Osteoporosis International

, Volume 17, Issue 9, pp 1358–1368

The interaction of ethnicity and chronic disease as risk factors for osteoporotic fractures: a comparison in Canadian Aboriginals and non-Aboriginals

  • W. D. Leslie
  • S. Derksen
  • H. J. Prior
  • L. M. Lix
  • C. Metge
  • J. O’Neil
Original Article



Efforts to develop global methods for absolute fracture risk prediction are currently limited by uncertainty over the validity of these models in non-White populations. Aboriginal Canadians have higher fractures rates than non-Aboriginals. This analysis examined the interaction of ethnicity with diabetes mellitus, disease comorbidity and substance abuse as possible explanatory variables.


A retrospective, population-based matched cohort study of fracture rates was performed using Manitoba administrative health data (1984–2003). The study cohort consisted of 27,952 registered Aboriginal adults (aged 20 years or older) and 83,856 non-Aboriginal controls (matched three to one for year of birth and gender). Diabetes mellitus, number of ambulatory disease groups (ADGs), substance abuse and incident fractures were based upon validated definitions. Poisson regression analyses of fracture rates modelled the explanatory variables as main effects and two-way interactions with ethnicity.


Osteoporotic fracture rates were approximately twofold higher in the Aboriginal cohort (p<0.0001). Diabetes, greater number of ADGs and substance abuse were all more common in the Aboriginal cohort (all p<0.0001). These factors were associated with increased fracture rates (all p<0.0001) and significantly higher population attributable risk percent in the Aboriginal cohort (all p<0.0001). However, no significant interactions between the risk factors and ethnicity were observed (p>0.1 for all interaction effects).


Greater prevalence of diabetes, comorbidity and substance abuse contributes to higher rates of fracture. The relative risk of fracture for these factors is similar for both Aboriginal and non-Aboriginals despite large differences in absolute fracture risk and risk factor prevalence.


Diabetes mellitus Ethnicity Fractures Indians, North American Morbidity Osteoporosis Substance abuse 


