Nicole C. Wright

The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine.

The goal of our study was to estimate the prevalence of osteoporosis and low bone mass based on bone mineral density (BMD) at the femoral neck and the lumbar spine in adults 50 years and older in the United States (US). We applied prevalence estimates of osteoporosis or low bone mass at the femoral neck or lumbar spine (adjusted by age, sex, and race/ethnicity to the 2010 Census) for the noninstitutionalized population aged 50 years and older from the National Health and Nutrition Examination Survey 2005–2010 to 2010 US Census population counts to determine the total number of older US residents with osteoporosis and low bone mass. There were more than 99 million adults aged 50 years and older in the US in 2010. Based on an overall 10.3% prevalence of osteoporosis, we estimated that in 2010, 10.2 million older adults had osteoporosis. The overall low bone mass prevalence was 43.9%, from which we estimated that 43.4 million older adults had low bone mass. We estimated that 7.7 million non‐Hispanic white, 0.5 million non‐Hispanic black, and 0.6 million Mexican American adults had osteoporosis, and another 33.8, 2.9, and 2.0 million had low bone mass, respectively. When combined, osteoporosis and low bone mass at the femoral neck or lumbar spine affected an estimated 53.6 million older US adults in 2010. Although most of the individuals with osteoporosis or low bone mass were non‐Hispanic white women, a substantial number of men and women from other racial/ethnic groups also had osteoporotic BMD or low bone mass.

Recent trends in hip fracture rates by race/ethnicity among older US adults

Hip fracture incidence has declined among whites in the United States since 1995, but data on recent trends in racial and ethnic minorities are limited. The goal of this analysis was to investigate hip fracture incidence trends in racial/ethnic subgroups of older Medicare beneficiaries. We conducted a cohort study to determine annual hip fracture incidence rates from 2000 through 2009 using the Medicare national random 5% sample. Beneficiaries were eligible if they were ≥65 years of age and had 90 days of consecutive full fee‐for‐service Medicare coverage with no hip fracture claims. Race/ethnicity was self‐reported. The incidence of hip fracture was identified using hospital diagnosis codes or outpatient diagnosis codes paired with fracture repair procedure codes. We computed age‐standardized race/ethnicity‐specific incidence rates and assessed trends in the rates over time using linear regression. On average, 821,475 women and 632,162 men were included in the analysis each year. Beneficiaries were predominantly white (88%), with African, Hispanic, and Asian Americans making up 8%, 1.5%, and 1.5% of the population, respectively. We identified 102,849, 4,119, 813, and 1,294 hip fractures in white, black, Asian, and Hispanic beneficiaries over the 10 years. A significant decreasing trend (p < 0.05) in hip fracture incidence from 2000‐2001 to 2008‐2009 was present in white women and men. Black and Asian beneficiaries experienced nonsignificant declines. Irrespective of gender, the largest rate of decline was seen in beneficiaries ≥75 years of age. The overall and age‐specific rates of Hispanic women or men changed minimally over time. Hip fracture incidence rates continued to decline in recent years among white Medicare beneficiaries. Further research is needed to understand mechanisms responsible for declining rates in some and not others, as hip fractures continue to be a major problem among the elderly.

Arthritis Increases the Risk for Fractures---Results from the Women’s Health Initiative

Objective. To examine the relationship between arthritis and fracture. Methods. Women were classified into 3 self-reported groups at baseline: no arthritis (n = 83,295), osteoarthritis (OA; n = 63,402), and rheumatoid arthritis (RA; n = 960). Incident fractures were self-reported throughout followup. Age-adjusted fracture rates by arthritis category were generated, and the Cox proportional hazards model was used to test the association between arthritis and fracture. Results. After an average of 7.80 years, 24,137 total fractures were reported including 2559 self-reported clinical spinal fractures and 1698 adjudicated hip fractures. For each fracture type, age-adjusted fracture rates were highest in the RA group and lowest in the nonarthritic group. After adjustment for several covariates, report of arthritis was associated with increased risk for spine, hip, and any clinical fractures. Compared to the nonarthritis group, the risk of sustaining any clinical fracture in the OA group was HR 1.09 (95% CI 1.05, 1.13; p < 0.001) and HR 1.49 (95% CI 1.26, 1.75; p < 0.001) in the RA group. The risk of sustaining a hip fracture was not statistically increased in the OA group (HR 1.11; 95% CI 0.98, 1.25; p = 0.122) compared to the nonarthritis group; however, the risk of hip fracture increased significantly (HR 3.03; 95% CI 2.03, 4.51; p < 0.001) in the RA group compared to the nonarthritis group. Conclusion. The increase in fracture risk confirms the importance of fracture prevention in patients with RA and OA.

