Prospective associations between energy balance-related behaviors at 2 years of age and subsequent adiposity: the EDEN mother-child cohort.

BACKGROUND/OBJECTIVES: Sedentary behavior, physical activity and dietary behavior are formed early during childhood and tend to remain relatively stable into later life. No longitudinal studies have assessed the independent influence of these three energy balance-related behaviors during toddlerhood on later adiposity. We aimed to analyze the associations between TV/DVD watching time, outdoor play time and dietary patterns at the age of 2 years and child adiposity at the age of 5 years, in boys and girls separately. SUBJECTS/METHODS: This study included 883 children from the French EDEN mother-child cohort. TV/DVD watching time, outdoor play time and dietary intakes were reported by parents in questionnaires when the child was aged 2 years. Two dietary patterns, labeled 'Guidelines' and 'Processed, fast foods', were identified in a previous study. The percentage of body fat (%BF) based on bioelectrical impedance analysis and body mass index were measured at the age of 5 years. RESULTS: In boys, TV/DVD watching time at the age of 2 years was positively associated with %BF at the age of 5 years (ß=0.50 (95% confidence interval: 0.001, 1.00) for those boys with ⩾60 min per day of TV/DVD watching time vs those with ⩽15 min per day, P-value for trend 0.05). In girls, outdoor play was inversely associated with %BF (ß=-0.96 (95% confidence interval: -1.60, -0.32) for those in the highest tertile of outdoor play time vs those in the lowest tertile, P=0.001). Overall, at the age of 2 years, dietary patterns were associated with both TV/DVD watching time and outdoor play time, but no significant and independent association was observed between dietary patterns and later adiposity. CONCLUSION: This study shows longitudinal and gender-differentiated relations between both TV/DVD watching time and outdoor play time in toddlerhood and later adiposity, whereas evidence for a relation between dietary patterns and subsequent fat development was less conclusive. Early childhood-by the age of 2 years-should be targeted as a critical time for promoting healthy energy balance-related behaviors.

A comprehensive fracture prevention strategy in older adults: the European Union Geriatric Medicine Society (EUGMS) statement.

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society, in collaboration with the International Association of Gerontology and Geriatrics for the European Region, the European Union of Medical Specialists, and the International Osteoporosis Foundation-European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

Beneficial effects of vitamin D on falls and fractures: is cognition rather than bone or muscle behind these benefits?

The beneficial effect of vitamin D on bone tissue has long been attributed mainly to its positive effect on the intestinal absorption of calcium and on bone mineralization, which increases the bone mineral density (BMD) and thus decreases the risk of fracture. Recently, numerous extra osseous effects of vitamin D have been described, amongst them a positive effect on neuromuscular and cognitive functions. Several lines of evidence suggest that the beneficial effects of vitamin D on fall and fracture risk can be explained more by its action on the neuromuscular and cognitive functions than by its direct effect on bone metabolism. In this review, we first report on the relationships between vitamin D and osteoporotic fracture risk. Then, we present the data from the literature regarding the effects of vitamin D on risk factors such as fall risk and reduction in BMD, physical performance, and cognitive performance. Specific emphasis is put on the latter because there is evidence of a relationship between low concentration of serum 25-hydroxyvitamin D (the primary indicator of vitamin D status) and low cognitive abilities which have been shown to be a risk factor for falling. It can be further suggested that high risk of fracture in cognitively impaired adults could be explained by lower protective reaction when falling, which would result, for instance, from a lack of planning and foresight of the fall. Future studies are nonetheless needed to elucidate the associations between vitamin D and different risk factors, in particular the link between vitamin D and various cognitive functions.

Mobility impairment is associated with urge but not stress urinary incontinence in community-dwelling older women: results from the Ossébo study.

