Katie L. Stone

Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group.

BACKGROUND Many risk factors for hip fractures have been suggested but have not been evaluated in a comprehensive prospective study. METHODS We assessed potential risk factors, including bone mass, in 9516 white women 65 years of age or older who had had no previous hip fracture. We then followed these women at 4-month intervals for an average of 4.1 years to determine the frequency of hip fracture. All reports of hip fractures were validated by review of x-ray films. RESULTS During the follow-up period, 192 women had first hip fractures not due to motor vehicle accidents. In multivariable age-adjusted analyses, a maternal history of hip fracture doubled the risk of hip fracture (relative risk, 2.0; 95 percent confidence interval, 1.4 to 2.9), and the increase in risk remained significant after adjustment for bone density. Women who had gained weight since the age of 25 had a lower risk. The risk was higher among women who had previous fractures of any type after the age of 50, were tall at the age of 25, rated their own health as fair or poor, had previous hyperthyroidism, had been treated with long-acting benzodiazepines or anticonvulsant drugs, ingested greater amounts of caffeine, or spent four hours a day or less on their feet. Examination findings associated with an increased risk included the inability to rise from a chair without using ones arms, poor depth perception, poor contrast sensitivity, and tachycardia at rest. Low calcaneal bone density was also an independent risk factor. The incidence of hip fracture ranged from 1.1 (95 percent confidence interval, 0.5 to 1.6) per 1,000 woman-years among women with no more than two risk factors and normal calcaneal bone density for their age to 27 (95 percent confidence interval, 20 to 34) per 1,000 woman-years among those with five or more risk factors and bone density in the lowest third for their age. CONCLUSIONS Women with multiple risk factors and low bone density have an especially high risk of hip fracture. Maintaining body weight, walking for exercise, avoiding long-acting benzodiazepines, minimizing caffeine intake, and treating impaired visual function are among the steps that may decrease the risk.

BMD at multiple sites and risk of fracture of multiple types: long-term results from the Study of Osteoporotic Fractures.

In a large cohort of U.S. women aged 65 and older, we report the relationships of BMD measured at several sites, and subsequent fracture risk at multiple sites over >8 years of follow‐up. Although we found almost all fracture types to be related to low BMD, the overall proportion of fractures attributable to low BMD is modest.

The Association of Radiographically Detected Vertebral Fractures with Back Pain and Function: A Prospective Study

