Osteoporosis International

, Volume 20, Issue 3, pp 393–398 | Cite as

Poverty is a risk factor for osteoporotic fractures

  • M. C. Navarro
  • M. SosaEmail author
  • P. Saavedra
  • P. Lainez
  • M. Marrero
  • M. Torres
  • C. D. Medina
Original Article



This study assesses the possible association between poverty and osteoporosis and/or fragility fractures in a population of postmenopausal women. We found that postmenopausal women with low socioeconomic status had lower values of BMD at the lumbar spine, a higher prevalence of densitometric osteoporosis, and a higher prevalence of total and vertebral fractures.


Some lifestyles are related to the presence of osteoporosis and/or fragility fractures, whereas poverty is related to some lifestyles. Because of this, we studied the possible association of poverty with osteoporosis and fractures.


This was an observational, cross-sectional study performed in the Canary Islands, Spain. Participants consisted of a total of 1,139 ambulatory postmenopausal women aged 50 years or older with no previous osteoporosis diagnosis and who were enrolled in some epidemiological studies. The prevalence of fractures (vertebral and non-vertebral) and the prevalence of osteoporosis (T-score <–2.5 either at the lumbar spine or the femoral neck). A previously validated questionnaire elicited the most important risk factors for osteoporosis: socioeconomic status, defined by the annual income was also assessed by a personal interview. A dorso-lateral X-ray of the spine was performed, and bone mineral density (BMD) was measured by DXA in the lumbar spine (L2–L4) and proximal femur.


Compared to women with a medium and high socioeconomic status (n = 665), those who were classified into poverty (annual family income lower than 6,346.80 Euros, in a one-member family, n = 474), were older and heavier and had lower height, lower prevalence of tobacco and alcohol consumption, lower use of HRT and higher use of thiazides.

After correcting for age and body mass index (BMI), women in poverty had lower spine BMD values than women with a medium and high socioeconomic status (0.840 g/cm2 vs. 0.867 g/cm2, p = 0.005), but there were no statistical differences in femoral neck BMD between groups. The prevalence of osteoporosis was also higher in women in poverty [40.6% vs. 35.6%, (OR 1.35, CI 95%: 1.03; 1.76)] after adjusting by age and BMI. Moreover, 37.8% of women in poverty had a history of at least one fragility fracture compared to 27.7% of women not in poverty (OR: 1.45, CI 95%: 1.11; 1.90). The prevalence of vertebral fractures was also higher in women in poverty 24.7% vs. 13.4%, (OR 2.01, CI 95%: 1.44; 2.81).


Postmenopausal women with low socioeconomic status had lower values of BMD at the lumbar spine, and a higher prevalence of densitometric osteoporosis, and a higher prevalence of total and vertebral fractures. Because of this, apart from the well known risk factors for osteoporosis, poverty should be taken into account as a possible risk factor for both osteoporosis and fragility fractures, in order to establish sanitary strategies to protect unfavoured postmenopausal women.


Alcohol Densitometry Fractures Life styles Menopause Obesity Osteoporosis Poverty Tobacco Vertebral Women 



We would like to thank Professor L.J. Melton III of the Mayo Clinic, Rochester, Minesota, USA, for his constructive comments.

