Osteoporosis International

, Volume 24, Issue 9, pp 2405–2412 | Cite as

Associations between adverse social position and bone mineral density in women aged 50 years or older: data from the Manitoba Bone Density Program

Original Article
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Abstract

Summary

We examined the independent contribution of income to low bone mineral density in women aged 50 years and older. A significant dose–response association was observed between low income and low (bone mineral density) BMD, which was not explained by clinical risk factors or osteoporotic treatment in the year prior.

Introduction

The association between social disadvantage and osteoporosis is attracting increased attention; however, little is known of the role played by income. We examined associations between income and bone mineral density (BMD) in 51,327 women aged ≥50 years from Manitoba, Canada.

Methods

Low BMD was defined as a T-score ≥2.5SD (femoral neck or minimum) measured by dual energy X-ray absorptiometry (DXA) 1996–2001. Mean household income was extracted from Canada Census 2006 public use files and categorized into quintiles. Age, weight and height were recorded at time of DXA. Parental hip fracture was self-reported. Diagnosed comorbidities, including osteoporotic fracture and rheumatoid arthritis, were ascertained from hospital records and physician billing claims. Chronic obstructive pulmonary disease was used as a proxy for smoking and alcohol abuse as a proxy for high alcohol intake. Corticosteroid use was obtained from the comprehensive provincial pharmacy system. Logistic regression was used to assess relationships between income (highest income quintile held as referent) and BMD, accounting for clinical risk factors.

Results

Compared to quintile 5, the adjusted odds ratio (OR) for low BMD at femoral neck for quintiles 1 through 4 were, respectively, OR1.41 (95 %CI 1.29–1.55), OR1.32 (95 %CI 1.20–1.45), OR1.19 (95 %CI 1.08–1.30) and OR1.10 (95 %CI 1.00–1.21). Similar associations were observed when further adjustment was made for osteoporotic drug treatment 12 months prior and when low BMD was defined by minimum T-score.

Conclusions

Lower income was associated with lower BMD, independent of clinical risk factors. Further work should examine whether lower income increases the likelihood of treatment qualification.

Keywords

Bone mineral density Disadvantage Income Osteoporosis Social determinants 
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Notes

Acknowledgments

The authors are indebted to Manitoba Health for the provision of data (HIPC file number 2012/2013-15). The results and conclusions are those of the authors, and no official endorsement by Manitoba Health is intended or should be inferred. This article has been reviewed and approved by the members of the Manitoba Bone Density Program Committee. SL Brennan is supported by a National Health and Medical Research Council (NHMRC) of Australia Early Career Fellowship (1012472) and a Dyason Fellowship 2012 from The University of Melbourne. LM Lix is supported by a Manitoba Research Chair.

Conflicts of interest

Sharon L Brennan has no disclosures. William D Leslie has served on advisory boards for Novartis, Amgen, Genzyme; received unrestricted research grants from Amgen; received speaker fees from Amgen. Lisa Lix has received an unrestricted research grant from Amgen.

Supplementary material

198_2013_2311_MOESM1_ESM.doc (76 kb)
ESM 1 (DOC 76 kb)

