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. 2025 Sep 15;15(10):10391–10402. doi: 10.21037/qims-2025-1790

Considerations on the lumbar spine bone mineral density cutpoint values for defining osteofrailia among older Chinese men

Yì Xiáng J Wáng 1,✉
PMCID: PMC12514713  PMID: 41081175

Osteoporosis is a systemic skeletal disease characterised by a reduction in bone mass and qualitative skeletal changes that cause an increase in bone fragility and a higher fracture (Fx) risk. The clinical significance of osteoporosis lies in the occurrence of fragility fractures (FFx), and the most relevant Fx site is the hip. Because hip FFx typically necessitates hospitalization, data on their incidence is more reliable than data on other types of Fx. Although bone mineral density (BMD) is recognized as a continuous risk factor for Fx (i.e., no natural Fx threshold exists), operational ranges for the T-score were initially proposed for epidemiological purposes. When the femoral neck (FN) is measured in adult Caucasian women, a cutpoint value of patient BMD of 2.5 standard deviation (SD) below the young adult mean BMD results in a prevalence of osteoporosis for those aged ≥50 years of about 16.2%, the same as the lifetime risk of hip FFx for Caucasian women. This definition is the cornerstone of densitometric osteoporosis classification epidemiologically.

Following the 1994 World Health Organization (WHO) definition, densitometric osteoporosis prevalence among a specific population should be in proportion to its relative osteoporotic Fx risk with Caucasian female data as reference (1). For men, we recently described that older men suffer from hip FFx at FN T-score approximately 0.6 higher than older women, thus we proposed a new category of low BMD status, osteofrailia, for older Caucasian men with T-score ≤−2.0 (T-score ≤−2.1 for older East Asian men) who are likely to suffer from hip FFx (2,3). For the FN T-score defined osteofrailia, initial analysis shows it is associated with these features (2): (I) epidemiologically, prevalence of osteofrailia in men would be similar to prevalence of osteoporosis in women; (II) hip FFx risk of osteofrailiac men is approximately half of that of osteoporotic women; (III) mean hip FFx T-score is approximately 0.5 lower than the FN osteofrailia cutpoint value, thus, FN osteofrailia cutpoint value is suitable for hip FFx risk screening. Literature analysis shows that, if a hip dual-energy X-ray absorptiometry (DXA) scan is regularly performed, approximately 70% of the hip FFx incidents can be predicted for older women and men (3). However, compared with that of women, men’s hip FFx is still less predictable with studies reporting larger SDs for men’s mean hip FFx T-score (2). That osteofrailia classification is tied to the FFx prevalence of the population is relevant so that, an osteofrailia diagnosis among different populations can have the same meaning thus allowing international comparison. For example, a FN osteofrailiac Chinese man in China has the same risk of hip FFx in itself as a FN osteofrailiac Caucasian man in the USA.

While we established the FN T-score cutpoint value for defining osteofrailia among older men with strong evidence (2), the lumbar spine (LS) T-score for defining osteofrailia among older men has not been studied. Note that, while the LS quantitative computed tomography (QCT) BMD cutpoint value for defining osteoporosis among Chinese women (i.e., 50 mg/mL) is likely suitable for FFx risk screening purpose (4,5), the QCT BMD cutpoint value for defining osteoporosis among Chinese men (i.e., also 50 mg/mL) was defined mainly with epidemiology concept (6), and not suitable for the purpose of FFx risk screening. In this letter, we propose LS T-score and QCT cutpoint values for defining osteofrailia among older Chinese men, which may also serve the purpose for screening FFx risk. An optimal osteoporosis BMD screen threshold for women and osteofrailia BMD screen threshold for men will be particularly useful for case-finding of FFx high risk subjects at an ‘earlier’ age.

