Osteoporosis International

, Volume 22, Issue 2, pp 517–527 | Cite as

Association between socioeconomic status and bone mineral density in adults: a systematic review

  • S. L. Brennan
  • J. A. Pasco
  • D. M. Urquhart
  • B. Oldenburg
  • Y. Wang
  • A. E. Wluka
Original Article



For most causes of mortality and morbidity, a socioeconomic gradient exists; however, this systematic review identified limited evidence for the role of education on bone mineral density (BMD). Further research is required to build upon the current paucity of data examining influences of socioeconomic status (SES) on BMD, especially in men.


For most causes of mortality and morbidity, a socioeconomic gradient exists, although little is understood of the relationship between BMD and SES. We systematically evaluated evidence of SES as a risk factor for low BMD at the clinically relevant sites of hip and spine in adults.


We conducted a computer-aided search of Medline, EMBASE, CINAHL, and PsychINFO from January 1, 1966 until December 31, 2008. Reviewed studies investigated the relationship between SES parameters of income, education, and occupation, and the level of BMD. Studies were rated based on their methodological quality, and a best-evidence synthesis was used to summarise the results.


One case-control and seven cross-sectional studies were identified for inclusion, of which four cross-sectional studies were high-quality. Best-evidence analysis identified consistent, yet limited, evidence for a positive association between educational attainment and BMD in women. No evidence was available regarding an association between income or occupation and BMD in either gender, or education and BMD in men.


Limited good quality evidence exists for the role that education level may play in BMD levels. Cohort studies are required to examine the relationship between individual SES parameters and BMD in order to identify potential intervention targets.


Bone density Hip Social disadvantage spine Socioeconomic factors Systematic review 



This study was funded by the National Health and Medical Research Council (NHMRC) of Australia. Ms. Brennan is supported by NHMRC PhD Scholarship (519404). Associate Professor Pasco and Dr. Wluka are the recipients of NHMRC Project Grant (436665). Dr. Urquhart was supported by a NHMRC Health Capacity Building Grant (546248) and a Monash Senior Research Fellowship. Dr. Wluka and Dr. Wang are the recipients of NHMRC Public Health (Australia) Fellowships (317840 and 465142).

