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Socio-economic inequalities in fragility fracture incidence: a systematic review and meta-analysis of 61 observational studies

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Abstract

Summary

Individuals with low socio-economic status (SES) have a more than 25% higher risk of fragility fractures than individuals with high SES. Body mass index and lifestyle appear to mediate the effect of SES on fracture risk. Strategies to prevent fractures should aim to reduce unhealthy behaviours through tackling structural inequalities.

Introduction

This systematic review and meta-analysis aimed to evaluate the impact of socio-economic status (SES) on fragility fracture risk.

Methods

Medline, Embase, and CINAHL databases were searched from inception to 28 April 2021 for studies reporting an association between SES and fragility fracture risk among individuals aged ≥50 years. Risk ratios (RR) were combined in meta-analyses using random restricted maximum likelihood models, for individual-based (education, income, occupation, cohabitation) and area-based (Index of Multiple Deprivation, area income) SES measures.

Results

A total of 61 studies from 26 different countries including more than 19 million individuals were included. Individual-based low SES was associated with an increased risk of fragility fracture (RR 1.27 [95% CI 1.12, 1.44]), whilst no clear association was seen when area-based measures were used (RR 1.08 [0.91, 1.30]). The strength of associations was influenced by the type and number of covariates included in statistical models: RR 2.69 [1.60, 4.53] for individual-based studies adjusting for age, sex and BMI, compared with RR 1.06 [0.92, 1.22] when also adjusted for health behaviours (smoking, alcohol, and physical activity). Overall, the quality of the evidence was moderate.

Conclusion

Our results show that low SES, measured at the individual level, is a risk factor for fragility fracture. Low BMI and unhealthy behaviours are important mediators of the effect of SES on fracture risk. Strategies to prevent fractures and reduce unhealthy behaviours should aim to tackle structural inequalities in society thereby reducing health inequalities in fragility fracture incidence.

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Funding

AB was supported by a Linda Edwards Memorial PhD Studentship funded by the Royal (formerly National) Osteoporosis Society.

Author information

Authors and Affiliations

  1. Department of Public Health and Health Services Research, DEFACTUM, Central Denmark Region, Aarhus, Denmark

    G. Valentin, M.B. Ravn, E.K. Jensen, K. Friis & C.P. Nielsen

  2. Department of Clinical Medicine, Aarhus University, Aarhus, Denmark

    G. Valentin & B. Langdahl

  3. Department of Clinical Biochemistry, Royal Free Hospital, London, UK

    A. Bhimjiyani

  4. Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

    Y. Ben-Shlomo

  5. MRC Integrative Epidemiology Unit, Bristol Medical School, Oakfield House, Bristol, BS8 2BN, UK

    A. Hartley

  6. Department of Endocrinology, Aarhus University Hospital, Aarhus, Denmark

    B. Langdahl

  7. Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK

    C.L. Gregson

Authors
  1. G. Valentin
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  2. M.B. Ravn
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  3. E.K. Jensen
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  4. K. Friis
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  5. A. Bhimjiyani
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  6. Y. Ben-Shlomo
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  7. A. Hartley
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  8. C.P. Nielsen
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  9. B. Langdahl
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  10. C.L. Gregson
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Corresponding author

Correspondence to G. Valentin.

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Conflict of interest

GV, MBR, EKJ, KF, AB, YBS, AH, CPN, and CLG declare that they have no conflicts of interest. BL has received research funding for her institution from Amgen and Novo Nordisk and honoraria for advisory boards and lectures from UCB, Eli Lilly, Amgen, Gedeon Richter, and Gilead.

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Valentin, G., Ravn, M., Jensen, E. et al. Socio-economic inequalities in fragility fracture incidence: a systematic review and meta-analysis of 61 observational studies. Osteoporos Int 32, 2433–2448 (2021). https://doi.org/10.1007/s00198-021-06038-7

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  • DOI: https://doi.org/10.1007/s00198-021-06038-7

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