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Socioeconomic influences on bone health in postmenopausal women: findings from NHANES III, 1988–1994

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Our objectives were (1) to examine the associations of education and income with bone health in non-Hispanic White, non-Hispanic Black and Mexican-American postmenopausal women, (2) to determine if any observed associations can be explained by behavioral factors such as calcium intake and physical activity and (3) to determine if government food assistance and education are associated with increased calcium intake among low-income women. Cross-sectional data were gathered by the Third National Health and Nutrition Examination Survey, 1988–1994 (NHANES III) using a stratified multistage probability design. Bone health was indicated by total hip bone mineral density (BMD, g/cm2). Multiple linear regression was used to evaluate the associations of education, income and behavioral factors with BMD. There were 2,905 postmenopausal women with acceptable DXA scans and complete relevant data selected from a nationally representative sample of the civilian non-institutionalized population aged 2 months and older. Education and income were positively associated with BMD in Black and White women, respectively, but not in Mexican-American women. When behavioral factors were included in the analyses, associations with education and income were eliminated. Instead, positive associations with estrogen use, calcium intake and physical activity, and a negative association with smoking, were noted in White women. Among low-income women, education was associated with increased calcium intake, while participation in the Food Stamp Program was associated with increased calcium intake in Black women. We conclude that education and/or income are positively associated with BMD among Black and White postmenopausal women, and that efforts to promote bone health among low-income women are warranted.

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  1. World Health Organization (2003) The burden of musculoskeletal conditions at the start of the new millennium. WHO Technical Report Series No. 919

  2. Consensus Development Conference (1993) Diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 94:646–649

    Article  PubMed  Google Scholar 

  3. Ray NF, Chan JK, Thamer M, Melton LJ III (1997) Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: Report from the National Osteoporosis Foundation. J Bone Miner Res 12:24–35

    Article  CAS  PubMed  ADS  MATH  Google Scholar 

  4. Melton LJ III (2003) Adverse outcomes of osteoporotic fractures in the general population. J Bone Miner Res 18:1139–1141

    Article  PubMed  Google Scholar 

  5. Nelson DA, Megyesi MS (2004) Sex and ethnic differences in bone architecture. Curr Osteoporos Rep 2:65–69

    PubMed  Google Scholar 

  6. Wilkinson RG, Marmot MG (eds) (1998) Social determinants of health: the solid facts. WHO European Region, Copenhagen

    Google Scholar 

  7. Winkleby MA, Kraemer HC, Ahn DK, Varady AN (1998) Ethnic and socioeconomic differences in cardiovascular disease risk factors: findings for women from the Third National Health and Nutrition Examination Survey, 1988–1994. JAMA 280:356–362

    Article  CAS  PubMed  Google Scholar 

  8. Sobal J, Stunkard AJ (1989) Socioeconomic status and obesity: a review of the literature. Psychol Bull 105:260–275

    Article  CAS  PubMed  Google Scholar 

  9. Farahmand BY, Persson PG, Michaelsson K et al (2000) Socioeconomic status, marital status and hip fracture risk: a population-based case-control study. Osteoporosis Int 11:803–808

    Article  CAS  Google Scholar 

  10. del Rio Barquero, L, Baures, MR, Segura, JP, Quinquer, JS, Majem, LS, Ruiz, PG, Navarro, CL, Torne, FMD (1992) Bone mineral density in two different socioeconomic population groups. Bone Miner 18:159–168

    Article  PubMed  Google Scholar 

  11. Elliot JR, Gilchrist NL, Wells JE (1996) The effect of socioeconomic status on bone density in a male Caucasian population. Bone 18:371–373

    Article  CAS  PubMed  Google Scholar 

  12. Pearson D, Taylor R, Masud T (2004) The relationship between social deprivation, osteoporosis, and falls. Osteoporos Int 15:132–138

    Article  PubMed  Google Scholar 

  13. Inanici-Ersoz F, Gokce-Kutsal Y, Oncel S, Eryavuz M, Peker O, Ok S (2002) A multicenter, case control study of risk factors for low tibial speed of sound among residents of urban areas in Turkey. Rheumatol Int 22:20–26