References

  1. 1.
    Wilkinson RG, Marmot MG (eds) (1998) Social determinants of health: the solid facts. WHO European Region, CopenhagenGoogle Scholar
  2. 2.
    Wilkinson R, Pickett K (2009) The spirit level: why more equal societies almost always do better. Allen Lane, London, UKGoogle Scholar
  3. 3.
    Meyer HE, Henriksen C, Falch JA, Pedersen JI, Tverdal A (1995) Risk factors for hip fracture in a high incidence area: a case-control study from Oslo, Norway. Osteoporos Int 5:239–246PubMedCrossRefGoogle Scholar
  4. 4.
    Bacon WE, Hadden WC (2000) Occurrence of hip fractures and socioeconomic position. J Aging Health 12:193–203PubMedCrossRefGoogle Scholar
  5. 5.
    Farahmand BY, Persson PG, Michaelsson K, Baron JA, Parker MG, Ljunghall S (2000) Socioeconomic status, marital status and hip fracture risk: a population-based case–control study. Osteoporos Int 11:803–808PubMedCrossRefGoogle Scholar
  6. 6.
    Brennan SL, Henry MJ, Kotowicz MA, Nicholson GC, Zhang Y, Pasco JA (2011) Incident hip fracture and social disadvantage in an Australian population aged 50 years or greater. Bone 48:607–610PubMedCrossRefGoogle Scholar
  7. 7.
    Jones S, Johansen A, Brennan J, Butler J, Lyons RA (2004) The effect of socioeconomic deprivation on fracture incidence in the United Kingdom. Osteoporos Int 15:520–524PubMedCrossRefGoogle Scholar
  8. 8.
    Zingmond DS, Soohoo NF, Silverman SL (2006) The role of socioeconomic status on hip fracture. Osteoporos Int 17:1562–1568PubMedCrossRefGoogle Scholar
  9. 9.
    Peel NM, McClure RJ, Hendrikz JK (2007) Psychosocial factors associated with fall-related hip fractures. Age Ageing 36:145–151PubMedCrossRefGoogle Scholar
  10. 10.
    Wilson R, Chase GA, Chrischilles EA, Wallace RB (2006) Hip Fracture Risk Among Community-Dwelling Elderly People in the United States: a prospective study of physical, cognitive and socioeconomic indicators. Amer J Public Health 96:1210–1218CrossRefGoogle Scholar
  11. 11.
    Johnell O, Borgstrom F, Jonsson B, Kanis J (2007) Latitude, socioeconomic prosperity, mobile phones and hip fracture risk. Osteoporos Int 18:333–337PubMedCrossRefGoogle Scholar
  12. 12.
    Leslie WD, Tsang JF, Caetano PA, Lix LM, Program MBD (2006) Effectiveness of bone density measurement for predicting osteoporotic fractures in clinical practice. J Clin Endocrinol Metab 92:77–81PubMedCrossRefGoogle Scholar
  13. 13.
    Brennan SL, Pasco JA, Urquhart DM, Oldenburg B, Wang Y, Wluka AE (2010) Association between socioeconomic status and bone mineral density in adults: a systematic review. Osteoporos Int 22(2):517–527PubMedCrossRefGoogle Scholar
  14. 14.
    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 and Mineral 18:159–168CrossRefGoogle Scholar
  15. 15.
    Kanis JA, Oden A, Johansson H, Borgstrom F, Strom O, McCloskey E (2009) FRAX and its applications to clinical practice. Bone 44:734–743PubMedCrossRefGoogle Scholar
  16. 16.
    Ball K, Mishra G, Crawford D (2002) Which aspects of socioeconomic status are related to obesity among men and women? Int J Obes 26:559–565CrossRefGoogle Scholar
  17. 17.
    Wang MC, Dixon LB (2006) Socioeconomic influences on bone health in postmenopausal women: Findings from NHANES III, 1988-1994. Osteoporos Int 17:91–98PubMedCrossRefGoogle Scholar
  18. 18.
    Brennan SL, Henry MJ, Nicholson GC, Kotowicz MA, Pasco JA (2009) Socioeconomic status and risk factors for obesity and metabolic disorders in a population-based sample of adult females. Prev Med 49:165–171PubMedCrossRefGoogle Scholar
  19. 19.
    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
  20. 20.
    Roos NP, Shapiro E (1999) Revisiting the Manitoba Centre for Health Policy and Evaluation and its population-based health information system. Med Care 37:JS10–JS14PubMedCrossRefGoogle Scholar
  21. 21.
    Roos NP (1999) Establishing a population data-based policy unit. Med Care 37(6 Suppl):JS15–JS26PubMedCrossRefGoogle Scholar
  22. 22.
    Leslie WD, Caetano PA, MacWilliam LR et al (2005) Construction and validation of a population-based bone densitometry database. J Clin Densitom 8:25–30PubMedCrossRefGoogle Scholar
  23. 23.
    Leslie WD, Metge C (2003) Establishing a regional bone density program: lessons from the Manitoba experience. J Clin Densitom 6:275–282PubMedCrossRefGoogle Scholar
  24. 24.
    (Accessed July 2011) www.gov.mb.ca/health/programs/mbd. In Government of Manitoba. Manitoba, Canada
  25. 25.
    Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis JA, Manitoba Bone Density Program (2010) Independent clinical validation of a Canadian FRAX tool: fracture prediction and model calibration. J Bone Miner Res 25:2350–2358PubMedCrossRefGoogle Scholar
  26. 26.
    Looker AC, Johnston CC Jr, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP, Lindsay R (1995) Prevalence of low femoral BMD in older US women from NHANES III. J Bone Miner Res 10:796–802PubMedCrossRefGoogle Scholar
  27. 27.
    Leslie WD, Derksen S, Metge C, Lix LM, Salamon EA, Steiman PW, Roos LL (2004) Fracture risk among First Nations people: a retrospective matched cohort study. CMAJ 171:869–873PubMedCrossRefGoogle Scholar
  28. 28.
    Leslie WD, Derksen SA, Metge C, Lix LM, Salamon EA, Steiman PW, Roos LL (2005) Demographic risk factors for fracture in First Nations people. Canadian J Public Health Revue Canadienne de Sante Publique 96(Suppl 1):S45–S50Google Scholar
  29. 29.
    Hamilton R, Briceland L (1992) Use of prescription-refill records to assess patient compliance. Am J Hosp Pharm 49:1691–1696PubMedGoogle Scholar
  30. 30.
    Starfield B, Weiner J, Mumford L et al (1991) Ambulatory care groups: a categorization of diagnoses for research and management. Heal Serv Res 26:53–74Google Scholar
  31. 31.
    Weiner JPSB, Steinwachs DM et al (1991) Development and application of a population-oriented measure of ambulatory care case-mix. Med Care 29:452–472PubMedCrossRefGoogle Scholar
  32. 32.
    Smith NS, Weiner JP (1994) Applying population-based case mix adjustment in managed care: the Johns Hopkins ambulatory care group system. Manag Care Q 2:21–34PubMedGoogle Scholar
  33. 33.
    Leslie WD, Derksen S, Prior HJ, Lix LM, Metge C, O’Neil J (2006) The interaction of ethnicity and chronic disease as risk factors for osteoporotic fractures: a comparison in Canadian Aboriginals and non-Aboriginals. Osteoporos Int 17:1358–1368PubMedCrossRefGoogle Scholar
  34. 34.
    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
  35. 35.
    Gur A, Sarac AJ, Nas K, Cevik R (2004) The relationship between educational level and bone mineral density in postmenopausal women. BMC family practice 5:18PubMedCrossRefGoogle Scholar
  36. 36.
    Koster A, Bosma H, Kempen GI, Penninx BW, Beekman AT, Deeg DJ, van Eijk JT (2006) Socioeconomic differences in incident depression in older adults: the role of psychosocial factors, physical health status, and behavioural factors. J Psychosom Res 61:619–627PubMedCrossRefGoogle Scholar
  37. 37.
    Everson SA, Maty SC, Lynch JW, Kaplan GA (2002) Epidemiologic evidence for the relation between socioeconomic status and depression, obesity, and diabetes. J Psychosom Res 53:891–895PubMedCrossRefGoogle Scholar
  38. 38.
    Williams LJ, Henry MJ, Berk M, Dodd S, Jacka FN, Kotowicz MA, Nicholson GC, Pasco JA (2008) Selective serotonin reuptake inhibitor use and bone mineral density in women with a history of depression. Int Clin Psychopharmacol 23:84–87PubMedCrossRefGoogle Scholar
  39. 39.
    Lauderdale DS, Salant T, Han KL, Tran PL (2001) Life-course predictors of ultrasonic heel measurement in a cross-sectional study of immigrant women from Southeast Asia. Amer J Epidemiol 153:581–586CrossRefGoogle Scholar
  40. 40.
    Alver K, Sogaard AJ, Falch JA, Meyer HE (2007) The Oslo Health Study: is bone mineral density higher in affluent areas? Int J Equity in Health 6. doi: 10.1186/1475-9276-1186-1119
  41. 41.
    Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. Brit Med J 312:1254–1259PubMedCrossRefGoogle Scholar
  42. 42.
    Kaastad TS, Meyer HE, Falch JA (1998) Incidence of hip fracture in Oslo, Norway: differences within the city. Bone 22:175–178PubMedCrossRefGoogle Scholar
  43. 43.
    Keleher H, MacDougall C, Murphy B (eds) (2008) Understanding health promotion. Oxford University Press, New YorkGoogle Scholar
  44. 44.
    Leslie WD (2012) Ethnic differences in bone mass—clinical implications. J Clin Endocrinol Metab 97(12):4329–4340PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2013

Authors and Affiliations

  1. 1.NorthWest Academic Centre, The University of MelbourneSunshine HospitalSt AlbansAustralia
  2. 2.Australian Institute for Musculoskeletal SciencesSt AlbansAustralia
  3. 3.School of Medicine, Deakin UniversityGeelongAustralia
  4. 4.Department of MedicineSt Boniface HospitalWinnipegCanada
  5. 5.Department of Community Health SciencesUniversity of ManitobaWinnipegCanada

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