Radiographically detected vertebral fractures (hereafter referred to as vertebral fractures) are a hallmark of postmenopausal osteoporosis and an important end point in clinical trials of osteoporosis treatment. Women with vertebral fractures have low bone mass compared with women without these fractures and, independently of bone mass, have an increased risk for additional vertebral and other fractures [1-4]. Vertebral fractures are common: Five percent of 50-year-old white women and 25% of 80-year-old women have had at least one vertebral fracture [5]. Surprisingly, however, the manner in which vertebral fractures affect health remains uncertain. Cross-sectional studies in community-derived samples of older women have demonstrated only a modest association [6-8] or no association [9-11] between prevalent vertebral fractures and back pain or disability. Cross-sectional studies do not distinguish more recent fractures from older vertebral fractures and may fail to capture transient increases in pain or disability [12], a limitation that may underestimate the clinical effect of these fractures [13]. Back pain is common among elderly women [14], and frequent causes of back pain, such as degenerative disc disease, facet joint osteoarthritis, spinal stenosis, and scoliosis, may obscure the impact of vertebral fracture. Only about one third of new vertebral fractures come to medical attention [15, 16], suggesting that most vertebral fractures are asymptomatic. However, attitudes toward back pain in older women and access to health care may also play a role in determining whether vertebral fractures come to medical attention. We examined the effect of incident vertebral fractures on back pain and back-related functional limitations in a large community-based sample of elderly women who underwent serial spinal radiography and annual assessments of back pain and disability over the same period. Methods Participants Study patients were participants in the Study of Osteoporotic Fractures, a cohort recruited from population-based listings in four U.S. metropolitan areas. Details of the design of this study are published elsewhere [17]. Lateral spine radiographs were obtained for 9677 white women between the ages of 65 and 99 years (median age, 70 years) who underwent baseline examination between 1986 and 1988. Repeated spinal radiographs suitable for morphometry were obtained for 7223 women (75% of the original cohort) at a follow-up clinic visit held an average of 3.7 years (range, 1.3 to 5.1 years) later. All participants gave informed consent. Vertebral Morphometry Lateral radiographs of the thoracic and lumbar spine were obtained in accordance with current guidelines [18]. Quantitative vertebral morphometry was performed using six-point digitization as described elsewhere [3, 19] to calculate the anterior (Ha), mid- (Hm), and posterior (Hp) height for each vertebral body from T4 to L4. A system of triage of radiographs, described elsewhere [3, 20], was used to reduce the number of radiographs requiring morphometric measurements. Briefly, trained technicians separated sets of radiographs into normal, uncertain, or probably fractured groups on the basis of a limited semiquantitative grading scheme that categorized women by the most abnormal vertebral level [20]. Uncertain grades were further categorized by the study radiologist as normal or probably fractured. Morphometry was done on the radiograph pairs that were categorized as probably fractured (42%). In a random sample of 503 women whose radiographs were triaged and then digitized, triage missed no incident fractures according to the study definition. Definition of Vertebral Fracture A vertebra was classified as having a prevalent fracture on the baseline radiograph if any of the following ratios were more than 3 SDs (>4 SDs for severe fractures) below the normal mean for that vertebral level: (Ha/Hp), (Hm/Hp), or a combination of (H/H [] 1) and (Hai/Hai 1) [3, 21]. A new (incident) fracture was identified if any of the three vertebral heights (Ha, Hm, or Hp) on follow-up radiographs decreased by 20% or more and by at least 4 mm compared with the baseline height. Incident fractures identified by morphometry were reviewed by a radiologist to exclude imaging artifacts or such conditions as osteophytosis and Scheuermann disease; 7% of vertebrae meeting the morphometric criteria for incident fracture were reclassified as not fractured. Incident Clinical Fractures We used previously described methods [22] to assess the occurrence of clinical fractures of any bone during follow-up. Women were considered to have a clinical vertebral fracture if they reported a new diagnosis of spinal fracture and a clinical radiology report confirmed that a vertebral fracture was present. Measurements of Pain, Disability, and Limited Activity We evaluated outcome measures by using a previously described questionnaire [7, 23] that asked about back pain and back-related disability in the past 12 months and the number of days of limited activity due to back pain. The questionnaire was administered at baseline and at three annual follow-up contacts held before assessment of vertebral fractures. The third follow-up contact coincided with follow-up radiography. Back pain was assessed on scales of frequency (0, never or rarely; 1, some of the time; 2, most of the time; or 3, all of the time) and severity (0, no pain; 1, mild pain; 2, moderate pain; or 3, severe pain). The two pain questions had high internal consistency (Cronbach = 0.81) and were summed for a total score that could range from 0 to 6. We defined clinically significant back pain as pain that was experienced most or all of the time or pain that was moderate or severe. Women without significant back pain at baseline were considered to have increased back pain if clinically significant pain had developed between any follow-up contacts. For women with clinically significant back pain at baseline, increased back pain was defined as an increase in total pain score of at least two points. Both types of increase had a similar association with incident fractures and thus were combined for a single outcome. Back-related disability was assessed with questions about the degree of difficulty (0, no difficulty; 1, some difficulty; 2, much difficulty; or 3, unable to perform activity) in six activities of daily living that involved the back (bending down to pick up light-weight objects, lifting a 10-pound object from the floor, reaching for objects just above the head, putting on socks or stockings, getting in and out of an automobile, and standing for 2 hours). These measures were combined in a back-related disability score ranging from 0 to 18. As reported elsewhere [7], this scale has high internal consistency (Cronbach = 0.82) and is highly correlated (Spearman r = 0.73) with a more extensive instrument used to assess disability caused by low back pain [24]. We defined clinically significant disability as much difficulty or unable in one or more of the six activities. Women without significant disability at baseline were considered to have increased disability if clinically significant disability had developed between any follow-up contacts. For women with clinically significant disability at baseline, increased disability was defined as an increase in disability score of at least three points. Both types of increase had a similar association with incident fractures and thus were combined for a single outcome. We also asked participants if they had limited their activities because of back pain since the last contact; if the answer was yes, we asked for the number of days they had stayed in bed and the number of days on which activity was limited (not including days in bed) because of back pain. Questions were adapted from previous surveys [25, 26]. For all follow-up contacts, we summed the number of days of bed rest and, in a separate measure, the number of days of limited activity; we then divided these numbers by the total years of follow-up to estimate the average number of affected days per year. Other Measurements The baseline questionnaire assessed potential confounding factors that may be associated with the risk for incident vertebral fracture and with back pain or disability, including smoking (current or past smoker); inactivity, defined as walking less than one block daily (yes or no); a previous physician diagnosis of osteoporosis or spinal fracture (yes or no); current use of estrogen (yes or no); hip pain in the past 12 months (yes or no); and height at 25 years of age. At the baseline examination, we assessed height and weight and calculated body mass index (kg/m2). We assessed grip strength by using an isometric dynamometer (Jamar Hydraulic Hand Dynamometer, JA Preston, Jackson, Mississippi) at baseline and at the follow-up examination and calculated change in grip strength between the two measurements. A random sample of 16% of baseline spine radiographs was assessed for spinal disc degeneration by using previously published methods [27]. Statistical Analysis Unless otherwise indicated, analyses were done separately in groups stratified by the presence of one or more baseline prevalent vertebral fractures. Descriptive and bivariate associations were assessed by using the t-test for continuous variables and the chi-square test for dichotomous variables. The association between incident vertebral fractures and dichotomous outcomes (increased back pain and increased back disability) was analyzed with logistic regression techniques. We analyzed the association of incident vertebral fracture with days of bed rest and days of limited activity per year by using Poisson regression. The distribution of days of bed rest (mean SD, 0.44 5.15) and limited-activity days (16.3 53.7) indicate that considerable overdispersion is present. Poisson regression allowing for this overdispersion provides a good estimation and inferential scheme [2