Conflicts of interest



  1. 1.
    Melton LJ 3rd, Chrischilles EA, Cooper C, Lane AW, Riggs BL (1992) Perspective. How many women have osteoporosis? J Bone Miner Res 7:1005–1010PubMedGoogle Scholar
  2. 2.
    Pachucki-Hyde L (2001) Assessment of risk factors for osteoporosis and fracture. Nurs Clinics N Am 36:401–408 viiGoogle Scholar
  3. 3.
    Green AD, Colon-Emeric CS, Bastian L, Drake MT, Lyles KW (2004) Does this woman have osteoporosis? JAMA 292:2890–2900PubMedCrossRefGoogle Scholar
  4. 4.
    Gourlay ML, Miller WC, Richy F, Garrett JM, Hanson LC, Reginster JY (2005) Performance of osteoporosis risk assessment tools in postmenopausal women aged 45–64 years. Osteoporos Int 16:921–927PubMedCrossRefGoogle Scholar
  5. 5.
    Khan S, Murray RP, Barnes GE (2002) A structural equation model of the effect of poverty and unemployment on alcohol abuse. Addictive Behav 27:405–423CrossRefGoogle Scholar
  6. 6.
    Wagenknecht LE, Perkins LL, Cutter GR, Sidney S, Burke GL, Manolio TA, Jacobs DR Jr, Liu KA, Friedman GD, Hughes GH et al (1990) Cigarette smoking behavior is strongly related to educational status: the CARDIA study. Prev Med 19:158–169PubMedCrossRefGoogle Scholar
  7. 7.
    Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J (1998) Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA 279:1703–1708PubMedCrossRefGoogle Scholar
  8. 8.
    Meara E (2006) Welfare reform, employment, and drug and alcohol use among low-income women. Harvard Rev Psychiatry 14:223–232CrossRefGoogle Scholar
  9. 9.
    Winkleby MA, Fortmann SP, Barrett DC (1990) Social class disparities in risk factors for disease: eight-year prevalence patterns by level of education. Prev Med 19:1–12PubMedCrossRefGoogle Scholar
  10. 10.
    Olson CM, Bove CF, Miller EO (2007) Growing up poor: long-term implications for eating patterns and body weight. Appetite 49:198–207PubMedCrossRefGoogle Scholar
  11. 11.
    Osler M (1993) Social class and health behaviour in Danish adults: a longitudinal study. Public Health 107:251–260PubMedCrossRefGoogle Scholar
  12. 12.
    Davey Smith G, Egger M (1993) Socioeconomic differentials in wealth and health. BMJ (Clinical research) 307:1085–1086CrossRefGoogle Scholar
  13. 13.
    Haan M, Kaplan GA, Camacho T (1987) Poverty and health. Prospective evidence from the Alameda County Study. Am J Epidemiol 125:989–998PubMedGoogle Scholar
  14. 14.
    Miech RA, Kumanyika SK, Stettler N, Link BG, Phelan JC, Chang VW (2006) Trends in the association of poverty with overweight among US adolescents, 1971–2004. JAMA 295:2385–2393PubMedCrossRefGoogle Scholar
  15. 15.
    Cooper C, O’Neill T, Silman A (1993) The epidemiology of vertebral fractures. European Vertebral Osteoporosis Study Group. Bone 14(Suppl 1):S89–S97PubMedCrossRefGoogle Scholar
  16. 16.
    Sosa M, Hernandez D, Estevez S, Rodriguez M, Liminana JM, Saavedra P, Lainez P, Diaz P, Betancor P (1998) The range of bone mineral density in healthy Canarian women by dual X-ray absorptiometry radiography and quantitative computer tomography. J Clin Densitom 1:385–393PubMedCrossRefGoogle Scholar
  17. 17.
    Sosa M, Saavedra P, Munoz-Torres M, Alegre J, Gomez C, Gonzalez-Macias J, Guanabens N, Hawkins F, Lozano C, Martinez M, Mosquera J, Perez-Cano R, Quesada M, Salas E (2002) Quantitative ultrasound calcaneus measurements: normative data and precision in the Spanish population. Osteoporos Int 13:487–492PubMedCrossRefGoogle Scholar
  18. 18.
    World Health Organization Scientific Group (1981) Research on the Menopause, WHO Technical Services Report Series 670. Geneva: World Health OrganizationGoogle Scholar
  19. 19.
    Working Group on Protocols (2000) Basic data on osteoporosis. Rev Esp Enf Metab Óseas 9:84–85Google Scholar
  20. 20.
    Spanish National Institute of Statistics (2004) Life conditions questionnaire. Main results. INE. Avaiable at
  21. 21.
    Cummings SR, Block G, McHenry K, Baron RB (1987) Evaluation of two food frequency methods of measuring dietary calcium intake. Am J Epidemiol 126:796–802PubMedGoogle Scholar
  22. 22.
    Diaz Curiel M, Carrasco de la Pena JL, Honorato Perez J, Perez Cano R, Rapado A, Ruiz Martinez I (1997) Study of bone mineral density in lumbar spine and femoral neck in a Spanish population. Multicentre Research Project on Osteoporosis. Osteoporos Int 7:59–64PubMedCrossRefGoogle Scholar
  23. 23.
    Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148PubMedCrossRefGoogle Scholar