Pilot study of dietary influences on mammographic density in pre- and postmenopausal Hispanic and non-Hispanic white women

Objective: The extent to which modifiable dietary factors may account for some of the variability demonstrated in mammographic density across ethnic groups is unknown. The purpose of this study was to provide pilot data describing the relationship between dietary variables and mammographic density in pre- and postmenopausal Hispanic and non-Hispanic white (NHW) women (N = 238) ranging in age from 41 to 50 years (premenopausal only) or 56 to 70 years (postmenopausal only). Design: Using a cross-sectional design, computer-assisted density assessments were performed on mammograms of both breasts and averaged for analysis. The Arizona Food Frequency Questionnaire was used to estimate dietary intake. Results: Study participants were well educated and overweight, with mean mammographic densities ranging from 20.25% for postmenopausal Hispanic women to 46.94% for premenopausal NHW women. Hispanic women reported higher energy intake than NHW women, but energy-adjusted intake of other nutrients was generally comparable. There was preliminary evidence of ethnic variability in diet-mammographic density associations. Among premenopausal Hispanic women, density was inversely associated with dairy, calcium, and vitamin D intakes (P ≤ 0.05 for all). Among premenopausal NHW women, lower mammographic density was associated with greater intake of vegetables (P ≤ 0.05), and higher density was associated with greater fruit intake (P ≤ 0.05). Among postmenopausal Hispanic women, for every 4.54 increase in the polyunsaturated-to-saturated fat ratio, there was a 9.0% reduction in mammograph density. Conclusions: These preliminary results suggest that a differential pattern of dietary nutrient associations with mammographic density could potentially exist among Hispanic and NHW women. These ethnic differences in diet and mammographic density associations need to be further explored in larger studies.

Postmenopausal weight change and incidence of fracture: post hoc findings from Women’s Health Initiative Observational Study and Clinical Trials

Objectives To determine associations between postmenopausal change in body weight and incidence of fracture and associations between voluntary and involuntary weight loss and risk of fracture. Design Post hoc analysis of data from the Women’s Health Initiative Observational Study and Clinical Trials. Setting 40 clinical centers in the United States. Participants 120 566 postmenopausal women, aged 50-79 at baseline (1993-98), followed through 2013 (mean fracture follow-up duration 11 years from baseline). Exposures Annualized percentage change in measured body weight from baseline to year 3, classified as stable (<5% change), weight loss (≥5%), or weight gain (≥5%). Self assessment of whether weight loss was intentional or unintentional. Cox proportional hazards regression models were adjusted for age, race/ethnicity, baseline body mass index (BMI), smoking, alcohol intake, level of physical activity, energy expenditure, calcium and vitamin D intake, physical function score, oophorectomy, hysterectomy, previous fracture, comorbidity score, and drug use. Main outcomes Incident self reported fractures of the upper limbs, lower limbs, and central body; hip fractures confirmed by medical records. Results Mean participant age was 63.3. Mean annualized percent weight change was 0.30% (95% confidence interval 0.28 to 0.32). Overall, 79 279 (65.6%) had stable weight; 18 266 (15.2%) lost weight; and 23 021 (19.0%) gained weight. Compared with stable weight, weight loss was associated with a 65% higher incidence rates of fracture in hip (adjusted hazard ratio 1.65, 95% confidence interval 1.49 to 1.82), upper limb (1.09, 1.03 to 1.16), and central body (1.30, 1.20 to 1.39); weight gain was associated with higher incidence rates of fracture in upper limb (1.10, 1.05 to 1.18) and lower limb (1.18, 1.12 to 1.25). Compared with stable weight, unintentional weight loss was associated with a 33% higher incidence rates of hip fracture (1.33, 1.19 to 1.47) and increased incidence rates of vertebral fracture (1.16, 1.06 to 1.26); intentional weight loss was associated with increased incidence rates of lower limb fracture (1.11, 1.05 to 1.17) and decreased incidence of hip fracture (0.85, 0.76 to 0.95). Conclusions Weight gain, weight loss, and intentional weight loss are associated with increased incidence of fracture, but associations differ by fracture location. Clinicians should be aware of fracture patterns after weight gain and weight loss.