  1. 1.
    Barrett-Connor E, Siris ES, Wehren LE, Miller PD, Abbott TA, Berger ML, Santora AC, Sherwood LM (2005) Osteoporosis and fracture risk in women of different ethnic groups. J Bone Miner Res 20(2):185–194PubMedCrossRefGoogle Scholar
  2. 2.
    Kanis JA, Borgstrom F, De Laet C, Johansson H, Johnell O, Jonsson B, Oden A, Zethraeus N, Pfleger B, Khaltaev N (2005) Assessment of fracture risk. Osteoporos Int 16(6):581–589PubMedCrossRefGoogle Scholar
  3. 3.
    De Laet C, Oden A, Johansson H, Johnell O, Jonsson B, Kanis JA (2005) The impact of the use of multiple risk indicators for fracture on case-finding strategies: a mathematical approach. Osteoporos Int 16:313–318PubMedCrossRefGoogle Scholar
  4. 4.
    Kanis JA, Johnell O, De Laet C, Jonsson B, Oden A, Ogelsby AK (2002) International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res 17(7):1237–1244PubMedCrossRefGoogle Scholar
  5. 5.
    Lunt M, Felsenberg D, Reeve J, Benevolenskaya L, Cannata J, Dequeker J, Dodenhof C, Falch JA, Masaryk P, Pols HA, Poor G, Reid DM, Scheidt-Nave C, Weber K, Varlow J, Kanis JA, O’Neill TW, Silman AJ (1997) Bone density variation and its effects on risk of vertebral deformity in men and women studied in thirteen European centers: the EVOS Study. J Bone Miner Res 12(11):1883–1894PubMedCrossRefGoogle Scholar
  6. 6.
    Leslie WD, Derksen S, Metge C, Lix LM, Salamon EA, Wood SP, Roos LL (2004) Fracture risk among First Nations people: a retrospective matched cohort study. CMAJ 171(8):869–873PubMedGoogle Scholar
  7. 7.
    Leslie WD, Derksen SA, Metge C, Lix LM, Salamon EA, Steiman PW, Roos LL (2005) Demographic risk factors for fracture in First Nations people. Can J Public Health 96(Suppl 1):S45–S50PubMedGoogle Scholar
  8. 8.
    MacMillan HL, MacMillan AB, Offord DR, Dingle JL (1996) Aboriginal health. CMAJ 155(11):1569–1578PubMedGoogle Scholar
  9. 9.
    Karmali S, Laupland K, Harrop AR, Findlay C, Kirkpatrick AW, Winston B, Kortbeek J, Crowshoe L, Hameed M (2005) Epidemiology of severe trauma among status Aboriginal Canadians: a population-based study. CMAJ 172(8):1007–1011PubMedGoogle Scholar
  10. 10.
    De Liefde I, van der Klift M, De Laet CE, van Daele PL, Hofman A, Pols HA (2005) Bone mineral density and fracture risk in type-2 diabetes mellitus: the Rotterdam Study. Osteoporos Int 16:1713–1720PubMedCrossRefGoogle Scholar
  11. 11.
    Roos NP, Shapiro E (1999) Revisiting the Manitoba Centre for Health Policy and Evaluation and its population-based health information system. Med Care 37(6 Suppl):JS10–JS14PubMedCrossRefGoogle Scholar
  12. 12.
    Roos NP (1999) Establishing a population data-based policy unit. Med Care 37(6 Suppl):JS15–JS26PubMedCrossRefGoogle Scholar
  13. 13.
    Jebamani LS, Burchill CA, Martens PJ (2005) Using data linkage to identify First Nations Manitobans: technical, ethical, and political issues. Can J Public Health 96(Suppl 1):S28–S32PubMedGoogle Scholar
  14. 14.
    Martens P, Sanderson D, Bond R, Jebamani L, Burchill C, Roos N, Tanner-Spence M, Derksen S, Leader A, Beaulieu M, Elias B, Steinbach C, O’Neil J, MacWilliam L, Walld R, Dik N (2002) The health and health care use of registered First Nations people living in Manitoba: a population-based study. Manitoba Centre for Health Policy, Winnipeg, ManitobaGoogle Scholar
  15. 15.
    Income quintiles based on the 1996 census. Manitoba Centre for Health Policy . 2003. URL:http://www.umanitoba.ca/academic/centres/mchp/concept/diet/income/income_quintile.html (Last accessed June 6, 2005)
  16. 16.
    Blanchard JF, Ludwig S, Wajda A, Dean H, Anderson K, Kendall O, Depew N (1996) Incidence and prevalence of diabetes in Manitoba, 1986–1991. Diabetes Care 19(8):807–811PubMedCrossRefGoogle Scholar
  17. 17.
    Starfield B, Weiner J, Mumford L, Steinwachs D (1991) Ambulatory care groups: a categorization of diagnoses for research and management. Health Serv Res 26(1):53–74PubMedGoogle Scholar
  18. 18.
    Smith NS, Weiner JP (1994) Applying population-based case mix adjustment in managed care: the Johns Hopkins Ambulatory Care Group system. Manag Care Q 2(3):21–34PubMedGoogle Scholar
  19. 19.
    Weiner JP, Starfield BH, Steinwachs DM, Mumford LM (1991) Development and application of a population-oriented measure of ambulatory care case-mix. Med Care 29(5):452–472PubMedCrossRefGoogle Scholar