If osteofrailia LS T-score criterion is ≤−2.5, then LS osteofrailia prevalence is approximately similar to the LS osteoporosis prevalence for Chinese women

The osteoporosis prevalence for Chinese women is approximately half of that of Caucasian women (7-9). When LS T-score of ≤−3.7 is used to define osteoporosis, osteoporosis prevalence for Hong Kong Chinese women is around 8% (8). Note that, vertebral FFx among East Asian women is no more than half of those of Caucasian women (10,11). From the epidemiological point of view, LS DXA T-score criterion for defining osteoporosis among older Chinese men has been proposed to ≤−3.2 (8). Since the FN osteoporosis T-score cutpoint is 0.6 lower than the osteofrailia FN T-score cutpoint (i.e., −2.7 vs. −2.1), we can tentatively suggest osteofrailia LS T-score cutpoint to be ≤−2.5 (3). When LS osteofrailia T-score criterion is ≤−2.5 among older Chinese men, the LS osteofrailia prevalence is 8.27%, which is approximately similar to the LS densitometric osteoporosis prevalence for Chinese women [Tab. 2 in (8)]. Therefore, from the epidemiological point of view, LS T-score criterion osteofrailia of ≤−2.5 is appropriate for Chinese men.

For Chinese men, LS T-score of ≤−2.5 better predicts hip FFx risk than other LS T-score values

We have shown that, for older Chinese males, osteofrailia FN T-score cutpoint (i.e., −2.1 rather than −2.5 or −2.7) appears to be a natural turning point for higher hip FFx risk (Figure 1) (3). With our osteoporotic fractures in men (MrOS) Hong Kong study, the study subjects (n=2,000 at baseline) had a baseline mean age of 72.3 years (range, 65–92 years). They were followed up for 9.9±2.8 years, and 63 hip FFx were recorded. Positive predictive value was the percentage hip Fx cases (during the follow-up) out of the total tested positive cases at baseline by a metric; detection sensitivity was the percentage tested positive cases at baseline by a metric out of the total hip Fx cases (during the follow-up). If LS DXA T-score criterion for defining osteofrailia among older Chinese men is to be −2.5, the associated positive predictive value was 8.85% (17/192) and the detection sensitivity was 27.0% (17/63); if it is to be ≤−2.2, then associated positive predictive value was 6.86% (19/277) and the detection sensitivity was 30.2% (19/63). Thus, LS DXA T-score ≤−2.5 is favored over ≤−2.2 (3).

Figure 1.

Figure 1

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Hip FFx prevalence (Y-axis) among older Chinese men associated with various groupings (A,B) of baseline FN T-score (blue dots). Data are from MrOS Hong Kong study follow-up results for males (n=1,260 cases with FN T-score <−1). X-axis is the mean age for each FN T-score grouping. In an observational manner, male participants were followed up for a total of 9.9±2.8 years, and 63 hip FFx (mean fracture age: 82.5±5.7 years) were recorded (dropouts have not been adjusted in these two graphs). The data show that when baseline FN T-score was higher than −2.1, then hip FFx prevalence was ‘low’ during the follow-up period. After the baseline FN T-score was lower than −2.1, hip FFx prevalence increased substantially. After the FN T-score was lower than −2.7, hip FFx prevalence increased further but only relatively slightly. Note that FN T-score ≤−2.1 predicted 46.0% (29/63) of hip FFx cases, while FN T-score ≤−2.7 predicted only 15.9% (10/63) of hip FFx cases (2). FFx, fragility fracture; FN, femoral neck; MrOS, osteoporotic fractures in men.

Hereby in this letter, we conduct another test to see which LS T-score cutpoint value will predict hip Fx best for 5 years’ hip FFx risk, being ≤−2.7, ≤−2.5 or ≤−2.3. In total 23 hip FFx were observed for MrOS Hong Kong study 5 years’ follow-up. Figure 2 shows that LS T-score of ≤−2.5 is the favored cutpoint value for hip FFx prediction, over the cutpoint value of ≤−2.7 or ≤−2.3.

Figure 2.

Figure 2

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Positive predicative value (A) and detection sensitivity (B) for hip Fx during 5 years’ follow-up. (7/132) for ‘spine T-2.7’ means: out of the total 1,951 subjects follow-up for 5 years, 132 subjects had baseline LS T-score ≤−2.7, and of them 7 cased developed hip Fx during the follow-up. (10/23) for ‘spine T-2.3’ means: out of the 23 subjects who developed hip Fx during the follow-up, 10 of them had baseline LS T-score ≤−2.3. (A) LS T-score ≤−2.3 is disfavored; (B) LS T-score ≤−2.7 is disfavored. The results suggest LS T-score being ≤−2.5 a good compromise. √, favored. Fx, fracture; LS, lumbar spine.

