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. Author manuscript; available in PMC: 2024 Sep 1.
Published in final edited form as: Am J Manag Care. 2024 Mar;30(3):140–144. doi: 10.37765/ajmc.2024.89515

Challenges of Fracture Risk Assessment in Asian and Black Women

Joan C Lo 1,2, Malini Chandra 1, Wei Yang 2,3, Nailah Thompson 2,4, Catherine Lee 1,2, Mohan Ramaswamy 2,5, Mehreen Khan 2,6, Amber Wheeler 2,7
PMCID: PMC11034894  NIHMSID: NIHMS1971803  PMID: 38457822

Abstract

OBJECTIVES:

Bone mineral density (BMD) and fracture risk calculators (e.g., FRAX) guide primary prevention care in postmenopausal women. BMD scores use non-Hispanic White (NHW) reference data for T-score classification, while FRAX incorporates BMD, clinical risk factors, and population differences when calculating risk. This study compares findings among Asian, Black, and NHW women undergoing osteoporosis screening in a US healthcare system.

STUDY DESIGN:

Retrospective cross-sectional study.

METHODS:

Asian, Black, and NHW women aged 65–75 years undergoing BMD testing (with no recent fracture, osteoporosis treatment, bone disorders, metastatic cancer, or kidney replacement therapy) were compared across the following measures: femoral neck BMD T-score (normal ≥ −1, osteoporosis ≤ −2.5); high FRAX 10-year hip fracture risk (FRAX-Hip ≥3%), FRAX risk factors, and diabetes status.

RESULTS:

Among 3,640 Asian women, 23.8% had osteoporosis and 8.7% had FRAX-Hip ≥3% (34.5% among those with osteoporosis). Among 11,711 NHW women, 12.3% had osteoporosis and 17.2% had FRAX-Hip ≥3% (84.8% among those with osteoporosis). Among 1,711 Black women, 68.1% had normal BMD, 4.1% had BMD-osteoporosis, and 1.8% had FRAX-Hip ≥3% (32.4% among those with osteoporosis). Fracture risk factors differed by group. Diabetes was twofold more prevalent in Black and Asian (35–36%) versus NHW (16%) women.

CONCLUSIONS:

A large subset of Asian women have discordant BMD and FRAX scores, presenting challenges in osteoporosis management. Furthermore, FN-BMD and especially FRAX identified few Black women at high fracture risk warranting treatment. Studies should examine whether fracture risk assessment can be optimized in understudied racial minority populations, particularly when findings are discordant.

Keywords: bone mineral density, Asian women, Black women, fracture risk, osteoporosis

INTRODUCTION

Osteoporosis screening by bone mineral density (BMD) testing is a quality metric for older women.1 The BMD T-score compares a woman’s BMD to peak BMD in a reference population, with guidelines recommending the young adult non-Hispanic White (NHW) female reference for all women.2 The BMD report can include FRAX (https://frax.shef.ac.uk/FRAX/), a calculator that incorporates age, race and ethnicity, clinical risk factors, and BMD to estimate ten-year probabilities of hip and major osteoporotic fracture. Primary prevention guidelines recommend pharmacologic therapy for postmenopausal women with BMD-defined osteoporosis and those with low bone mass and high FRAX score.3 To account for known racial and ethnic variation in fracture risk,4,5 the US FRAX includes calibration factors for Black, Asian, and Hispanic race and ethnicity (0.43–0.53) based on epidemiologic studies demonstrating their much lower incidence of hip fracture compared to NHW women.6 This approach reduces potential overestimation of fracture risk,4,5 especially relevant for populations with lower BMD but lower fracture risk.7

To date, our understanding of skeletal health and fracture risk in US racial minority populations remains limited.8 Few studies have examined clinical BMD and FRAX results that inform care for those with lower (Asian women) or higher (Black women) BMD than NHW women. As the fastest-growing US race group,9 Asian women comprise an increasing subset undergoing BMD assessment. Their lower (areal) BMD10,11 is attributable partly to smaller bone size, and studies consistently demonstrate lower hip fracture incidence among US Asian compared to NHW women.12,13 Black women comprise another understudied population, with higher BMD14,15 and lower hip fracture incidence12,13,16 than NHW women. Optimizing fracture prevention in non-White populations is essential for personalizing effective intervention strategies.

As the US population becomes increasingly diverse,9 identifying knowledge gaps in fracture prevention care relevant to real world populations is paramount. Using contemporary data from a Western US population of women undergoing routine osteoporosis screening at the age target of 65–75 years,1 femoral neck BMD and FRAX scores were examined to characterize the discordance in fracture risk-based scores among Asian, Black, and NHW women.