Endogenous Hormones and the Risk of Hip and Vertebral Fractures among Older Women

BACKGROUND AND METHODS In postmenopausal women, the serum concentrations of endogenous sex hormones and vitamin D might influence the risk of hip and vertebral fractures. In a study of a cohort of women 65 years of age or older, we compared the serum hormone concentrations at base line in 133 women who subsequently had hip fractures and 138 women who subsequently had vertebral fractures with those in randomly selected control women from the same cohort. Women who were taking estrogen were excluded. The results were adjusted for age and weight. RESULTS The women with undetectable serum estradiol concentrations (<5 pg per milliliter [18 pmol per liter]) had a relative risk of 2.5 for subsequent hip fracture (95 percent confidence interval, 1.4 to 4.6) and subsequent vertebral fracture (95 percent confidence interval, 1.4 to 4.2), as compared with the women with detectable serum estradiol concentrations. Serum concentrations of sex hormone-binding globulin that were 1.0 microg per deciliter (34.7 nmol per liter) or higher were associated with a relative risk of 2.0 for hip fracture (95 percent confidence interval, 1.1 to 3.9) and 2.3 for vertebral fracture (95 percent confidence interval, 1.2 to 4.4). Women with both undetectable serum estradiol concentrations and serum sex hormone-binding globulin concentrations of 1 microg per deciliter or more had a relative risk of 6.9 for hip fracture (95 percent confidence interval, 1.5 to 32.0) and 7.9 for vertebral fracture (95 percent confidence interval, 2.2 to 28.0). For those with low serum 1,25-dihydroxyvitamin D concentrations (< or =23 pg per milliliter [55 pmol per liter]), the risk of hip fracture increased by a factor of 2.1 (95 percent confidence interval, 1.2 to 3.5). CONCLUSIONS Postmenopausal women with undetectable serum estradiol concentrations and high serum concentrations of sex hormone-binding globulin have an increased risk of hip and vertebral fracture.

Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women

BACKGROUND Frailty, as defined by the index derived from the Cardiovascular Health Study (CHS index), predicts risk of adverse outcomes in older adults. Use of this index, however, is impractical in clinical practice. METHODS We conducted a prospective cohort study in 6701 women 69 years or older to compare the predictive validity of a simple frailty index with the components of weight loss, inability to rise from a chair 5 times without using arms, and reduced energy level (Study of Osteoporotic Fractures [SOF index]) with that of the CHS index with the components of unintentional weight loss, poor grip strength, reduced energy level, slow walking speed, and low level of physical activity. Women were classified as robust, of intermediate status, or frail using each index. Falls were reported every 4 months for 1 year. Disability (> or =1 new impairment in performing instrumental activities of daily living) was ascertained at 4(1/2) years, and fractures and deaths were ascertained during 9 years of follow-up. Area under the curve (AUC) statistics from receiver operating characteristic curve analysis and -2 log likelihood statistics were compared for models containing the CHS index vs the SOF index. RESULTS Increasing evidence of frailty as defined by either the CHS index or the SOF index was similarly associated with an increased risk of adverse outcomes. Frail women had a higher age-adjusted risk of recurrent falls (odds ratio, 2.4), disability (odds ratio, 2.2-2.8), nonspine fracture (hazard ratio, 1.4-1.5), hip fracture (hazard ratio, 1.7-1.8), and death (hazard ratio, 2.4-2.7) (P < .001 for all models). The AUC comparisons revealed no differences between models with the CHS index vs the SOF index in discriminating falls (AUC = 0.61 for both models; P = .66), disability (AUC = 0.64; P = .23), nonspine fracture (AUC = 0.55; P = .80), hip fracture (AUC = 0.63; P = .64), or death (AUC = 0.72; P = .10). Results were similar when -2 log likelihood statistics were compared. CONCLUSION The simple SOF index predicts risk of falls, disability, fracture, and death as well as the more complex CHS index and may provide a useful definition of frailty to identify older women at risk of adverse health outcomes in clinical practice.

Sleep-Disordered Breathing, Hypoxia, and Risk of Mild Cognitive Impairment and Dementia in Older Women

CONTEXT Sleep-disordered breathing (characterized by recurrent arousals from sleep and intermittent hypoxemia) is common among older adults. Cross-sectional studies have linked sleep-disordered breathing to poor cognition; however, it remains unclear whether sleep-disordered breathing precedes cognitive impairment in older adults. OBJECTIVES To determine the prospective relationship between sleep-disordered breathing and cognitive impairment and to investigate potential mechanisms of this association. DESIGN, SETTING, AND PARTICIPANTS Prospective sleep and cognition study of 298 women without dementia (mean [SD] age: 82.3 [3.2] years) who had overnight polysomnography measured between January 2002 and April 2004 in a substudy of the Study of Osteoporotic Fractures. Sleep-disordered breathing was defined as an apnea-hypopnea index of 15 or more events per hour of sleep. Multivariate logistic regression was used to determine the independent association of sleep-disordered breathing with risk of mild cognitive impairment or dementia, adjusting for age, race, body mass index, education level, smoking status, presence of diabetes, presence of hypertension, medication use (antidepressants, benzodiazepines, or nonbenzodiazepine anxiolytics), and baseline cognitive scores. Measures of hypoxia, sleep fragmentation, and sleep duration were investigated as underlying mechanisms for this relationship. MAIN OUTCOME MEASURES Adjudicated cognitive status (normal, dementia, or mild cognitive impairment) based on data collected between November 2006 and September 2008. RESULTS Compared with the 193 women without sleep-disordered breathing, the 105 women (35.2%) with sleep-disordered breathing were more likely to develop mild cognitive impairment or dementia (31.1% [n = 60] vs 44.8% [n = 47]; adjusted odds ratio [AOR], 1.85; 95% confidence interval [CI], 1.11-3.08). Elevated oxygen desaturation index (≥15 events/hour) and high percentage of sleep time (>7%) in apnea or hypopnea (both measures of disordered breathing) were associated with risk of developing mild cognitive impairment or dementia (AOR, 1.71 [95% CI, 1.04-2.83] and AOR, 2.04 [95% CI, 1.10-3.78], respectively). Measures of sleep fragmentation (arousal index and wake after sleep onset) or sleep duration (total sleep time) were not associated with risk of cognitive impairment. CONCLUSION Among older women, those with sleep-disordered breathing compared with those without sleep-disordered breathing had an increased risk of developing cognitive impairment.

Urinary Incontinence: Does it Increase Risk for Falls and Fractures?

OBJECTIVE: To determine if urge urinary incontinence is associated with risk of falls and non‐spine fractures in older women.