  20. 20.
    Reid RJ, Roos NP, MacWilliam L, Frohlich N, Black C (2002) Assessing population health care need using a claims-based ACG morbidity measure: a validation analysis in the Province of Manitoba. Health Serv Res 37(5):1345–1364PubMedCrossRefGoogle Scholar
  21. 21.
    Reid RJ, MacWilliam L, Verhulst L, Roos N, Atkinson M (2001) Performance of the ACG case-mix system in two Canadian provinces. Med Care 39(1):86–99PubMedCrossRefGoogle Scholar
  22. 22.
    Reed M, Demeter S, Lix L, MacWilliam L (2004) Is there an association between socioeconomic factors and the per capita utilization of selected diagnostic imaging modalities? In: Finlayson G, Leslie WD, MacWilliam L (eds) Diagnostic imaging data in Manitoba-assessment and applications. Manitoba Centre for Health PolicyGoogle Scholar
  23. 23.
    Ross HE, Lin E, Cunningham J (1999) Mental health service use: a comparison of treated and untreated individuals with substance use disorders in Ontario. Can J Psychiatry 44(6):570–577PubMedGoogle Scholar
  24. 24.
    Martens P, Burchill C, Freund J, DeCoster C, McKeen N, Ekuma O, Prior H, Chateau D, Burland E, Robinson R, Jebamani L, Metge C (2004) Patterns of regional mental illness disorder diagnoses and service use in Manitoba: a population-based study. Manitoba Centre for Health Policy, Winnipeg, ManitobaGoogle Scholar
  25. 25.
    McCulloch CE, Searle SR (2001) Generalized, linear, and mixed models. Wiley, New YorkGoogle Scholar
  26. 26.
    Fox J (1997) Applied regression analysis, linear models, and related methods. Sage, Thousand Oaks, CAGoogle Scholar
  27. 27.
    Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC Jr, Lindsay R (1998) Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 8(5):468–489PubMedCrossRefGoogle Scholar
  28. 28.
    Looker AC, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Johnston CC Jr, Lindsay RL (1995) Proximal femur bone mineral levels of US adults. Osteoporos Int 5(5):389–409PubMedCrossRefGoogle Scholar
  29. 29.
    Cauley JA, Lui LY, Ensrud KE, Zmuda JM, Stone KL, Hochberg MC, Cummings SR (2005) Bone mineral density and the risk of incident nonspinal fractures in black and white women. JAMA 293(17):2102–2108PubMedCrossRefGoogle Scholar
  30. 30.
    Ross PD, Norimatsu H, Davis JW, Yano K, Wasnich RD, Fujiwara S, Hosoda Y, Melton LJ III (1991) A comparison of hip fracture incidence among native Japanese, Japanese Americans, and American Caucasians. Am J Epidemiol 133(8):801–809PubMedGoogle Scholar
  31. 31.
    Ross PD, He Y, Yates AJ, Coupland C, Ravn P, McClung M, Thompson D, Wasnich RD (1996) Body size accounts for most differences in bone density between Asian and Caucasian women. The EPIC (Early Postmenopausal Interventional Cohort) Study Group. Calcif Tissue Int 59(5):339–343PubMedCrossRefGoogle Scholar
  32. 32.
    Bhudhikanok GS, Wang MC, Eckert K, Matkin C, Marcus R, Bachrach LK (1996) Differences in bone mineral in young Asian and Caucasian Americans may reflect differences in bone size. J Bone Miner Res 11(10):1545–1556PubMedCrossRefGoogle Scholar
  33. 33.
    Cummings SR, Cauley JA, Palermo L, Ross PD, Wasnich RD, Black D, Faulkner KG (1994) Racial differences in hip axis lengths might explain racial differences in rates of hip fracture. Study of Osteoporotic Fractures Research Group. Osteoporos Int 4(4):226–229PubMedCrossRefGoogle Scholar
  34. 34.
    Binkley NC, Schmeer P, Wasnich RD, Lenchik L (2002) What are the criteria by which a densitometric diagnosis of osteoporosis can be made in males and non-Caucasians? J Clin Densitom 5(Suppl):S19–S27PubMedCrossRefGoogle Scholar
  35. 35.
    Lewiecki EM, Kendler DL, Kiebzak GM, Schmeer P, Prince RL, El-Hajj FG, Hans D (2004) Special report on the official positions of the International Society for Clinical Densitometry. Osteoporos Int 15(10)779–784PubMedCrossRefGoogle Scholar
  36. 36.
    Krieger N, Davey SG (2004) “Bodies count,” and body counts: social epidemiology and embodying inequality. Epidemiol Rev 26:92–103PubMedCrossRefGoogle Scholar
  37. 37.
    Cooper R (2002) A note on the biological concept of race and its application in epidemiologic research. In: LaVeist TA (ed) Race, ethnicity and health: a public health reader 1st(6). Jossey-Bass, San Francisco, pp 99–114Google Scholar