OBJECTIVE: To assess the association between functional limitations related to mobility and urinary incontinence (UI) in elderly women. DESIGN: An observational cross-sectional study. SETTING: Nine 'balance' workshops in France. POPULATION: A total of 1942 community-dwelling women aged 75-85 years, who were invited, based on voter registration lists, to a 'balance assessment'. METHODS: Mobility and balance test results for incontinent women were compared with those for continent women according to the severity and type of incontinence. MAIN OUTCOME MEASURES: Data on UI were collected using a self-administered questionnaire (International Consultation on Incontinence Questionnaire-Short Form). Motor-related physical abilities were assessed using standardised balance and functional gait tests. RESULTS: Forty-two per cent of women had involuntary urine leakage, with daily leaks in 57% of them; 24% had stress UI, 31% had urge UI, and 37% had mixed UI. Results for each functional test were poorer for women with UI and the limitation was more pronounced when the incontinence was severe. Multivariate logistic regression analyses showed that balance and gait impairments were significantly and independently associated with urge UI (walking speed, lower versus higher quartile, odds ratio (OR) 2.2; 95% confidence interval (95% CI) 1.4-3.5; walking balance, unable versus able to do four tandem steps (OR 1.6; 95% CI 1.2-2.2) but not with stress UI. CONCLUSIONS: In this large population of older women living at home, there was a strong association between limitation of motor and balance skills and UI, which was proportional to the severity of incontinence and related specifically to urge incontinence. These results offer new perspectives on the prevention and treatment of urge incontinence in elderly women.

Is vascular calcification associated with bone mineral density and osteoporotic fractures in ambulatory, elderly women?

UNLABELLED: We analyzed the relationship between aortic calcification and two osteoporotic parameters (bone mineral density (BMD) and incident osteoporotic fractures) in 667 ambulatory, elderly women from the Epidemiology of Osteoporosis (EPIDOS) cohort (mean age, 80 years; range, 72-94 years). We did not find any correlation between the aortic calcification score and BMD or osteoporotic fractures. INTRODUCTION: The aging process is associated with osteoporosis and aortic calcification; conditions which may have similar disease mechanisms. However, the relationship between these two settings remains to be elucidated. We analyzed the relationship between aortic calcification and osteoporotic parameters (BMD and incident osteoporotic fractures) in a cohort of ambulatory, elderly women. METHODS: The study included 667 ambulatory women from the EPIDOS cohort (mean age, 80 years; age range, 72-94 years). The baseline examination included bone investigations, a clinical and functional examination, and a comprehensive questionnaire on health status and lifestyle. Semiquantitative methods were used to determine the abdominal aortic calcification score on baseline radiographs. Incident fractures were recorded via postal questionnaires issued every 4 months for about 4 years. RESULTS: Five hundred three women (75%) had aortic calcification. The mean aortic calcification score was 5.5 (median, 4). During the follow-up period, 186 (28%) women reported one or more incident osteoporotic fractures. We did not find any correlation between the aortic calcification score on one hand and the BMD or the occurrence of incident osteoporotic fractures on the other. Only age and systolic blood pressure were found to be independently associated with the aortic calcification score. Osteoporotic fractures were independently associated with age and BMD. CONCLUSIONS: Osteoporosis and aortic calcification appear to be independent processes in a cohort of ambulatory, elderly women. However, potential confounding factors may be present and prospective studies are needed to investigate this situation further.

Persistence with teriparatide in postmenopausal osteoporosis; impact of a patient education and follow-up program: the French experience.

SUMMARY: This study evaluated the 18-month persistence with teriparatide in 5413 postmenopausal osteoporotic women who were enrolled in an education and follow-up program. Analysis showed that the persistence rate was 81.5% for women who follow the program, higher than for existing oral antiresorptive treatments. INTRODUCTION: An education and follow-up program was developed after launch of teriparatide in France in September 2004, to help women to follow the treatment. The objective of this study was to evaluate the persistence with teriparatide in postmenopausal osteoporotic women following this program. METHODS: Data about persistence are available for the period September 2004 to June 2007. Persistence is defined as the percentage of patients still on treatment at the end of the 18-month course, and it has been compared to the data provided by the French universal health insurance system. RESULTS: Since the launch of teriparatide in France in September 2004, 5413 postmenopausal women (mean age 72.3 +/- 14.5 years) with osteoporosis and vertebral fractures (mean 3.9 +/- 2) have participated in the program. The persistence rate at 15 months was 81.5%, and our analysis suggested that a majority of patients completed the 18-month treatment course. The main reason for discontinuation was adverse events (46.7%). Data of the French Universal Health Insurance suggest that the persistence may be close to 0% for women who are not in the program. CONCLUSIONS: Postmenopausal osteoporotic women treated by teriparatide and enrolled in an education and follow-up program have a high persistence rate.