Central DXA utilization shifts from office-based to hospital-based settings among medicare beneficiaries in the wake of reimbursement changes

In the United States, Medicare gradually reduced payments for central dual‐energy X‐ray absorptiometry (DXA) performed at physician offices (or other nonhospital settings) from an average of

Self-reported osteoarthritis, ethnicity, body mass index, and other associated risk factors in postmenopausal women - Results from the women's health initiative

139 in 2006 to about

Stronger bone correlates with African admixture in African‐American women

82 in 2007 and 2008 and

Physicians' explanations for apparent gaps in the quality of rheumatology care: Results from the US Medicare Physician Quality Reporting System

72 in 2009. Reimbursement for hospital outpatient DXA service was unchanged. We investigated the utilization of hip and spine (central) DXA in the Medicare population before and after the reduction. We identified individuals from the national 5% random sample of Medicare beneficiaries who were ≥65 years of age and enrolled in Medicare Parts A and B but not in a Medicare Advantage plan from 2002 through 2009. For each calendar year, we calculated the proportion of beneficiaries who submitted claims for DXA, the proportions of DXAs performed in hospitals and in physician offices and the number of physician office‐based practices that discontinued or started to provide DXA services. From 2002 to 2006, the proportion of beneficiaries who had at least one central DXA increased from 7.9% to 9.6% at an annual increase of 0.4% and from 2006 to 2009, the annual increase dropped to 0.1%. The number of DXAs performed in physician offices dropped from 1,643,720 (69% of 2,363,500 total DXAs) in 2006 to 1,534,240 (66% of 2,338,240) in 2009. This decline was offset by an increase in the number of DXAs performed in hospitals, which increased from 719,780 (31%) in 2006 to 804,000 (34%) in 2009. Among physician office‐based practices, more practices initiated than discontinued DXA service each year from 2002 to 2006. However, the trend was reversed since 2007 such that in 2009, 1876 practices discontinued and only 1394 initiated DXA service. The reduction in DXA reimbursement was associated with a decrease in the number of DXAs performed in physician offices and fewer physician offices that provided DXA services.

Determinants of mortality among postmenopausal women in the women's health initiative who report rheumatoid arthritis.

The objective of this analysis was to assess risk factors for self‐reported osteoarthritis (OA) in an ethnically diverse cohort of women. The participants were postmenopausal women aged 50 to 79 (n=146,494) participating in the clinical trial and observational study of the Womens Health Initiative (WHI). Baseline OA and risk factors were collected from WHI questionnaires. Logistic regression was used to find the association between the risk factors and OA. Risk factor distribution and ethnicity interaction terms were used to assess ethnic differences in OA risk. Forty‐four percent of the participants reported OA. Older age (odds ratio (OR)70–79 vs 50–59=2.69, 95% confidence interval (CI)=2.60–2.78) and higher body mass index (BMI) (ORBMI≥40.0 vs <24.9=2.80, 95% CI=2.63–2.99) were found to be the strongest risk factors associated with self‐reported OA. The prevalence of obesity (BMI≥30.0) was 57.9% in African Americans, 51.0% in American Indians, 41.9% in Hispanic whites, and 32.9% in non‐Hispanic whites. The prevalence of other major OA risk factors was higher in African‐American, American‐Indian, and Hispanic white women than in non‐Hispanic white women. Non‐Hispanic white women who were in the extreme obese category (BMI≥40.0 kg/m2) had a 2.80 times (95% CI=2.63, 2.99) greater odds of self‐reported OA. The odds were even higher in American‐Indian (OR=4.22, 95% CI=1.82, 9.77) and African‐American (OR=3.31, 95% CI=2.79, 3.91) women, indicating a significant interactive effect of BMI and ethnicity on odds of OA. In conclusion, OA is a highly prevalent condition in postmenopausal women, and there are differential effects according to ethnicity.