  38. 38.
    Muntaner C, Nieto FJ, O’Campo P (2002) The bell curve: on race, social class, and epidemiologic research. In: LaVeist TA (ed) Race, ethnicity and health: a public health reader 1st(8). Jossey-Bass, San Francisco, pp 129–140Google Scholar
  39. 39.
    Leslie WD, Metge CJ, Weiler HA, Yuen CK, Krahn J, Doupe M, Salamon EA, Wood Steiman P, O’Neil J, Greenberg CR, Lix L, Roos LL, Tenenhouse A (2004) Site specific reductions in bone density in Canadian Aboriginal women: the First Nations Bone Health Study. J Bone Miner Res 19(Suppl 1):S288Google Scholar
  40. 40.
    Stone KL, Seeley DG, Lui LY, Cauley JA, Ensrud K, Browner WS, Nevitt MC, Cummings SR (2003) BMD at multiple sites and risk of fracture of multiple types: long-term results from the Study of Osteoporotic Fractures. J Bone Miner Res 18(11):1947–1954PubMedCrossRefGoogle Scholar
  41. 41.
    Beyene Y, Martin MC (2001) Menopausal experiences and bone density of Mayan women in Yucatan, Mexico. Am J Human Biol 13(4):505–511CrossRefGoogle Scholar
  42. 42.
    Lebrun JB, Moffatt ME, Mundy RJ, Sangster RK, Postl BD, Dooley JP, Dilling LA, Godel JC, Haworth JC (1993) Vitamin D deficiency in a Manitoba community. Can J Public Health 84(6):394–396PubMedGoogle Scholar
  43. 43.
    Ellestad-Sayed JJ, Haworth JC, Coodin FJ, Dilling LA (1981) Growth and nutrition of preschool Indian children in Manitoba: II. Nutrient intakes. Can J Public Health 72(2):127–133PubMedGoogle Scholar
  44. 44.
    Campbell M, Diamant RMF, MacPherson BD, Grunau M, Halladay J (1994) Energy and nutrient intakes of men (56–74 years) and women (16–74 years) in three northern Manitoba Cree communities. J Can Diet Assoc 55:167–174Google Scholar
  45. 45.
    Haworth JC, Dilling LA (1986) Vitamin-D-deficient rickets in Manitoba, 1972–84. CMAJ 134(3):237–241PubMedGoogle Scholar
  46. 46.
    Schwartz AV, Sellmeyer DE, Ensrud KE, Cauley JA, Tabor HK, Schreiner PJ, Jamal SA, Black DM, Cummings SR (2001) Older women with diabetes have an increased risk of fracture: a prospective study. J Clin Endocrinol Metab 86(1):32–38PubMedCrossRefGoogle Scholar
  47. 47.
    Forsen L, Meyer HE, Midthjell K, Edna TH (1999) Diabetes mellitus and the incidence of hip fracture: results from the Nord-Trondelag Health Survey. Diabetologia 42(8):920–925PubMedCrossRefGoogle Scholar
  48. 48.
    van Daele PL, Stolk RP, Burger H, Algra D, Grobbee DE, Hofman A, Birkenhager JC, Pols HA (1995) Bone density in non-insulin-dependent diabetes mellitus. The Rotterdam Study. Annf Intern Med 122(6):409–414PubMedGoogle Scholar
  49. 49.
    Stolk RP, van Daele PL, Pols HA, Burger H, Hofman A, Birkenhager JC, Lamberts SW, Grobbee DE (1996) Hyperinsulinemia and bone mineral density in an elderly population: The Rotterdam Study. Bone 18(6):545–549PubMedCrossRefGoogle Scholar
  50. 50.
    Kanis JA, Johansson H, Johnell O, Oden A, De Laet C, Eisman JA, Pols H, Tenenhouse A (2005) Alcohol intake as a risk factor for fracture. Osteoporos Int 16(7):737–742PubMedCrossRefGoogle Scholar
  51. 51.
    Black DM, Steinbuch M, Palermo L, Dargent-Molina P, Lindsay R, Hoseyni MS, Johnell O (2001) An assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int 12(7):519–528PubMedCrossRefGoogle Scholar
  52. 52.
    Espallargues M, Sampietro-Colom L, Estrada MD, Sola M, del Rio L, Setoain J, Granados A (2001) Identifying bone-mass-related risk factors for fracture to guide bone densitometry measurements: a systematic review of the literature. Osteoporos Int 12(10):811–822PubMedCrossRefGoogle Scholar
  53. 53.
    Baltzan MA, Suissa S, Bauer DC, Cummings SR (1999) Hip fractures attributable to corticosteroid use. Study of Osteoporotic Fractures Group. Lancet 353(9161):1327PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2006

Authors and Affiliations

  • W. D. Leslie
    • 1
  • S. Derksen
    • 2
  • H. J. Prior
    • 2
  • L. M. Lix
    • 2
  • C. Metge
    • 2
  • J. O’Neil
    • 3
  1. 1.Department of MedicineUniversity of ManitobaWinnipegCanada
  2. 2.Manitoba Centre for Health PolicyUniversity of ManitobaWinnipegCanada
  3. 3.Centre for Aboriginal Health ResearchUniversity of ManitobaWinnipegCanada

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