Association of hypovitaminosis D with triceps brachii muscle fatigability among older women: Findings from the EPIDOS cohort.

BACKGROUND: Vitamin D affects physical performance in older adults. Its effects on muscles, notably on muscle strength, remain unclear. The objective of this cross-sectional study was to determine whether hypovitaminosis D is associated with triceps brachii muscle fatigability in community-dwelling older women. METHODS: A randomized subset of 744 women aged ≥75years from the EPIDOS cohort was categorized into two groups according to triceps brachii muscle fatigability, defined as loss of strength >5% between two consecutive maximal isometric voluntary contractions. Hypovitaminosis D was defined using consensual threshold values (i.e., serum 25-hydroxyvitamin D concentration [25OHD] ≤10 ng/mL, ≤20 ng/mL, and ≤30 ng/mL). Age, body mass index, comorbidities, use psychoactive drugs, physical activity, first triceps strength measure, hyperparathyroidism, serum concentrations of calcium, albumin and creatinine, season and study centers were used as potential confounders. RESULTS: The prevalence of hypovitaminosis D ≤ 30 ng/mL was greater among women with muscle fatigability compared with the others (P = .009). There was no between-group difference using the other definitions of hypovitaminosis D. The serum 25OHD concentration was inversely associated with the between-test change in triceps strength (adjusted ß = -0.09 N, P = .04). Hypovitaminosis D ≤ 30 ng/mL was positively associated with triceps fatigability (adjusted OR = 3.15, P = .02). CONCLUSIONS: Vitamin D concentration was inversely associated with the ability to maintain strength over time in this cohort of community-dwelling older women. This is a relevant new orientation of research toward understanding the involvement of vitamin D in muscle function.

A Comprehensive Fracture Prevention Strategy in Older Adults: The European Union Geriatric Medicine Society (EUGMS) Statement.

Prevention of fragility fractures in older people has become a public health priority, although the most appropriate and cost-effective strategy remains unclear. In the present statement, the Interest Group on Falls and Fracture Prevention of the European Union Geriatric Medicine Society (EUGMS), in collaboration with the International Association of Gerontology and Geriatrics for the European Region (IAGG-ER), the European Union of Medical Specialists (EUMS), the International Osteoporosis Foundation - European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, outlines its views on the main points in the current debate in relation to the primary and secondary prevention of falls, the diagnosis and treatment of bone fragility, and the place of combined falls and fracture liaison services for fracture prevention in older people.

Quantitative ultrasound parameters as well as bone mineral density are better predictors of trochanteric than cervical hip fractures in elderly women. Results from the EPIDOS study.