Conflicts of interest



  1. 1.
    Wilkinson RG, Marmot M (1998) Social determinants of health: the solid facts. World Health Organisation, European Region, CopenhagenGoogle Scholar
  2. 2.
    Pincus T, Callahan LF, Burkhauser RV (1987) Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18–64 United States population. J Chronic Dis 40:865–874PubMedCrossRefGoogle Scholar
  3. 3.
    Mol GD, van de Lisdonk EH, Smits JPJM, van den Hoogen JMP, Bor JHJ, Westert GP (2005) A widening health gap in general practice? Socio-economic differences in morbidity between 1975 and 2000 in The Netherlands. Public Health 119:616–625PubMedCrossRefGoogle Scholar
  4. 4.
    World Health Organisation (2006) Summary of Proceedings. In Commission on the Social Determinants of Health: Fifth Meeting of the Commission on the Social Determinants of Health. Geneva: WHO, Nairobi Kenya.Google Scholar
  5. 5.
    Turrell G, L Stanley, M de Looper, B Oldenburg (2006) Health Inequalities in Australia: Morbidity, health behaviours, risk factors and health service use. In Canberra, Queensland University of Technology and the Australian Institute of Health and Welfare.Google Scholar
  6. 6.
    la Vecchia C, Negri E, Pagano R, Decarli A (1987) Education, prevalence of disease, and frequency of health care utilisation. The 1983 Italian National Health Survey. J Epidemiol Comm Health 41:161–165CrossRefGoogle Scholar
  7. 7.
    Australian Institute of Health and Welfare (2006) Australia’s Health 2006. AIHW, CanberraGoogle Scholar
  8. 8.
    Begg S, Vos T, Barker B, Stanley L, Lopez AD (2008) Burden of disease and injury in Australia in the new millennium: measuring health loss from diseases, injuries and risk factors. Med J Aust 188:36–40PubMedGoogle Scholar
  9. 9.
    Cummings S, Kelsey JL, Nevitt MC, O’Dowd KJ (1985) Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev 7:178–208PubMedGoogle Scholar
  10. 10.
    Pasco JA, Seeman E, Henry MJ, Merriman EN, Nicholson GC, Kotowicz MA (2006) The population burden of fractures originates in women with osteopenia, not osteoporosis. Osteoporos Int 17:1404–1409PubMedCrossRefGoogle Scholar
  11. 11.
    World Health Organisation (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. In WHO Tech Rep Series. WHO Study Group, pp 1–129.Google Scholar
  12. 12.
    Pasco JA, Sanders KM, Hoekstra FM, Henry MJ, Nicholson GC, Kotowicz MA (2005) The human cost of fracture. Osteoporos Int 16:2046–2052PubMedCrossRefGoogle Scholar
  13. 13.
    Cooper C (1997) The crippling consequences of fractures and their impact on quality of life. Am J Med 103:12S–17SPubMedCrossRefGoogle Scholar
  14. 14.
    Keene GS, Parker MJ, Pryor GA (1993) Mortality and morbidity after hip fractures. BMJ 307:1248–1250PubMedCrossRefGoogle Scholar
  15. 15.
    Galindo-Ciocon D, Ciocon JO, Galindo D (1995) Functional impairment among elderly women with osteoporotic vertebral fractures. Rehabil Nurs 20:79–83PubMedGoogle Scholar
  16. 16.
    Brennan SL, Pasco JA, Urquhart DM, Oldenburg B, Hanna FS, Wluka AE (2009) The association between socioeconomic status and osteoporotic fracture in population-based adults: a systematic review. Osteoporos Int 49:165–171Google Scholar
  17. 17.
    Demeter S, Leslie WD, Lix L, MacWilliam L, Finlayson GS, Reed M (2007) The effect of socioeconomic status on bone density testing in a public health-care system. Osteoporos Int 18:153–158PubMedCrossRefGoogle Scholar
  18. 18.
    Neuner J, Zhang X, Sparapani R, Laud PW, Nattinger AB (2007) Racial and socioeconomic disparities in bone density testing before and after hip fracture. J General Int Med 22:1239–1245CrossRefGoogle Scholar
  19. 19.
    Anastasopoulou C, Rude RK (2002) Bone mineral density screening: assessment of influence on prevention and treatment of osteoporosis. Endocrine Practice 8:199–201PubMedGoogle Scholar
  20. 20.
    Wang M, Dixon LB (2006) Socioeconomic influences on bone health in postmenopausal women: findings from NHANES III, 1988–1994. Osteoporos Int 17:91–98PubMedCrossRefGoogle Scholar
  21. 21.
    Brennan SL, Henry MJ, Wluka AE, Nicholson GC, Kotowicz MA, Williams JW, Pasco JA (2009) Bone mineral density in population-based adult women is associated with socioeconomic status. J Bone Miner Res 24:809–815PubMedCrossRefGoogle Scholar
  22. 22.
    Lievense A, Bierma-Zeinstra SMA, Vergahen AP, van Baar ME, Verhaar JAN, Koes BW (2002) Influence of obesity on the development of osteoarthritis of the hip: a systematic review. Rheumatol 41:1155–1162CrossRefGoogle Scholar
  23. 23.
    Lievense A, Bierma-Zeinstra SMA, Verhagen AP, Verhaar JAN, Koes BW (2001) Influence of work on the development of osteoarthritis of the hip: a systematic review. J Rheumatol 28:2520–2528PubMedGoogle Scholar
  24. 24.
    Brennan SL, Pasco JA, Urquhart DM, Oldenburg B, Hanna F, Wluka AE (2009) The association between urban or rural locality and hip fracture: a systematic review. J Epidemiol Comm Health Published Online First: 19 August 2009 (in press)Google Scholar
  25. 25.