If LS DXA criterion for osteofrailia is ≤−2.5 for Chinese men, then LS QCT cutpoint value is <67.6 mg/mL

With the Hong Kong local BMD reference for males, we recommend the LS DXA BMD cutpoint value for classifying osteofrailia in Chinese men to be 0.715 g/cm2 (i.e., T-sore of −2.5, Hologic densitometer) (8,9). A correlation analysis was conducted with the data of 328 cases of Chinese men (age: 73.6±4.4 years) who had LS QCT and DXA BMD at the same time. The data are from the MrOS Hong Kong study year-2 follow-up conducted during the period of September 2003 to March 2005. The result is shown in Figure 3A. Figure 3A shows the LS QCT BMD threshold for classifying osteofrailia is approximately 68 mg/mL. This is approximately in agreement with other studies such as the mixed-sex cohort study of Chen et al. (Figure 3B) (12).

Figure 3.

Figure 3

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Correlation analyses of LS BMD measured by QCT and by DXA. (A) Three hundred and twenty-eight Chinese men (age: 73.6±4.4 years) who had LS (L1 and L2) QCT BMD and LS DXA BMD measured at the same time. The data are from MrOS Hong Kong year-2 follow-up study. The DXA BMD cutpoint value to define osteofrailia is 0.715 g/cm2 (T-score of −2.5, Hologic densitometer) (8), and the corresponding QCT BMD is 67.6 mg/mL. (B) Results of mixed-sex 48 primary hyperparathyroidism patients (age: 53.77±11.04 years) reported by Chen et al. (12). The blue dotted crosses show the relationship between DXA measure and QCT measure in (B) is approximately similar to that in (A). BMD, bone mineral density; DXA, dual-energy X-ray absorptiometry; LS, lumbar spine; MrOS, osteoporotic fractures in men; QCT, quantitative computed tomography.

Around 78 years old, with the cutpoint LS QCT BMD of <68 mg/mL, half of the Chinese men are osteofrailiac

It has been consistently shown that, at 78 years old, the mean LS QCT BMD is around 80 mg/mL for Caucasian women (13-18). Thus, considering LS QCT BMD is <80 mg/mL for defining osteoporosis, at 78 years old, half of the Caucasian women are densitometrically osteoporotic. It has been consistently shown that, at 78 years old, the mean LS QCT BMD is around 50 mg/mL for East Asian women (5,19-23), and the mean LS DXA T-score is −3.7 for Chinese women (24). At such an age, half of the Chinese women are also densitometrically osteoporotic.

Figure 4 shows, at the age of around 78 years old, Chinese males have a LS QCT BMD of approximately 18.7 mg/mL higher than the females. Thus, as at 78 years old, if the mean LS QCT BMD cutpoint value is <68 mg/mL (i.e., approximately =50+18.7 mg/mL), half of the Chinese men are osteofrailiac.

Figure 4.

Figure 4

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Difference in male subjects’ LS QCT BMD and female subjects LS QCT BMD (M vs. F diff) at the age of approximately 78 years. Data is based on a random selection of literature. Green dots for Caucasian data and red dots for East Asian data (including Thais). Data are from Compston et al. (15), Karantanas et al. (17), Fujii et al. (20), Hoonpongsimanon et al. (23), Richardson et al. (25), Cann et al. (26), Dinç et al. (27), Jahng et al. (28), Jiang et al. (29), Tian et al. (30), Liu et al. (31). Median Cauc means the median value of the five Caucasian reports is 20 mg/mL. Median Asia means the median value of the six East Asian reports is 18.7 mg/mL. ‘Fitted’ mean the value is derived from curve fitting rather than directly measured data. Jahng et al. (28) reported results of subjects with radiographic spine Fx (Fx) and subjects without radiographic spine Fx (no Fx). BMD, bone mineral density; Fx, fracture; LS, lumbar spine; QCT, quantitative computed tomography.