RATIONALE: Hip fractures can be separated into cervical and trochanteric fractures. Trochanteric fractures have been associated with up to twice the short-term mortality of cervical fractures in the elderly. There is also evidence suggesting that the mechanisms are different. Evidence from the literature remains limited on the predictive power of bone mineral density (BMD) and quantitative ultrasounds (QUS) for both types of hip fractures. METHODS: 5703 elderly women aged 75 years or more, who were recruited from the voting lists in the EPIDOS study, and had baseline calcaneal ultrasounds (QUS) and DXA measurements at the hip and the whole body, were analyzed in this paper. Among those, 192 hip fractures occurred during an average follow-up of 4 years, 108 cervical and 84 trochanteric fractures. RESULTS: Femoral neck, trochanteric and whole body BMD were able to predict trochanteric hip fracture (RR's and 95% CI were, respectively, 3.2 (2.4-4.2); 4.8 (3.5-6.6); and 2.8 (2.2-3.6)) more accurately than cervical fractures (respectively, 2.1 (1.7-2.7); 2.3 (1.8-3.0); 1.2 (1.0-1.6)). All ultrasound parameters, SOS, BUA, and stiffness index (SI) were significant predictors of trochanteric (RR's respectively 3.0 (2.2-4.1), 2.5(2.0-3.1), and 3.5(2.6-4.7)) but not cervical fractures. After adjustment for femoral neck or trochanteric BMD ultrasound parameters were still significant predictors of trochanteric fracture, and stiffness tended to be a better predictor of trochanteric fractures than either BUA or SOS with a relative risk of 2.25 (1.6-3.1). CONCLUSIONS: A significant decrease of all bone measurements, BMD and QUS, was highly predictive of trochanteric fractures, whereas a decrease of femoral neck and trochanteric BMD were only associated with a slight increase in cervical fracture risk and a low total body BMD or QUS parameters were not significant predictors of cervical fractures. In women who sustained a hip fracture, the decrease of BMD and QUS values increases the risk of trochanteric fracture as compared to cervical fracture. Trochanteric fractures were mostly a consequence of a generalized low BMD and QUS, whereas other parameters might be involved in cervical fractures.

Prevalence of vertebral fractures in French women older than 75 years from the EPIDOS study.

The aim of this study was to ascertain the prevalence and severity of vertebral fractures in French elderly women. We used spinal radiographs collected during the baseline examination of the Epidémiologie de l'Ostéoporose (EPIDOS) study, a multicentric prospective study of risk factors for hip fracture. A total of 7598 ambulatory women volunteers were recruited in the EPIDOS cohort using large population-based listings such as voter-registration lists. A subsample of 770 participants were selected for spinal radiographs using a systematic selection procedure. Anteroposterior and lateral radiographs of the thoracic and lumbar spine were reviewed by two trained rheumatologists using the semiquantitative (SQ) method described by Genant et al. [J. Bone Miner Res. 8 (1993) 1137]. Vertebral deformities that could be related to causes other than osteoporosis (i.e., Scheuermann's disease or osteoarthritis) were disregarded. The final analysis was made over 745 women after excluding 25 women whose spine radiographs were incomplete or of poor quality. The sample average age was 80.1 +/- 3.4 years. Vertebral fractures were found in 170 women: 22.8% (95% CI, 19.8-25.8%). A single, two, three, or more vertebral fractures were seen in 99 (58.2%), 43 (25.3%), and 28 (16.5%) of the 170 affected women, respectively. The prevalence of vertebral fractures increased with age from 19.0% (95% CI, 14.9-23.1%) among women 75-79 years old to 21.9% (95% CI, 17.3-26.5%) among those 80-84 years old and to 41.4%(95% CI, 31.0-51.7%) among those 85 years of age and over (Chi-square test for trend P < 0.00016). A significant correlation was found also between the number of vertebral fractures per woman and age (r = 0.108, P = 0.003) and between the spinal fracture index and age (r = 0.105, P = 0.004). We conclude that the prevalence of vertebral fractures is high in French ambulatory elderly women, which confirms the results of previous studies conducted in various Caucasian and Asian populations.

Sensory impairments and physical disability in aged women living at home.

