Risk factors for low bone mass in healthy 40–60 year old women: A systematic review of the literature

  • E. J. WaughEmail author
  • M.-A. Lam
  • G. A. Hawker
  • J. McGowan
  • A. Papaioannou
  • A. M. Cheung
  • A. B. Hodsman
  • W. D. Leslie
  • K. Siminoski
  • S. A. Jamal



Based on a systematic review of the literature, only low body weight and menopausal status can be considered with confidence, as important risk factors for low BMD in healthy 40–60 year old women. The use of body weight to identify high risk women may reduce unnecessary BMD testing in this age group.


BMD testing of perimenopausal women is increasing but may be unnecessary as fracture risk is low. Appropriate assessment among younger women requires identification of risk factors for low BMD specific to this population.


We conducted a systematic literature review of risk factors for low BMD in healthy women aged 40–60 years. Articles were retrieved from six databases and reviewed for eligibility and methodological quality. A grade for overall strength of evidence for each risk factor was assigned.


There was good evidence that low body weight and post-menopausal status are risk factors for low BMD. There was good or fair evidence that alcohol and caffeine intake, and reproductive history are not risk factors. There was inconsistent or insufficient evidence for the effect of calcium intake, physical activity, smoking, age at menarche, history of amenorrhea, family history of OP, race and current age on BMD.


Based on current evidence in Caucasians, we suggest that, in healthy women aged 40–60 years, only those with a low body weight (< 70 kg) be selected for BMD testing. Further research is necessary to determine optimal race-specific discriminatory weight cut-offs and to evaluate the risk factors for which there was inconclusive evidence.


BMD Bone density Osteoporosis Risk factors Systematic review 



The authors gratefully acknowledge Osteoporosis Canada for coordinating this project.

No sources of support were received for this project.