If LS QCT BMD cutpoint value is <68 mg/mL for Chinese men, the detection sensitivity for vertebral FFx is 77%, being consistent with the detection sensitivity for vertebral FFx in Caucasian women (32)

When the LS QCT BMD of <80 mg/mL was proposed as the threshold for defining osteoporosis, this value was shown to be associated with around 77% vertebral FFx detection sensitivity for Caucasian women (32). In our MrOS Hong Kong study for men, we have noted that 7.9%, 4.5% of the subjects had OLVFss ≤−2.5, and ≤−3 respectively (33), therefore, in epidemiological sense, OLVFss ≤−2.5 and OLVFss ≤−3 can be considered as the cutpoint value for osteofrailia and osteoporosis in Chinese men, respectively. Hereby in this letter, we further show that, male subjects with OLVFss ≤−2.5 and OLVFss ≤−3 are associated with distinctly lower LS QCT BMD (Figure 5A). LS QCT BMD being < 68 mg/mL offers a detection sensitivity for vertebral FFx of 77% [area under the receiver operating characteristic curve (AUROC) of 78.9%] (Figure 5B,5C). This is consistent with LS QCT BMD <80 mg/mL offers a detection sensitivity for vertebral FFx of around 77% for Caucasian women (32) (Figure 6).

Figure 5.

Figure 5

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Relationship between OLVFss and LS QCT BMD. The QCT data are from MrOS Hong Kong year-2 follow-up study with 324 Chinese men. These subjects (n=324, mean age: 73.6 years) had QCT LS (L1 and L2) BMD measured. At year-2 follow-up study no spine radiograph was taken, thus randomly, half of the radiographs read were from baseline study, and the other half of the radiographs read were from the year-4 follow-up study. (A) shows study subjects with OLVFss ≤−3.0 and OLVFss being 2.5 have distinctly lower BMD than other OLVFss groups, suggesting the reasonableness of only considering OLVFss ≤−2.5 as being with osteofrailia or osteoporosis. (B) LS QCT BMD of subjects with FFx (OLVFss ≤−2.5, median BMD: 64.35 mg/mL) and subject without FFx (OLVFss >−2.5, median BMD: 95.93 mg/mL). These results are approximately consistent with the data of Mao et al. (34) [mean QCT of 57.22 mg/mL for FFx group males (mean age: 77.5 years), mean QCT of 99.29 mg/mL for non-FFx group males (mean age: 77.5 years)]. (C) AUROC of 78% for data in (B). For the calculation of OLVFss using spine radiograph, vertebrae L3 to L5 are evaluated with an eSQ scheme with the following criteria (35,36): (I) minimal grade refers to radiographical VF deformity with <20% height loss, which would be theoretically equivalent to Genant SQ grade 0.5; (II) mild grade VF is the same as Genant mild grade (≥20–25% height loss); (III) Genant moderate grade VF is divided into two subgrades: ≥25%–1/3 height loss (moderate grade) and ≥1/3–40% height loss (moderately-severe grade); (IV) Genant severe grade VF is divided into two subgrades: ≥40%–2/3 height loss (markedly-severe grade) and with ≥2/3 height loss (collapsed grade). The term ‘OLVF’ is used, as only based on spine radiograph it is not possible to absolutely diagnose a vertebral deformity as osteoporotic Fx in every case. For each vertebra in a subject, a score of 0, −0.5, −1, −1.5, −2, −2.5, and −3 is assigned for no OLVF or OLVF of <20%, ≥20–25%, ≥25%–1/3, ≥1/3–40%, ≥40%–2/3, and ≥2/3 vertebral height loss, respectively. An OLVFss is calculated by summing up the scores of vertebrae T3 to L5. Two adjacent minimal OLVF are assigned as −0.5, and three adjacent minimal OLVF are assigned to be −1. A minimal grade OLVF adjacent to a more severe grade OVLF is commonly ignored for this minimal grade. For example, if T2 of −0.5 grade and L1 of −2.0 grade are seen, the total score for the T12 and L1 is only recorded as −2.0 (rather than −2.5). AUROC, area under the receiver operating characteristic curve; BMD, bone mineral density; eSQ, extended version of semi-quantitative; FFx, fragility fracture; Fx, fracture; LS, lumbar spine; MrOS, osteoporotic fractures in men; OLVF, osteoporotic-like vertebral fractural deformity; OLVFss, osteoporotic-like vertebral fractural deformity sum score; QCT, quantitative computed tomography; SQ, semi-quantitative; VF, vertebral fractural.