BACKGROUND: Studies of the impact of visual or hearing impairments on physical disability in older people have provided conflicting results. Furthermore, the consequences of the loss of such visual functions as depth perception or contrast sensitivity have rarely been studied. We examined the relationship of visual acuity, depth perception, contrast sensitivity, and hearing difficulty to the ability of older women living at home to accomplish instrumental activities of daily living independently. METHODS: Data on self-reported physical disability and hearing impairment, as well as objective measures of functional vision and physical ability were collected from a sample of 1210 community-dwelling women aged 75 years and older. Multivariate logistic regression modelling was used to assess the strength of the association between physical disability and sensory impairments, controlling for age, education level, motor limitations, and prevalent chronic diseases. RESULTS: Women with low visual acuity or low contrast sensitivity were significantly more likely to be physically dependent than women with good vision. Contrast sensitivity was, however, a better predictor than functional acuity, after controlling for age, education level, motor limitations and chronic medical conditions (adjusted odds ratio: 5.1; 95% confidence interval: 2.0-12.9). Depth perception was not related to physical disability. Women with serious hearing difficulty had significantly increased odds of dependency (4.1; 1. 4-12.1). CONCLUSIONS: Severe sensory impairments are strongly related to physical dependency in older women. It may be useful to add a test of contrast sensitivity to the traditional acuity test to predict better which elderly individuals may have difficulty carrying out routine daily activities.

Association between maternal education and infant diarrhea in different household and community environments of Cebu, Philippines.

Maternal education is one of the strongest determinants of infant survival in developing countries, however, questions remain regarding the extent to which its effects vary as a function of contextual variables. In this study, a multi-level interactive model is used to assess whether the protective effect of maternal education on the risk of infant diarrhea is modified by three aspects of the mother's familial and community environment: household assets, community economic resources and the availability of mothers' clubs. 2484 study participants were interviewed in 1984 as part of the Cebu Longitudinal Infant Health and Nutrition Study. The findings suggest that the protective effect of maternal education on infant diarrhea varies according to the socio-economic environment in which the mother lives: maternal education protects against infant diarrhea in the more economically and socially advantaged communities but has no effect in the more disadvantaged communities. The results also indicate that the protective effect of maternal education is smaller in the wealthier households. These data suggest that improvement in maternal education level, alone, may not always have the expected beneficial effects on infant health. Corollary measures to improve access of mothers and children to basic community resources and efforts to help mothers be more effective in their various social roles may be necessary preconditions for higher levels of maternal education to result in improved infant health.

Prevalence of Paget's disease of bone and spinal hemangioma in French women older than 75 years: data from the EPIDOS study.

OBJECTIVE: To evaluate the prevalence in France of Paget's disease in elderly women. PATIENTS AND METHODS: The prevalences of Paget's disease and of thoracic and lumbar vertebral hemangioma were determined in a random nested cohort of 770 women from the EPIDOS study cohort. EPIDOS is a prospective study of the risk of proximal femoral fracture in 7,598 female, community-dwelling volunteers older than 75 years of age. The EPIDOS study patients were recruited at five centers in France (Amiens, Lyon, Paris, Montpellier, and Toulouse). For the nested study, anteroposterior and lateral radiographs of the thoracic and lumbar spine were read by two rheumatologists and classified into four groups: no Paget's disease or hemangioma, possible Paget's disease or hemangioma, definite Paget's disease, and definite hemangioma. Radiographs in the last three groups were read by a rheumatology professor and a radiology professor, both independent from the study. RESULTS: Twenty-five patients had incomplete or poor-quality radiograph sets, leaving 745 patients for the study. A vertebral hemangioma was found in four patients (0.54%; 95% confidence interval [CI], 0.01-1.1%) and vertebral Paget's disease in four other patients (0.54%; 95% CI, 0.01-1.1 %). All the pagetic vertebrae were at the lumbar spine. Three of the four Paget's disease patients were unaware of the condition before their inclusion in the study. Based on previous estimates that thoracic and lumbar foci are present in 30 to 50% of Paget's disease patients, our data suggest that the overall prevalence of Paget's disease in French women older than 75 years may be in the 1.1-1.8% range. CONCLUSION: The prevalence of Paget's disease in elderly French women is similar to that recently reported in Britain.

[Epidemiology of falls and fall-related injuries in the aged]. / Epidémiologie des chutes et des traumatismes liés aux chutes chez les personnes âgées.