Risk for fracture in women with low serum levels of thyroid-stimulating hormone

Osteoporosis and thyroid dysfunction are both common in older women; 8% to 13% of women older than 50 years of age have biochemical evidence of thyroid dysfunction (1, 2), and 30% are osteoporotic according to bone density criteria (3). Although osteoporotic fractures have long been associated with florid hyperthyroidism (4) and, more recently, with a history of hyperthyroidism in older women (5), the relationship between biochemical evidence of excess thyroid hormone and fracture risk is not known (6, 7). Indirect evidence suggests that excess thyroid hormone due to endogenous disease or exogenous overuse of thyroid hormone may be associated with detrimental effects on bone, even in asymptomatic persons. For example, several biochemical markers of bone turnover are elevated in women with excess thyroid hormone (8, 9). Findings from studies of the relationship between excess thyroid hormone and bone mass are conflicting (10-17). However, factors other than bone mass, such as neuromuscular function and bone quality, contribute to risk for fracture (5) and may be adversely affected by excess thyroid hormone. Results of previous small, retrospective studies of thyroid function and fractures have also been conflicting (18-21). To our knowledge, no large prospective studies have examined the relationship between excess thyroid hormone and subsequent fracture. In light of the conflicting information on bone mass and the paucity of studies with fracture as an end point, several experts have noted the need for longitudinal studies of thyroid function and fracture risk (22-26). To test the hypothesis that low levels of serum thyroid-stimulating hormone (TSH) increase the risk for hip, vertebral, and any nonspine fracture, we performed a prospective study of postmenopausal women enrolled in the Study of Osteoporotic Fractures. Methods Patients The Study of Osteoporotic Fractures is a prospective cohort study of risk factors for fracture among 9704 women (5). White women older than 65 years of age were recruited in 1986 to 1988 from population-based listings at four clinical centers (Portland, Oregon; Minneapolis, Minnesota; Pittsburgh, Pennsylvania; and Baltimore, Maryland). The institutional review boards of all four centers gave approval for this study involving human research subjects. Measurements Baseline Measurements Participants were interviewed and examined during the baseline visit. Detailed information about physician-diagnosed medical conditions and past medication use was collected, and trained interviewers confirmed current medication use by examination of pill bottles. Participants were asked specifically about self-rated health, previous physician diagnoses of hyperthyroidism or Graves disease, and previous use of thyroid hormone. In addition to standardized assessments of height and weight, bone mass of the calcaneus was determined by using single-photon absorptiometry (OsteoAnalyzer, Siemens-Osteon, Wahiawa, Hawaii) and lateral radiographs of the thoracic and lumbar spine were obtained (27, 28). Serum was collected from each participant and stored at 190 C. Approximately 2 years after the baseline visit, bone mineral density of the proximal femur was measured in 82% of the cohort by using dual-energy x-ray absorbtiometry (Hologic QDR 1000, Waltham, Massachusetts) (29). Levels of TSH were measured in archived sera obtained at baseline by using a highly sensitive, third-generation chemiluminescent assay (Endocrine Science, Calabasas, California). The normal range for this assay is 0.5 to 5.5 mU/L; the functional sensitivity (defined as the concentration at which the interassay coefficient of variation is 20%) is approximately 0.05 mIU/L (30). At TSH concentrations of 0.5 mIU/L, the intra-assay coefficient of variation is 4.7% and the interassay coefficient of variation is 6.3%. Thirty randomly selected specimens were blindly submitted for duplicate analysis; the correlation between these two TSH results was high (r = 0.95). Previous studies have shown that TSH levels are highly stable in frozen sera over prolonged periods (31, 32). Other studies have demonstrated that among ambulatory adults, TSH levels of 0.1 mIU/L or less are highly correlated with a diminished response to thyroid-releasing hormone stimulation (33) and are associated with an increased incidence of atrial fibrillation (34). Ascertainment of Incident Fractures After the baseline visit, women were contacted by mail every 4 months about the occurrence of fractures. Hip fractures were confirmed by review of the appropriate radiographs by a radiologist at the coordinating center; other nonspine fractures were confirmed by review of written radiology reports. Fractures resulting from excessive trauma (such as motor vehicle accidents) were excluded. Follow-up for fracture and vital status was more than 99% complete. Lateral spine radiographs were repeated in 7299 women (79% of surviving women) after a mean (SD) follow-up of 3.7 0.4 years, and 7238 pairs of radiographs were judged to be adequate for assessment of incident vertebral fractures. Women without follow-up radiographs were older and reported poorer health at baseline