Conflicts of interest



  1. 1.
    Consensus development conference (1993) Diagnosis, prophylaxis and treatment of osteoporosis. Am J Med 94:646–650CrossRefGoogle Scholar
  2. 2.
    NIH (2000) Osteoporosis prevention, diagnosis and therapy. NIH consensus statements 17:1–45Google Scholar
  3. 3.
    WHO (2003) Prevention and management of osteoporosis. Report of a WHO Study Group (ref type: report). World Health Organization, Geneva, Technical Report Series 919:1–165Google Scholar
  4. 4.
    Jagal SB (2002) Bone density testing. In Stewart DE, Ferris L, Hyman I et al (eds) Ontario Women’s Health Status Report (ref type: report). 113–120Google Scholar
  5. 5.
    Osteoporosis Action Plan Committee (2003) Osteoporosis Action Plan: an osteoporosis strategy for Ontario. Report of the Osteoporosis Action Plan Committee to the Ministry of Long-term Care (ref type: report). 1–86Google Scholar
  6. 6.
    Brown JP, Josse RG (2002) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 167:S1–S34PubMedGoogle Scholar
  7. 7.
    Sackett DL, Haynes RB, Guyatt GH et al (1991) Clinical epidemiology: a basic science for clinical medicine. Little, Brown and Company, BostonGoogle Scholar
  8. 8.
    Harris RP, Helfand M, Woolf SH et al (2001) Current methods of the US Preventive Services Task Force: a review of the process. Am J Prevent Med 20:S21–S35CrossRefGoogle Scholar
  9. 9.
    Coupland CA, Cliffe SJ, Bassey EJ et al (1999) Habitual physical activity and bone mineral density in postmenopausal women in England. Int J Epidemiol 28:241–246PubMedCrossRefGoogle Scholar
  10. 10.
    Tuppurainen M, Kroger H, Saarikoski S et al (1995) The effect of gynecological risk factors on lumbar and femoral bone mineral density in peri-and postmenopausal women. Maturitas 21:137–145PubMedCrossRefGoogle Scholar
  11. 11.
    Grainge MJ, Coupland CA, Cliffe SJ et al (1998) Cigarette smoking, alcohol and caffeine consumption, and bone mineral density in postmenopausal women. The Nottingham EPIC Study Group. Osteoporos Int 8:355–363PubMedCrossRefGoogle Scholar
  12. 12.
    Kroger H, Tuppurainen M, Honkanen R et al (1994) Bone mineral density and risk factors for osteoporosis - a population-based study of 1600 perimenopausal women. Calcif Tissue Int 55:1–7PubMedCrossRefGoogle Scholar
  13. 13.
    Ho SC, Chen YM, Woo JL (2005) Educational level and osteoporosis risk in postmenopausal Chinese women. Am J Epidemiol 161:680–690PubMedCrossRefGoogle Scholar
  14. 14.
    Mizuno K, Suzuki A, Ino Y et al (1995) Postmenopausal bone loss in Japanese women. Int J Gynaecol Obstet 50:33–39PubMedCrossRefGoogle Scholar
  15. 15.
    Takada H, Washino K, Iwata H (1997) Risk factors for low bone mineral density among females: the effect of lean body mass. Prev Med 26:633–638PubMedCrossRefGoogle Scholar
  16. 16.
    Holm K, Dan A, Wilbur J et al (2002) A longitudinal study of bone density in midlife women. Health Care Women Int 23:678–691PubMedCrossRefGoogle Scholar
  17. 17.
    New SA, Bolton-Smith C, Grubb DA et al (1997) Nutritional influences on bone mineral density: a cross-sectional study in premenopausal women. Am J Clin Nutr 65:1831–1839PubMedGoogle Scholar
  18. 18.
    Ryan PJ, Blake GM, Fogelman I (1992) Postmenopausal screening for osteopenia. Br J Rheumatol 31:823–828PubMedCrossRefGoogle Scholar
  19. 19.
    Keen RW, Hart DJ, Arden NK et al (1999) Family history of appendicular fracture and risk of osteoporosis: a population-based study. Osteoporos Int 10:161–166PubMedCrossRefGoogle Scholar
  20. 20.
    Cadarette SM, Jaglal SB, Murray TM et al (2001) Canadian Multicentre Osteoporosis Study. Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. JAMA 286:57–63PubMedCrossRefGoogle Scholar
  21. 21.
    Gourlay ML, Miller WC, Richy F et al (2005) Performance of osteoporosis risk assessment tools in postmenopausal women aged 45–53 years. Osteoporos Int 16:921–927PubMedCrossRefGoogle Scholar
  22. 22.
    National Osteoporosis Foundation (1999) Physician’s Guide to Prevention and Treatment of Osteoporosis. Excerpta Medica Inc, Bell Mead, New JerseyGoogle Scholar
  23. 23.
    Michaelsson K, Bergstrom R, Mallmin H et al (1996) Screening for osteopenia and osteoporosis: selection by body composition. Osteoporos Int 6:120–126PubMedCrossRefGoogle Scholar
  24. 24.
    Rubin LA, Hawker GA, Peltekova VD et al (1999) Determinants of peak bone mass: clinical and genetic analyses in a young female Canadian cohort. J Bone Miner Res 14:633–643PubMedCrossRefGoogle Scholar
  25. 25.
    Cobb KL, Bachrach LK, Greendale G et al (2003) Disordered eating, menstrual irregularity and bone mineral density in female runners. Med Sci Sports Exerc 35:711–719PubMedCrossRefGoogle Scholar
  26. 26.
    Davies MC, Hall JL, Jacobs HS (1990) Bone mineral loss in young women with amenorrhoea. BMJ 301:790–793PubMedCrossRefGoogle Scholar
  27. 27.
    Gordon CM, Nelson LM (2003) Amenorrhea and bone health in adolescents and young women. Curr Opin Obstet Gynecol 15:377–384PubMedCrossRefGoogle Scholar
  28. 28.
    Brown JP, Josse RG (2002) 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 167:S1–S34PubMedGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2008

Authors and Affiliations

  • E. J. Waugh
    • 1
    • 11
    Email author
  • M.-A. Lam
    • 1
  • G. A. Hawker
    • 2
  • J. McGowan
    • 3
    • 4
  • A. Papaioannou
    • 5
  • A. M. Cheung
    • 6
  • A. B. Hodsman
    • 7
  • W. D. Leslie
    • 8
  • K. Siminoski
    • 9
  • S. A. Jamal
    • 10
  1. 1.Osteoporosis Research ProgramWomen’s College HospitalTorontoCanada
  2. 2.Osteoporosis Research Program and Department of MedicineWomen’s College HospitalTorontoCanada
  3. 3.Institute of Population HealthOttawa Health Research InstituteOttawaCanada
  4. 4.Department of Medicine and Family MedicineUniversity of OttawaOttawaCanada
  5. 5.Division of Geriatrics, Department of MedicineHamilton Health Sciences and McMaster UniversityHamiltonCanada
  6. 6.Department of MedicineUniversity Health Network and University of TorontoTorontoCanada
  7. 7.Division of NephrologyDepartment of Medicine, St. Joseph’s Health CareLondonCanada
  8. 8.Departments of Medicine and RadiologyUniversity of ManitobaWinnipegCanada
  9. 9.Department of Radiology and Diagnostic Imaging and Division of Endocrinology and Metabolism, Department of MedicineUniversity of AlbertaEdmontonCanada
  10. 10.Osteoporosis Research Program and Department of MedicineWomen’s College HospitalTorontoCanada
  11. 11.Osteoporosis Research ProgramWomen’s College HospitalTorontoCanada

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