    Article  PubMed  Google Scholar 

  14. Gilsanz V, Gibbens DT, Roe TF, Carlson M, Senac MO, Boechat MI, Huang HK, Schulz EE, Libanatai CR, Cann CC (1988) Vertebral BMD in children: effect of puberty. Radiology 166:847–850

    CAS  PubMed  Google Scholar 

  15. Pollitzer WS, Anderson JJB (1989) Ethnic and genetic differences in bone mass: a review with a hereditary vs. environmental perspective. Am J Clin Nutr 50:1244–1259

    CAS  PubMed  Google Scholar 

  16. Khosla S, Atkinson E, Riggs BL (1996) Relationships between body composition and bone mass in women. J Bone Min Res 11:857–863

    CAS  Google Scholar 

  17. Heaney RP (1996) Nutrition and risk for osteoporosis. In: Marcus R, Feldman D, Kelsey JL (eds) Osteoporosis. Academic Press, New York, pp 483–510

  18. Mazess RB, Barden HS (1991) BMD in pre-menopausal women: effects of age, dietary intake, physical activity, smoking and birth-control pills. Am J Clin Nutr 53:132–142

    CAS  PubMed  Google Scholar 

  19. Subar AF, Heimendinger J, Patterson BH, Krebs-Smith SM, Pivonka E, Kessler R (1995) Fruit and vegetable intake in the United States: the baseline survey of the Five A Day for Better Health Program. Am J Health Promot 9:352–360

    CAS  PubMed  Google Scholar 

  20. Thompson B, Demark-Wahnefried W, Taylor G, McClelland JW, Stables G, Havas S, Feng Z, Topor M, Heimendinger J, Reynolds KD, Cohen N (1999) Baseline fruit and vegetable intake among adults in seven 5 a day study centers located in diverse geographic areas. J Am Diet Assoc 99:1241–1248

    Article  CAS  PubMed  Google Scholar 

  21. Leino M, Raitakari OT, Porkka KV, Taimela S, Viikari JS (1999) Associations of education with cardiovascular risk factors in young adults: the Cardiovascular Risk in Young Finns Study. Int J Epidemiol 28:667–675

    Article  CAS  PubMed  Google Scholar 

  22. Wadsworth ME (1997) Health inequalities in the life course perspective. Soc Sci Med 44:859–869

    Article  CAS  PubMed  Google Scholar 

  23. Wang MC, Crawford PB, Hudes M, Van Loan M, Siemering K, Bachrach LK (2003) Diet in midpuberty and sedentary activity in prepuberty predict peak bone mass. Am J Clin Nutr 77:495–503

    CAS  PubMed  Google Scholar 

  24. 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 U.S. women from NHANES III. J Bone Miner Res 10:796–802

    CAS  PubMed  Google Scholar 

  25. Looker AC, Orwoll ES, Johnston CC Jr, Lindsay RL, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP (1997) Prevalence of low femoral BMD in older U.S. adults from NHANES III. J Bone Miner Res 12:1761–1768

    Article  CAS  PubMed  Google Scholar 

  26. U.S. Department of Agriculture (2004) The Food Stamp program. (accessed 10 December 2004)

  27. U.S. Department of Health and Human Services. Administration on Aging (2004) The Elderly Nutrition Program. (accessed 10 December 2004)

  28. U.S. Department of Health and Human Services (1994) Plan and operation of the Third National Health and Nutrition Examination Survey, 1988–1994. Vital Health Statistics. DHHS publication PHS 94–1308, no. 32

  29. Wahner HW, Looker AC, Dunn WL, Hauser MF, Walters WC, Novak C (1994) Quality control of bone densitometry in a national health survey (NHANES III) using three mobile examination centers. J Bone Miner Res 9:951–960

    Article  CAS  PubMed  Google Scholar 

  30. United States Department of Health and Human Services (1996) NHANES III Manual and Reports. CD-ROM

  31. Lynch JW, Kaplan, GA, Shema, SJ (1997) Cumulative impact of sustained economic hardship on physical, cognitive, psychological, and social functioning. NEJM 337:1889–1895