METHODS

Kaiser Permanente Northern California (KPNC) is a large integrated healthcare delivery system which has championed osteoporosis screening among older women for >20 years. This report examines Asian, Black and NHW women aged 65–75 years with ≥2 years KPNC membership and initial BMD testing (2016–2017) on a Hologic densitometer, without recent fracture, osteoporosis therapy, metastatic cancer, multiple myeloma, metabolic bone disorders, or kidney replacement therapy, as previously described.10 BMD for Asian and NHW women were reported in an larger study.10 The study was approved by the KPNC Institutional Review Board, with waiver of informed consent.

Self-reported race and ethnicity were determined from health record/administrative databases, concordant with race and ethnicity in BMD records. Height, weight, body mass index (BMI), femoral neck (FN)-BMD, FRAX 10-year probability of hip fracture (FRAX-Hip), and FRAX risk factors (prior fracture, parental hip fracture history, smoking, alcohol ≥3 units/day, rheumatoid arthritis, glucocorticoid therapy, and secondary osteoporosis conditions) were obtained from BMD data. Diabetes was defined by ≥2 outpatient or problem-list diagnoses or ≥1 diagnosis with diabetes pharmacotherapy within two years prior to BMD testing.

FN-BMD T-score using the Hologic NHANES III young adult NHW female BMD reference (mean 0.849, SD 0.111 g/cm2)17 was classified as normal (≥ −1.0), low bone mass or osteopenia (between −1 and −2.5), or osteoporosis (≤ −2.5).2,17 For Black women, non-Hispanic Black female reference (mean 0.951, SD 0.142 g/cm2)17 T-scores were also calculated, consistent with an earlier era.18

Groups were compared using Student’s t-test or Wilcoxon test and Chi-square or Fisher exact tests. Analyses were performed using SAS version 9.4 (Cary, NC).

RESULTS

The cohort comprised 3,640 Asian women, 1,711 Black women, and 11,711 NHW women aged 65–75 years. Compared to NHW women, Black women were slightly older and more likely to have higher body weight (mean +7 kg), obesity, rheumatoid arthritis, and currently smoke, but less likely to have prior fracture or parental hip fracture history (Table). Asian women had lower height (mean −7 cm)10 and body weight (mean −16 kg), and were less likely to smoke, have obesity, prior fracture, or parental hip fracture history compared to NHW women. Diabetes prevalence was >2-fold higher among Black (34.7%) and Asian (36.3%) women compared with NHW women (16.0%).

Table.

Characteristics of US Asian and Black women compared to non-Hispanic White (NHW) women undergoing osteoporosis screening by bone mineral density (BMD) testing at ages 65–75 years old