    Akkus Z, Camdeviren H, Celik F, Gur A, Nas K (2005) Determination of osteoporosis risk factors using a mutiple logistic regression model in postmenopausal Turkish women. Saudi Med J 26:1351–1359PubMedGoogle Scholar
  26. 26.
    Varenna M, Binelli L, Zucchi F, Ghiringhelli D, Gallazzi M, Sinigaglia L (1999) Prevalence of osteoporosis by educational level in a cohort of postmenopausal women. Osteoporos Int 9:236–241PubMedCrossRefGoogle Scholar
  27. 27.
    Ho SC, Chen YM, Woo JLF (2005) Educational level and osteoporosis risk in postmenopausal Chinese women. Am J Epidemiol 161:680–690PubMedCrossRefGoogle Scholar
  28. 28.
    Bener A, Hammoudeh M, Zirie M (2007) Prevalence and predictors of osteoporosis and the impact of life style factors on bone mineral density. APLAR J Rheumatol 10:227–233CrossRefGoogle Scholar
  29. 29.
    Gur A, Sarac AJ, Nas K, Cevik R (2004) The relationship between educational level and bone mineral density in postmenopausal women. BMC family practice [electronic resource] 5:18%N 11.Google Scholar
  30. 30.
    Elliot JR, Gilchrist NL, Wells JE (1996) The effect of socioeconomic status on bone density in a male Caucasian population. Bone 18:371–373PubMedCrossRefGoogle Scholar
  31. 31.
    Del Rio BL, Romera Baures M, Pavia Segura J, Setoain Quinquer J, Serra Majem L, Garces Ruiz P, Lafuente Navarro C, Domenech Torne FM (1992) Bone mineral density in two different socio-economic population groups. Bone Miner 18:159–168CrossRefGoogle Scholar
  32. 32.
    Kondo T, Sakakibara H, Miyao M, Yamada S, Shirota T, Izuhara Y, Kumagai K (1995) Relationship of bone density with lifestyle and labor factors among middle-aged and elderly women in a rural community. Bulletin of the Physical Fitness Research Institute: 88:98–103.Google Scholar
  33. 33.
    Murillo-Uribe A, Carranza-Lira S, Martínez-Trejo NA, Santos-González JE (1999) Epidemiologic variables in postmenopausal women. Ginecol Obstet Mex 67:478–483PubMedGoogle Scholar
  34. 34.
    Australian Institute of Health and Welfare (2000) Australia’s Health 2000: the Seventh Biennial Health Report of the Australian Institute of Health and Welfare. AIHW, CanberraGoogle Scholar
  35. 35.
    WHO Commission on Social Determinants of Health (2008) Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the CSDH. World Health Organization, GenevaGoogle Scholar
  36. 36.
    Clark EM, Ness A, Tobias JH, ALSPAC Study Team (2005) Social position affects bone mass in childhood through opposing actions on height and weight. J Bone Miner Res 20:2082–2089PubMedCrossRefGoogle Scholar
  37. 37.
    Vidulich L, Norris SA, Cameron N, Pettifor JM (2007) Infant programming of bone size and bone mass in 10-year-old Black and White South African children. Paediatric Perinatal Epidemiol 21:354–362CrossRefGoogle Scholar
  38. 38.
    Nabulsi M, Mahfoud Z, Maalouf J, Arabi A, Fuleihan GEH (2008) Impact of maternal veiling during pregnancy and socioeconomic status on offspring’s musculoskeletal health. Osteoporos Int 19:295–302PubMedCrossRefGoogle Scholar
  39. 39.
    Jones G, Riley M, Dwyer T (2000) Breastfeeding in early life and bone mass in prepubertal children: a longitudinal study. Osteoporos Int 11:146–152PubMedCrossRefGoogle Scholar
  40. 40.
    Fehily AM, Coles RJ, Evans WD, Elwood PC (1992) Factors affecting bone density in young adults. Am J Clinical Nut 56:579–586Google Scholar
  41. 41.
    Bailey DA (1997) The Saskatchewan Pediatric Bone Mineral Accrual Study: bone mineral acquisition during the growing years. Int J Sports Med, Supplement 18:S191–S194CrossRefGoogle Scholar
  42. 42.
    Micklesfield LK, Levitt NS, Carstens MT, Dhansay MA, Norris SA, Lambert EV (2007) Early life and current determinants of bone in South African children of mixed ancestral origin. Ann Human Biol 34:647–655CrossRefGoogle Scholar
  43. 43.
    Moreno Villares JM, Galiano Segovia MJ (2007) Influence of nutrition and the social environment in the bone maturation of children [1]. Nutricion Hospitalaria 22:726–727PubMedGoogle Scholar
  44. 44.
    Oliver H, Jameson KA, Sayer AA, Cooper C, Dennison EM (2007) Growth in early life predicts bone strength in late adulthood: the Hertfordshire Cohort Study. Bone 41:400–405PubMedCrossRefGoogle Scholar
  45. 45.
    Pasco JA, Wark JD, Carlin JB, Ponsonby A-L, Vuillermin PJ, Morley R (2008) Maternal vitamin D in pregnancy may influence not only offspring bone mass but other aspects of musculoskeletal health and adiposity. Med Hypoth 71:266–269CrossRefGoogle Scholar
  46. 46.
    Morley R, Carlin JB, Pasco JA, Wark JD (2006) Maternal 25-hydroxyvitamin D and parathyroid hormone concentrations and offspring birth size. J Clin Endocrinol Metab 91:906–912PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2010

Authors and Affiliations

  • S. L. Brennan
    • 1
  • J. A. Pasco
    • 2
  • D. M. Urquhart
    • 1
  • B. Oldenburg
    • 1
  • Y. Wang
    • 1
  • A. E. Wluka
    • 1
  1. 1.Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, The Alfred HospitalMonash UniversityMelbourneAustralia
  2. 2.Department of Clinical and Biomedical Sciences: Barwon HealthThe University of MelbourneGeelongAustralia

Personalised recommendations