    Article  CAS  PubMed  Google Scholar 

  32. Wilde P, Dagata E (2002) Food stamp participation by eligible older Americans remains low. Food Rev 25:25–29

    Google Scholar 

  33. Dixon LB, Sundquist J, Winkleby M (2000) Differences in energy, nutrient, and food intakes in a US sample of Mexican-American women and men: Findings from the Third National Health and Nutrition Examination Survey, 1988–1994. Am J Epidemiol 152:548–557

    Article  CAS  PubMed  Google Scholar 

  34. Shah BV, Barnewell BG, Bieler GS (1997) SUDAAN User’s Manual, Release 7.5. Research Triangle Institute, Research Triangle Park, NC

  35. Goldman N (2001) Social inequalities in health disentangling the underlying mechanisms. Ann N Y Acad Sci 954:118–139

    Article  CAS  PubMed  ADS  Google Scholar 

  36. Berkman LF (1984) Assessing the physical health effects of social networks and social support. Ann Rev Public Health 413–432

  37. James WP, Nelson M, Ralph A, Leather S (1997) Socioeconomic determinants of health. The contribution of nutrition to inequalities in health. BMJ 314:1545–1549

    CAS  PubMed  Google Scholar 

  38. Marmot M, Wilkinson RG (2001) Psychosocial and material pathways in the relation between income and health: a response to Lynch et al. BMJ 322:1233–1236

    Article  CAS  PubMed  Google Scholar 

  39. Lauderdale DA, 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. Am J Epidemiology 153:581–586

    Article  CAS  Google Scholar 

  40. Opotowsky AR, Bilezikian JP (2003) Racial differences in the effect of early milk consumption on peak and postmenopausal bone mineral density. J Bone Miner Res 18:1978–1988

    Article  PubMed  Google Scholar 

  41. Lantz PM, Lynch JW, House JS, Lepkowski JM, Mero RP, Musick MA, Williams DR (2001) Socioeconomic disparities in health change in a longitudinal study of US adults: the role of health-risk behaviors. Soc Sci Med 53:29–40

    Article  CAS  PubMed  Google Scholar 

  42. Levedahl JW, Oliveira V (1999) Dietary impacts of food assistance programs. In: Frazao E (ed) America’s eating habits. US Department of Agriculture, Economic Research Service, Washington, DC

  43. Gleason P, Rangarajan A, Olson C (2000) Dietary intake and dietary attitudes among food stamp participants and other low-income individuals. Mathematica Policy Research Inc, Princeton, NJ

  44. Arnold CG, Ladipo P, Nguyen CH, Nkinda-Chaiban P, Olson CM (2001) New concepts for nutrition education in an era of welfare reform. J Nutr Educ 33:341–346

    CAS  PubMed  Google Scholar 

  45. Laraia BA, Siega-Riz AM, Kaufman JS, Jones SJ (2004) Proximity of supermarkets is positively associated with diet quality index for pregnancy. Prev Med 39:869–875

    Article  PubMed  Google Scholar 

  46. Horowitz CR, Colson KA, Hebert PL, Lancaster K (2004) Barriers to buying healthy foods for people with diabetes: evidence of environmental disparities. Am J Public Health 94:1549–1554

    Article  PubMed  Google Scholar 

  47. Boslaugh SE, Luke DA, Brownson RC, Naleid KS, Kreuter MW (2004) Perceptions of neighborhood environment for physical activity: is it “who you are” or “Where you live”? J Urban Health 81:671–681

    PubMed  Google Scholar 

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We wish to thank Professor Zak Sabry for his insightful comments on drafts of this manuscript. This study was supported by The United States Department of Agriculture, Economic Research Service, under Agreement no. 43-3AEM-8-80052 with San Jose State University, CA.

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Correspondence to May-Choo Wang.

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Neither author has competing financial interests to declare.

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Wang, MC., Dixon, L.B. Socioeconomic influences on bone health in postmenopausal women: findings from NHANES III, 1988–1994. Osteoporos Int 17, 91–98 (2006).

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