Asian Women
N = 3,640		 NHW Women
N = 11,711		 Black Women
N = 1,711
Age (years), mean ± SD 67.1 ± 2.7 a 67.1 ± 2.7 67.4 ± 2.9 a
Height (cm), mean ± SD 155.5 ± 5.7 a 162.8 ± 6.6 163.1 ± 6.6
Weight (kg), mean ± SD 61.7 ± 11.3 a 77.6 ± 18.2 84.7 ± 19.1 a
Body Mass Index (BMI, kg/m2), mean ± SD 25.5 ± 4.4 a 29.3 ± 6.7 31.8 ± 6.7 a
Obesity (BMI ≥30.0 kg/m2) 528 (14.5%) a 4641 (39.6%) 961 (56.2%) a
Diabetes Mellitus 1320 (36.3%) a 1879 (16.0%) 593 (34.7%) a
Current Smoking 62 (1.7%) a 683 (5.8%) 170 (9.9%) a
Alcohol Intake ≥3 units/day 7 (0.2%) a 175 (1.5%) 22 (1.3%)
Previous Fracture 198 (5.4%) a 1487 (12.7%) 134 (7.8%) a
Parental History of Hip Fracture 230 (6.3%) a 1538 (13.1%) 90 (5.3%) a
Rheumatoid Arthritis 64 (1.8%) a 156 (1.3%) 63 (3.7%) a
Glucocorticoid Therapy 35 (1.0%) a 388 (3.3%) 63 (3.7%)
Secondary Osteoporosis 191 (5.2%) a 743 (6.3%) 148 (8.6%) a
Femoral Neck BMD (g/cm2), mean ± SD 0.656 ± 0.109 a 0.705 ± 0.119 0.800 ± 0.141 a
Femoral Neck BMD T-score (standard NHW reference)
 Normal (T ≥ −1.0)
 Low Bone Mass/Osteopenia (−2.5 < T < −1.0)
 Osteoporosis (T ≤ −2.5)		 a
792 (21.8%)
1981 (54.4%)
867 (23.8%) a
4322 (36.9%)
5951 (50.8%)
1438 (12.3%)		 a
1165 (68.1%)
475 (27.8%)
71 (4.1%) a
Femoral Neck T-score, median (IQR) −1.8 (−2.4,−1.1) a −1.4 (−2.0,−0.7) −0.6 (−1.3,0.3) a
FRAX 10-year Risk of Hip Fracture (FRAX-Hip)
 <1%
 1% to <2%
 2% to <3%
 ≥3%		 a
1962 (53.9%)
997 (27.4%)
363 (10.0%)
318 (8.7%) a
5132 (43.8%)
3047 (26.0%)
1518 (13.0%)
2014 (17.2%)		 a
1528 (89.3%)
119 (7.0%)
34 (2.0%)
30 (1.8%) a
FRAX-Hip, median (IQR) 0.9 (0.4,1.6)% a 1.1 (0.5,2.3)% 0.2 (0.1,0.5)%a
Femoral neck T-score and FRAX-Hip by obesity status (BMI ≥30 kg/m2)
No Obesity FN Osteoporosis (T ≤ −2.5) 815 (26.2%) a 1231 (17.4%) 63 (8.4%) a
 Obesity FN Osteoporosis (T ≤ −2.5) 52 (9.8%) a 207 (4.5%) 8 (0.8%) a
No Obesity FRAX-Hip ≥3% 302 (9.7%) a 1644 (23.3%) 22 (2.9%) a
 Obesity FRAX-Hip ≥3% 16 (3.0%) a 370 (8.0%) 8 (0.8%) a
No Obesity Diabetes Mellitus 1023 (32.9%) a 600 (8.5%) 198 (26.4%) a
 Obesity Diabetes Mellitus 297 (56.3%) a 1279 (27.6%) 395 (41.1%) a
Femoral neck T-score and FRAX-Hip by diabetes mellitus status
No Diabetes FN Osteoporosis (T ≤ −2.5) 624 (26.9%) a 1304 (13.3%) 56 (5.0%) a
 Diabetes FN Osteoporosis (T ≤ −2.5) 243 (18.4%) a 134 (7.1%) 15 (2.5%) a
No Diabetes FRAX-Hip ≥3% 227 (9.8%) a 1797 (18.3%) 25 (2.2%) a
 Diabetes FRAX-Hip ≥3% 91 (6.9%) a 217 (11.5%) 5 (0.8%) a
No Diabetes Obesity (BMI ≥30.0 kg/m2) 231 (10.0%) a 3362 (34.2%) 566 (50.6%) a
 Diabetes Obesity (BMI ≥30.0 kg/m2) 297 (22.5%) a 1279 (68.1%) 395 (66.6%)
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a

p<0.05 compared to NHW women.

SD, standard deviation; IQR = interquartile range

FN-BMD T-scores were higher for Black women but lower for Asian versus NHW women (Table). T-score differences (median −0.4 units lower) for Asian women yielded 2-fold higher prevalence of FN-osteoporosis compared with NHW women (23.8% vs 12.3%), whereas T-score differences (median +0.8 units higher) for Black women yielded 3-fold lower prevalence of FN-osteoporosis (4.1% vs 12.3%). Between-group differences were partly attenuated with the young adult Black female reference for FN-BMD T-score in Black women (6.8% vs 12.3%). Only 1.8% of Black women had FRAX-Hip ≥3% (treatment threshold),3 whereas the proportion of Asian women with FRAX-Hip ≥3% (8.7%) was half that of NHW women (17.2%). Most Black women (89.3%) had FRAX-Hip <1% compared to 43.8% of NHW women, pointing to large differences in risk assignment by BMD and especially FRAX, compared to NHW women.

Since higher BMI is associated with higher BMD, and BMI differs by race, we compared findings by obesity status (BMI ≥30 kg/m2). In each race group, proportions with BMD-osteoporosis and high FRAX-Hip (≥3%) were lower for those with versus without obesity (p<0.01) and racial differences persisted regardless of weight status (Table). Women with diabetes were more likely to have obesity, higher BMD, and lower FRAX than women without diabetes (p<0.01).