Approximately one third of elderly persons over the age of 65 who live in the community fall each year. About 5% of falls result in a fracture, and 5 to 10% of them result in other serious injuries requiring medical care. Even in the absence of serious physical injury, falls may have severe psychological consequences leading to an accelerated decline in functional capacities. Several epidemiological studies have identified the main intrinsic risk factors for fall. These include advanced age, female sex, impaired balance, gait abnormalities, reduced muscular strength, cognitive deficiencies, impaired visual acuity and use of sedative-hypnotic medications. The results of recent epidemiological studies comparing falls with serious physical injuries to falls without injuries suggest that, besides bone mass, the speed and effectiveness of protective reflexes may greatly influence the risk of trauma after a fall. Contrary to what may be believed, the frequency of falls and fall-related trauma is also high in active and healthy subjects. However, the cause of falls are clearly different for persons of varying age, health status and level of mobility. Several authors have tried to define different types of falls according to the predominance of intrinsic or extrinsic factors in fall aetiology. This approach may allow to identify different risk factors or combinations of risk factors according to the type of falls or to the characteristics of fallers.

[Epidemiology and risk factors for osteoporosis]. / Epidémiologie et facteurs de risque d'ostéoporose.

It has been estimated that 40 % of white women aged 50 years will suffer at least one of the major osteoporotic fractures (hip, vertebrae, wrist) before the end of their life. Bone mineral density (BMD) measurement is the basis of osteoporosis diagnosis and is generally considered as a key element to identify high risk subjects who should benefit most from a bone active treatment preventive of fractures. However, for a given BMD level, the risk of fracture varies with age and with the presence of other risk factors (personal or familial history of fracture, low weight, corticotherapy, fall-related risk factors etc.). In the future, it is probable that densitometry results will be expressed in terms of risk of fracture within the next 10 years. Different intervention thresholds could then be defined depending on the age of the subject, the level and nature of the risk factors, as well as the type of preventive or therapeutic actions considered. In the elderly, fall-related factors such as neuromuscular and visual disorders have a weight similar to the one of BMD in the determinism of hip fracture. Recently, several randomized controlled trials have shown that multifactorial preventive programs tailored to individual risk factors or exercise programs emphasizing balance training can reduce the risk of falls in the elderly by 25 to 30%. The efficacy of such measures on fracture prevention must be demonstrated.

Falls' and fallers' profiles.

OBJECTIVE: To describe the different falls typology and to investigate whether different falls profiles and faller profiles could be identified among a cohort of community-dwelling women aged 75 years and older. DESIGN: Prospective cohort study. PARTICIPANTS: Women aged 75 years and older were enrolled in five French centers after a random selection from electoral lists and included in the EPIDOS study. MEASUREMENTS: During a 4 year follow-up, women were contacted by telephone every 4 months to investigate the occurrence of falls. To minimize the memory bias, the specific questionnaire on falls was completed only if the fall took place in the week preceding the contact. A multiple correspondence analysis followed by clustering was carried out to identify the typology of falls. RESULTS: 727 women described at least one fall. A full description of 662 falls was obtained during the follow-up period. In the multiple correspondence analysis the main discriminant item was outside versus inside falls. Moreover, four clusters were showed: outside falls linked to lack of attention (28% of women), outside falls related to exogenous/environmental factors (16%), inside falls associated with frailty (44%) and in height falls (11%). We also found that each type of falls was correlated with particular health or functional status (i.e.;dependence, motion difficulty, weakness, use of walking aid, ...). CONCLUSION: From frailty to hyperactivity there are different falls and fallers profiles. Assessing such fall profiles could be helpful to develop new dedicated fall prevention programs in the elderly.

Structural determinants of hip fracture in elderly women: re-analysis of the data from the EPIDOS study.

