, when age was added, it significantly increased the AUC of each model. CONCLUSION: These data suggest that all current screening modalities are effective in predicting fracture but not significantly better than age alone. Age should be considered carefully while evaluating patients for osteoporosis screening and treatment. LEVEL OF EVIDENCE: II.

Response to an adequate dietary intake of vitamin D3 modulates the effect of estrogen therapy on bone density.

INTRODUCTION: This study analyzed associations between plasma vitamin D(3) (25OHD(3)) and bone mineral density (BMD) and whether the effects of conjugated equine estrogens (CEE) on BMD are modulated by 25OHD(3). METHODS: Fifty cynomolgus monkeys were fed a diet containing 25OHD(3) (providing a woman's equivalent of 1000 IU/day of 25OHD3). The monkeys underwent bilateral oophorectomy and were randomized to either CEE (equivalent of 0.45 mg/day) (n=25) or placebo (n=25) and continued receiving the same diet. 25OHD(3) and BMD were measured at randomization and after 6 months. BMD also was measured after 20 months (equivalent to 6 human years). Associations between 25OHD(3) and BMD were subsequently analyzed. RESULTS: Baseline 25OHD(3) plasma concentrations varied from 26 to 95 ng/mL (mean±standard deviation [SD] 54 ± 15 ng/mL). Higher plasma concentrations of 25OHD(3) were associated with a significantly increased BMD. Monkeys on both CEE and placebo had increased BMD over 20 months; however, the increase was not significantly different (0.034 g/cm(2) vs. 0.020 g/cm(2), respectively; p=0.064). The 20-month BMD increased significantly with CEE treatment in those with higher vs. lower 25OHD(3) concentrations (p=0.027). The percent change in BMD over 20 months also increased significantly with CEE treatment in those with higher vs. lower 25OHD(3) concentrations (p=0.018). A higher 25OHD(3) concentration had no significant effect on BMD in those receiving placebo. CONCLUSIONS: Monkeys fed a diet containing 1000 IU/day equivalent of 25OHD(3) have a wide range of plasma 25OHD(3) concentrations. Those receiving CEE with higher 25OHD(3) concentrations had higher BMDs, suggesting 25OHD(3) and CEE have synergistic effects on BMD.

Osteoporosis screening and treatment guidelines: are they being followed?

OBJECTIVE: The objective of this study was to examine a cohort of women sent for dual-energy x-ray absorptiometry (DXA) screening to see whether they met the criteria for bone density testing. In addition, we sought to determine whether they were receiving appropriate interventions, based on published guidelines. METHODS: Between January 1, 2007, and March 1, 2009, inclusive, postmenopausal women (age >49 y) who were sent for DXA bone density screening were offered enrollment into the study. Risk factors for osteoporosis, demographic information, and current DXA results were recorded. The 2006 Osteoporosis Position Statement of The North American Menopause Society was used for screening and therapeutic intervention guidelines. RESULTS: Among the 615 women with data, the mean (SD) age was 61.5 (8.3) years. Using the 2006 guidelines of The North American Menopause Society, 41.3% (253 of 612) of the women who had DXA testing did not meet the criteria for such screening. Of these women, 25.5% (157 of 615) were not taking calcium, 31.1% (191 of 614) were not taking vitamin D, and 59.8% (343 of 574) were not exercising at least half an hour per week. Of the women with any of the approved indications for treatment, 15.7% (16 of 102) were not taking calcium, 18.6% (19 of 102) were not taking vitamin D, 52.7% (49 of 93) were not exercising at least 2 hours per week, and 35.3% (36 of 102) were not receiving therapy. In contrast, of those women without an indication for treatment, 17.8% (83 of 467) were receiving bisphosphonate, raloxifene, or calcitonin therapy. CONCLUSIONS: A large number of women are not properly screened or treated for osteoporosis. Inappropriate screening may also lead to improper management of osteoporosis and its associated complications.

The association of breast arterial calcification and coronary heart disease.