The Figure compares FRAX-Hip score by FN-BMD T-score categories. Both Asian and Black women with T-score −2.0 to −2.4 had very low proportions with FRAX-Hip ≥3% (2.2% and 4.3%, respectively) compared to NHW women (29.7%). For T-score −2.5 to −3.0 (17.1% of Asian women, 9.4% of NHW women, and only 3.4% of Black women), the proportion with FRAX-Hip ≥3% remained much lower for Asian (14.6%) and Black (25.9%) versus NHW (80.2%) women. These findings reflect lower (calibrated) FRAX scores for Asian and Black women at every BMD level, yielding differences in BMD-osteoporosis and FRAX-risk assignment by race. Among all women with FN-BMD osteoporosis (T-score ≤ −2.5), 34.5%, 32.4%, and 84.8% of respective Asian, Black, and NHW women had FRAX-Hip ≥3%.

Figure.

Figure.

Open in a new tab

Femoral neck bone mineral density (BMD) T-score and FRAX 10-year risk of hip fracture by race among US non-Hispanic White (NHW), Asian, and Black women ages 65–75 years

DISCUSSION

Among Asian and Black women aged 65–75 years, there were large differences in BMD and FRAX compared with NHW women and expected within group discordance. While lower BMD in Asian women and higher BMD in Black women are well-established in epidemiologic studies7,10,11,14,16 and greater BMD-FRAX differences result from US FRAX calibration for these groups,5,6 our findings point to challenges in caring for diverse populations and the potential limitations of FRAX with respect to race. Two-thirds of Black women had normal FN-BMD, only 4.1% had BMD-osteoporosis, and even fewer (1.8%) had FRAX-Hip ≥3%. Hence, few Black women were identified with high fracture risk warranting treatment, even among those with relatively low BMD for this population. While low FRAX scores reflected higher BMD, higher BMI, FRAX risk factors, and FRAX calibration, the accuracy of FRAX in identifying Black women at high fracture risk remains understudied. In contrast, 12.3% of NHW women had BMD-osteoporosis and 17.2% had FRAX-Hip ≥3%, where the vast majority (85%) with BMD-osteoporosis had FRAX-Hip ≥3%. Finally, Asian women had twofold greater prevalence of BMD-osteoporosis (23.8%) but only 8.7% had FRAX-hip ≥3%, including one-third (34%) among those with BMD-osteoporosis. For Asian women, FRAX calibration helps account for lower hip fracture risk despite lower FN-BMD (expected discordance), but guidelines recommend treatment of BMD-osteoporosis in Asian women and do not address their smaller bone size which contributes to lower areal BMD and overestimation of osteoporosis.7,10,11

When counseling Asian women with BMD-osteoporosis, evidence-based guidance is necessary. Their lower areal BMD is balanced by lower (calibrated) FRAX scores reducing fracture risk overestimation. Hence, among Asian women aged 65–75 years with T-score −2.5 to −3.0, only 1 in 7 had FRAX-hip ≥3%, compared to 4 in 5 NHW women. Ethnic T-scores,3 although contrary to guideline recommendations,2 may reduce overestimation of osteoporosis among US Chinese women7,11 and increase osteoporosis prevalence among Black women. However, the US Asian population is heterogeneous and generational differences exist. In an earlier era, ethnic T-scores identified US Black women with relatively low BMD using a young adult US Black reference population.18

Use of race and ethnicity-based calibration factors is debated,4,5,19,20 especially for Black women who have higher BMD than NHW women14,15 and lower hip fracture incidence.12,13 Avoiding risk overestimation in populations with lower fracture incidence is necessary, but underestimation is a concern if higher BMD and other risk factors contribute to the lower observed fracture incidence used to derive calibration factors. A 2008 survey in the Southern US found that only 7% of Black women (versus 56% of White women) aged 65–74 years had FRAX-hip ≥3% using FRAX with BMI (no BMD).21 FRAX classified almost all Black women below the 3% treatment threshold until age 75, suggesting its low utility in identifying Black women under age 75 at high fracture risk.21 Among 3484 White and 1041 Black women in Alabama, Georgia, and Iowa with BMD testing, Black women were more likely to have normal BMD (44.7% vs 20.9%), less likely to have BMD-osteoporosis (11.6% vs 21.7%), and similar to our study, only 0.3% had high calculated fracture risk (vs 23.7% White women).22 Black women were also less likely to be on guideline-concordant therapy.22 Among Black adults with rheumatoid arthritis, FRAX risk stratified those age ≥70 years regardless of weight status, but not younger adults with obesity.23 In our study, only 1% of Black women aged 65–75 years with obesity had high FRAX score (or BMD-osteoporosis) indicating potential challenges in fracture risk assessment for this subset. Overall, two-thirds of Black women had normal FN-BMD where follow-up testing might not be indicated for another ten years. Furthermore, a majority among the 4.1% of Black women with BMD-osteoporosis had FRAX-Hip scores below treatment threshold; this larger discordance could potentially contribute to undertreatment despite low BMD. These findings are important to consider because despite higher BMD and lower fracture risk, Black women experience higher morbidity and mortality after major osteoporotic fracture.24,25