  24. 24.
    Epstein S (2007) Is cortical bone hip? What determines cortical bone properties? Bone 41:S3–S8PubMedCrossRefGoogle Scholar
  25. 25.
    Melton LJ 3rd, Eddy DM, Johnston CC Jr (1990) Screening for osteoporosis. Ann Intern Med 112:516–528PubMedGoogle Scholar
  26. 26.
    NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis and Therapy (2001). JAMA 285:785–795Google Scholar
  27. 27.
    Kay’s SK, Hindmarsh PC (2006) Catch-up growth: an overview. Pediatr Endocrinol Rev 3:365–378PubMedGoogle Scholar
  28. 28.
    Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S (2004) Impact of the Mexican program for education, health, and nutrition (Progresa) on rates of growth and anemia in infants and young children: a randomized effectiveness study. JAMA 291:2563–2570PubMedCrossRefGoogle Scholar
  29. 29.
    McLaren L (2007) Socioeconomic status and obesity. Epidemiologic Rev 29:29–48CrossRefGoogle Scholar
  30. 30.
    Navarro MC, Saavedra P, Limiñana JM, Calvo JR, Betancor P, Sosa M (1997) Dietary calcium intake, bone mass and life-styles in postmenopausal women with and without osteoporosis. Rev Esp Nutr Comunit 3:15–24Google Scholar
  31. 31.
    Schroder H, Rohlfs I, Schmelz EM, Marrugat J (2004) Relationship of socioeconomic status with cardiovascular risk factors and lifestyle in a Mediterranean population. Eur J Nutr 43:77–85PubMedCrossRefGoogle Scholar
  32. 32.
    Borrell C, Dominguez-Berjon F, Pasarin MI, Ferrando J, Rohlfs I, Nebot M (2000) Social inequalities in health related behaviours in Barcelona. J Epidemiol Commun Health 54:24–30CrossRefGoogle Scholar
  33. 33.
    Wamala SP, Lynch J, Kaplan GA (2001) Women’s exposure to early and later life socioeconomic disadvantage and coronary heart disease risk: the Stockholm Female Coronary Risk Study. Int J Epidemiol 30:275–284PubMedCrossRefGoogle Scholar
  34. 34.
    Giskes K, Kunst AE, Benach J, Borrell C, Costa G, Dahl E, Dalstra JA, Federico B, Helmert U, Judge K, Lahelma E, Moussa K, Ostergren PO, Platt S, Prattala R, Rasmussen NK, Mackenbach JP (2005) Trends in smoking behaviour between 1985 and 2000 in nine European countries by education. J Epidemiol Commun Health 59:395–401CrossRefGoogle Scholar
  35. 35.
    Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J (2002) Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA 288:321–333PubMedCrossRefGoogle Scholar
  36. 36.
    Wassertheil-Smoller S, Hendrix SL, Limacher M, Heiss G, Kooperberg C, Baird A, Kotchen T, Curb JD, Black H, Rossouw JE, Aragaki A, Safford M, Stein E, Laowattana S, Mysiw WJ (2003) Effect of estrogen plus progestin on stroke in postmenopausal women: the Women’s Health Initiative: a randomized trial. JAMA 289:2673–2684PubMedCrossRefGoogle Scholar
  37. 37.
    Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767PubMedCrossRefGoogle Scholar
  38. 38.
    Yang K, McElmurry BJ, Park CG (2006) Decreased bone mineral density and fractures in low-income Korean women. Health Care Women Int 27:254–267PubMedCrossRefGoogle Scholar
  39. 39.
    Shatrugna V, Kulkarni B, Kumar PA, Rani KU, Balakrishna N (2005) Bone status of Indian women from a low-income group and its relationship to the nutritional status. Osteoporos Int 16:1827–1835PubMedCrossRefGoogle Scholar
  40. 40.
    Pearson D, Taylor R, Masud T (2004) The relationship between social deprivation, osteoporosis, and falls. Osteoporos Int 15:132–138PubMedCrossRefGoogle Scholar
  41. 41.
    Orces CH, Casas C, Lee S, Garci-Cavazos R, White W (2003) Determinants of osteoporosis prevention in low-income Mexican-American women. Southern Med J 96:458–464CrossRefGoogle Scholar
  42. 42.
    Oslo Ministerial Declaration (2007) Global health: a pressing foreign policy issue of our time. Lancet 369:1373–1378CrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2008

Authors and Affiliations

  • M. C. Navarro
    • 1
  • M. Sosa
    • 2
    • 4
    Email author
  • P. Saavedra
    • 3
  • P. Lainez
    • 1
  • M. Marrero
    • 1
  • M. Torres
    • 1
  • C. D. Medina
    • 1
  1. 1.Health Education and Promotion Working GroupCanary IslandsSpain
  2. 2.Bone Metabolic Unit, Hospital University InsularCanary IslandsSpain
  3. 3.Department of MathematicsUniversity of Las Palmas de Gran CanariaCanary IslandsSpain
  4. 4.University of Las Palmas de Gran Canaria, Faculty of Health SciencesCanary IslandsSpain

Personalised recommendations