compared with those who had follow-up radiographs (35). Vertebral fractures were identified by using computer-assisted morphometric evaluation (36), and incident vertebral fractures were defined as a 20% or greater and 4 mm or greater reduction in anterior, mid-vertebral, or posterior vertebral height between the baseline and follow-up radiographs (37). The persons who assessed the radiographs had no knowledge of the participants medical history or TSH level. Selection of Case and Control Samples for Fracture Analyses Using an efficient case-cohort approach that maintains statistical power but avoids expensive biochemical measurements in the entire cohort (38-40), we randomly selected baseline serum samples from 148 women with hip fracture and 149 women with incident vertebral fracture after the baseline visit. We randomly selected 398 women from the original cohort, independent of fracture status, to be controls. This random sample, which we refer to as the subsample in this report, included 14 of the 148 women selected as incident hip fracture cases and 15 of the 149 women selected as incident vertebral fracture cases; these women were removed from the subsample and were analyzed as cases of hip and vertebral fracture, respectively. To create a fracture-free control group, we excluded women from the subsample with other nonspine fractures during follow-up (n = 80 for the hip fracture analyses and n = 58 for the vertebral fracture analyses). Ninety women in the subsample had missing or technically inadequate radiographs and could not be analyzed for vertebral fracture outcomes. The analyses of any nonspine fracture were performed in the randomly selected subsample by using standard prospective cohort methods. After 14 women with unconfirmed fracture, 5 women with fracture from extreme trauma, and 6 women with spine fractures were excluded, the analysis of nonspine fracture included 100 women with documented nonspine fracture occurring after study entry and 273 without fracture. Random selection was done by using a computerized random-number generator. Statistical Analysis Continuous variables were plotted, and distributions, means, and standard deviations were examined. Levels of TSH were categorized as low ( 0.1 mIU/L), borderline low (>0.1 but <0.5 mIU/L), normal (0.5 to 5.5 mIU/L), or high (>5.5 mIU/L). Associations with hip fracture were examined by using proportional hazards analyses (Epicure, Hirosoft International, Seattle, Washington) that took into account the case-cohort sampling design. The proportionality assumption was not violated. Results are reported as relative hazards with 95% CIs. Logistic regression was used to analyze incident vertebral fracture; these results are reported as odds ratios with 95% CIs. Cox proportional-hazards models were used to determine associations with nonspine fracture among the randomly selected subsample. Multivariate models were constructed to adjust for potential confounders. Potential confounders were selected on the basis of biologic plausibility (for example, use of thyroid hormone) or a strong univariate association (P 0.1) with TSH level (for example, age) or fracture (for example, estrogen use). We found no association (P>0.1) between TSH level and maternal history of fracture, height, neuromuscular function, or corticosteroid use, which are known to be associated with fracture in this cohort (5). The final multivariate models for each fracture type included TSH level, age, previous hyperthyroidism, self-rated health, and current use of thyroid hormone and estrogen. To determine whether the increased risk for fracture in women with low TSH levels was mediated by reduced bone mass or some other mechanism, we examined the effect of further adjusting the final multivariate models for calcaneal bone mass measured at the baseline visit. The effect of adjustment for bone mineral density at the femoral neck, measured approximately 2 years after the baseline visit, was similar to that observed for calcaneal bone mineral density. Role of the Funding Source The funding source had no role in the collection, analysis, interpretation, or publication of these data. Results During a maximum follow-up of 5.9 years, 332 women had a first hip fracture, 389 had an incident vertebral fracture detected on paired spinal radiographs, and 2520 had nonspine fractures. Women who had incident hip, vertebral, or any nonspine fractures were older and had lower bone mass than controls (Table 1). Women with hip fractures were more likely to report previous hyperthyroidism. Mean TSH levels were similar among women with and without fracture, but the proportion of women with a low TSH level ( 0.1 mIU/L) was significantly greater among those with hip or vertebral fracture. Overall, 11% of participants

Intentional and Unintentional Weight Loss Increase Bone Loss and Hip Fracture Risk in Older Women

Objectives: To test the hypothesis that unintentional weight loss increases the rate of bone loss and risk of hip fracture more than intentional weight loss.

Long‐Term Prediction of Incident Hip Fracture Risk in Elderly White Women: Study of Osteoporotic Fractures

Objectives: To identify independent risk factors for first hip fracture over 10 years of follow‐up.