OBJECTIVE: To estimate whether mammography can be an early, valid tool for predicting the development of coronary heart disease (CHD) in women. METHODS: Women presenting for routine mammograms between June and August 2004 were recruited for the study. Baseline data collected included risk factors and family history of heart disease, as well as any cardiac events experienced by the patient. Similar follow-up data were collected during subsequent years, and these patient-completed surveys were correlated with the baseline mammograms screened for breast arterial calcifications. RESULTS: Throughout the 5-year follow-up, CHD was present in 20.8% of women who screened positive for breast arterial calcification and in 5.4% of who screened negative for breast arterial calcification (P<.001). Among women who did not have CHD at baseline, breast arterial calcification-positive women were more likely to develop CHD or a stroke than those who were breast arterial calcification-negative (6.3% compared with 2.3%, P=.003; and 58.3% compared with 13.3%, P<.001), respectively. These results remained significant even when controlling for age. CONCLUSION: The presence of breast arterial calcifications on mammograms indicates a significantly increased risk of developing CHD or a stroke. These results suggest that breast arterial calcifications should be routinely reported on mammograms and viewed as a marker for the development of CHD. LEVEL OF EVIDENCE: II.

Assessment of postmenopausal women and significant risk factors for osteoporosis.

The assessment of osteoporosis risk factors can help guide early intervention. The objective of this study was to analyze numerous potential risk factors to see which were associated with postmenopausal osteoporosis. Women aged 49 or greater presenting for dual-energy x-ray absorptiometry bone scans were recruited from radiology sites in the Hartford, Connecticut, area between January 2007 and March 2009, inclusive. Information was collected regarding primary and secondary risk factors for osteoporosis development, as well as family history and history of pregnancy and breast-feeding. Survey results were subsequently correlated with each woman's dual-energy x-ray absorptiometry scan results. In a sample of 619 women, history of fracture (odds ratio [OR], 12.49), weight less than 127 pounds (OR, 3.50), and use of anticoagulants (OR, 5.40) increased the chance of developing osteoporosis. In contrast, multiparity (OR, 0.45) and history of breast-feeding (OR, 0.38) decreased the development of osteoporosis in postmenopausal women. In women aged 49 to 54, breast-feeding was significantly protective, while low body mass index was most indicative of osteoporosis in women ages 55 to 64. Both previous fracture and low body mass index were associated with osteoporosis in women over age 64. The current results are consistent with other studies suggesting that previous fracture, low body weight, and use of anticoagulants increase the risk of osteoporosis. Our results also suggest that a history of pregnancy and breast-feeding protects against the development of postmenopausal osteoporosis, especially in women aged 49 to 54.

Effects of age at first pregnancy and breast-feeding on the development of postmenopausal osteoporosis.

OBJECTIVE: Although pregnancy and breast-feeding require adequate calcium mobilization, it is not known if these affect the acquisition of a healthy peak bone mass (PBM) and, hence, postmenopausal osteoporosis (OPS). The objective of this study was to analyze previous pregnancies and/or breast-feeding and their association with OPS. METHODS: After obtaining institutional review board approval, postmenopausal women (>49 y) presenting for a dual-energy x-ray absorptiometry bone density scan were invited to participate. Risk factors for OPS, including previous fractures, pregnancy information, and dual-energy x-ray absorptiometry results, were collected. OPS was defined as a T score of -2.5 or lower. RESULTS: Data were obtained from 619 women. Of these, 49.8% were smokers, 27.2% used a bisphosphonate, 64.1% used hormone therapy, and 5.5% had used steroids. Based on PBM, ages at first pregnancy were dichotomized to younger than 27 years and 27 years or older. Women with a history of breast-feeding had a lower prevalence of OPS (7.6%) versus women who had never breast-fed (18.7%; P < 0.001). Women with a first pregnancy when they were 27 years or older and a history of breast-feeding had the lowest prevalence of OPS (4.6%) versus women with a first pregnancy when they were younger than 27 years and no history of breast-feeding (16.3%; P = 0.001). CONCLUSIONS: Breast-feeding seems to significantly decrease the incidence of postmenopausal OPS. Women whose first pregnancy occurs after PBM (≥27 y of age) and who have a history of breast-feeding had the lowest prevalence of OPS. Thus, an association between OPS and both breast-feeding and age of pregnancy seems to be present.