FRAX performance is also limited in populations with diabetes26 which affected one-third of Asian and Black women in our study. Findings from Manitoba, Canada demonstrate improved fracture risk prediction when diabetes is included as a rheumatoid arthritis risk-equivalent in FRAX prediction,26 supporting the need for similar studies in non-White populations.5,26,27 Women with diabetes have higher BMI (contributing to both higher BMD and lower FRAX scores) but high BMI can paradoxically contribute to limb fracture risk,13,28,29 highlighting the complexity of fracture risk estimation in adults with diabetes and obesity. More research is needed among ethnically diverse populations to optimize fracture risk prediction.8

Our study from California, a state with a high diversity index,9 is the first to examine BMD and FRAX among contemporary Black women in the Western US compared to NHW and Asian women in the same healthcare setting. We specifically chose age 65–75 years, to reflect age targets for the Healthcare Effectiveness Data and Information Set (HEDIS) Osteoporosis Screening in Older Women metric.1 While study limitations include the lack of fracture outcome data (to examine FRAX calibration and accuracy)8,19 and relevant biologic and social factors, these BMD and FRAX findings from real world practice underscore the need for more research. Importantly, we recognize the limitations of race, a social construct that often includes a range of cultural and social determinants of health and does not account for social and genetic heterogeneity within and among groups. Our study lacked information on nativity, ancestry, and African admixture.30 Nonetheless, awareness of clinical data from risk assessment tools and their potential impact on fracture prevention care in non-White populations is necessary.

In summary, these observations may inform efforts to optimize fracture risk assessment among diverse populations. Our findings are timely as future updates to FRAX are planned, including pooled analyses to support ethnicity-specific risk considerations.31 A deeper understanding of skeletal health among racial and ethnic minority populations will support health equity for all women at high risk for fracture.

TAKE AWAY POINTS:

Bone density, FRAX-defined hip fracture risk, and their relationship differ by race among 65–75-year-old US women screened for osteoporosis.

  • While 12% of non-Hispanic White women screened met osteoporosis criteria, 17% had high FRAX-defined hip fracture risk.

  • 24% of Asian women screened met osteoporosis criteria, but only 9% had high FRAX-defined fracture risk. FRAX accounts for lower fracture risk despite lower BMD.

  • Few Black women had osteoporosis (4%) and fewer still (2%) had high FRAX-defined fracture risk.

  • A greater proportion of non-Hispanic White women with osteoporosis had high FRAX-defined fracture risk (85%), compared with 34% of Asian and 32% of Black women.

ACKNOWLEDGEMENTS:

The authors would like to thank Uzoezi Ozomaro, MD for her insightful review and editorial suggestions during final manuscript revisions.

FUNDING SOURCE:

Research reported in this publication was supported by the Kaiser Permanente Northern California Community Health Program and the National Institute on Aging of the National Institutes of Health (R01AG069992). The content is solely the responsibility of the authors and does not represent the official viewpoints of Kaiser Permanente or the National Institutes of Health. The sponsors had no role in the study concept or design, subject or data acquisition, data analysis and interpretation, or manuscript preparation.

Footnotes

Publisher's Disclaimer: DISCLAIMER: This is the pre-publication version of a manuscript that has been accepted for publication in The American Journal of Managed Care (AJMC). This version does not include post-acceptance editing and formatting. The editors and publisher of AJMC are not responsible for the content or presentation of the prepublication version of the manuscript or any version that a third party derives from it. Readers who wish to access the definitive published version of this manuscript and any ancillary material related to it (e.g., correspondence, corrections, editorials, etc) should go to www.ajmc.com or to the print issue in which the article appears. Those who cite this manuscript should cite the published version, as it is the official version of record.

CONFLICTS OF INTEREST: Joan Lo, Malini Chandra, Wei Yang, Nailah Thompson, Catherine Lee, Mohan Ramaswamy, Mehreen Khan, and Amber Wheeler have no conflicts of interest to disclose.

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