Hip fracture is the most disastrous osteoporotic fracture, characterized by high mortality, morbidity and institutionalization for the patient and by high economic costs for the health care system. The morphology of the upper part of the femur can influence the risk of hip fracture, e.g., a longer femoral neck is associated with a higher risk of cervical fractures, but not trochanteric ones. In this study, we evaluated the prediction of hip fracture risk by morphological parameters estimated from DXA measurements, and we compared their predictive value for cervical and trochanteric fractures in elderly women by reanalyzing previously published data (Duboeuf et al. J Bone Miner Res 1997 12 1895). This nested case-control study was performed in 232 elderly community-dwelling women from the EPIDOS cohort, including 65 women who sustained a hip fracture. After adjustment for confounding variables, women who sustained a cervical fracture had lower areal bone mineral density (aBMD), lower cortical thickness and a higher average buckling ratio (P<0.005 for all) as well as longer femoral neck (P<0.01) than controls. Women who sustained a trochanteric fracture had lower aBMD, lower cortical thickness and higher buckling ratio than controls (P<0.0001) and than women who sustained a cervical fracture (P<0.05). Their bending resistance (cross-sectional moment of inertia-CSMI, section modulus) was significantly lower in comparison with controls (P<0.05-0.001). A decrease in aBMD, cortical thickness, CSMI and section modulus as well as an increase in buckling ratio were predictive of all hip fractures (OR -1.42-2.46 per 1 SD, P<0.05-0.0001), but the ORs for all structural parameters were markedly higher for trochanteric than for cervical fractures. CSMI and section modulus were predictive of trochanteric, but not cervical fractures. However, aBMD was strongly correlated with the CSA, cortical thickness and buckling ratio (r2>0.74), which suggests that they convey the same information. CSMI and section modulus correlated with aBMD more weakly, but their OR lost statistical significance after adjustment for aBMD. In conclusion, low femoral neck aBMD, CSA and cortical thickness as well as a high buckling ratio are associated with the higher risk of hip fracture, especially trochanteric ones. These indices are highly correlated with aBMD and convey the same message. The calculated CSMI and section modulus predict trochanteric fractures, but not cervical fractures, and their statistical significance is lost after adjustment for aBMD, indicating that they reflect mainly aBMD, not mechanical properties. Thus, the independent contribution of the external diameter of the femoral neck to the risk of hip fracture cannot be reliably estimated by this technique.

A triage strategy based on clinical risk factors for selecting elderly women for treatment or bone densitometry: the EPIDOS prospective study.

A triage strategy, based on a clinical hip fracture risk score, may be used to classify elderly women into three groups: one at high risk and requiring treatment, another needing further assessment by bone densitometry, and a third at low risk. We used prospective data from the EPIDOS study (7512 women older than 75 years and followed for an average of 3.9 years) to assess the potential value of such a strategy for identifying elderly women with a hip fracture risk twice the cohort average (i.e. > or =20 per 1000 woman-years). An individual fracture risk score was calculated with the final risk function (Cox model). To compare this strategy with systematic BMD measurement and with current European recommendations, we examined the number of high-risk women identified, their average risk levels, sensitivity for hip fracture, and the number of high-risk women who need to be treated to prevent one hip fracture (hypotheses: all identified women are treated; sensitivity is equal to the point estimate; treatment reduces fracture risk by 35%). A triage strategy based on age, fracture history since the age of 40 years, body mass index, number of instrumental activities of daily living for which assistance is needed, grip strength, and visual acuity can identify 20% of the cohort as at high risk, 75% of them from clinical factors only, and the rest after BMD measurements (threshold: -2.5 T-score). The triage strategy would be significantly more sensitive than systematic BMD screening (51 versus 35%) and would require many fewer BMD examinations (10%). Compared with current recommendations, triage would identify fewer women (20 versus 28%) but at a significantly higher average risk of hip fracture (30 versus 20 per 1000 woman-years). Fewer high-risk women would be treated to prevent one hip fracture (29 versus 41) and fewer bone densitometry tests would be needed (10% versus 54%). The proposed triage strategy may be a useful clinical tool for selecting elderly women for treatment or bone densitometry.