Figure 6.

Figure 6

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A comparison of LS QCT BMD thresholds (dotted blue line) to separate subjects with and without spine Fx. (A) Osteofrailia threshold (68 mg/mL) for Hong Kong males. (B) Osteoporosis threshold (50 mg/mL) for Japanese females (21). (C) Osteoporosis threshold (80 mg/mL) for USA females (13,21). (D) Osteoporosis threshold (80 mg/mL) for UK females (37). It is noted that (A-D) show a similar pattern for the osteofrailia or osteoporosis thresholds to separate the group with Fx and the group without Fx. Data are presented with mean ± standard deviation. (A) MrOS Hong Kong study data; (B) data from Ito et al. (21); (C) data from Block et al. (13), recited from Ito et al. (21); (D) data from Paggiosi et al. (37). BMD, bone mineral density; Fx, fracture; LS, lumbar spine; MrOS, osteoporotic fractures in men; QCT, quantitative computed tomography.

Li et al. (38) reported 758 cases of symptomatic vertebral FFx, with a LS DXA T-score of −2.61±0.92. Thus, the LS osteofrailia T-score cutpoint value of −2.5 is applicable to the results of Li et al. (note that, some of their patients might not have genuine clinical vertebral FFx, if we could only count those with genuine clinical vertebral FFx, then their mean LS T-score might be lower than −2.61).

Osteoporosis and osteofrailia cutpoint values for Chinese females and males: DXA, QCT, and OLVFss

Considering all the discussions above, DXA, QCT, and OLVFss osteoporosis and osteofrailia cutpoint values for Chinese females and males are summarized in Table 1.

Table 1. Cutpoint values for older Chinese women and men: DXA, QCT, and OLVFss.

Variables Women’ value Relevance for women Men’s value Relevance for men
Osteoporosis
   FN osteoporosis—DXA T-score ≤−2.7a,‡ Epidemiology & screening ≤−2.7b,‡ Epidemiology
   LS osteoporosis—DXA T-score ≤−3.7c,‡ Epidemiology & screening ≤−3.2d,‡ Epidemiology
   LS osteoporosis—QCT BMD <50 mg/mLe Epidemiology & screening <50 mg/mLf Epidemiology
   LS osteoporosis—OLVFss ≤−1.5g Epidemiology & screening ≤−3h Epidemiology
Osteofrailia
   FN osteofrailia—DXA T-score – – ≤−2.1i,‡ Screening
   LS osteofrailia—DXA T-score – – ≤−2.5† Screening
   LS osteofrailia—QCT BMD – – <68 mg/mL† Screening
   LS osteofrailia—OLVFss – – ≤−2.5j Screening
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a, mainly based on FFx prevalence of Chinese women is no more than half of that of Caucasian women (8); Chinese women suffer from hip FFx at a lower FN T-score than Caucasian women (39). In one study, when spine OLVFss was −2.5, mean FN-score was −2.60 for Italian women and −2.77 for Chinese women (40). b, mainly based on FFx prevalence of Chinese men is approximately half of that of Chinese women (8), and Chinese men suffer from hip FFx at a lower FN T-score than Caucasian men (39). c, mainly based on FFx prevalence of Chinese women is no more than half of that of Caucasian women (8); at the age of 78 years, US women have a mean LS T-score of −2.5 while Chinese women have a mean LS T-score of −3.7 (24). In one study, when spine OLVFss was −2.5, mean LS T-score was −2.44 for Italian women and −3.75 for Chinese women (40). When FN T-score is −2.7 for Japanese women, the corresponding LS T-score is −3.7 (9,41). d, mainly based on FFx prevalence of Chinese men is approximately half of that of Chinese women (8). In one study, for Chinese men, a mean OLVFss value of −3 corresponded to a mean FN T-score and a mean LS T-score of −2.77 and −3.37, and an OLVFss of −2.5 corresponded to a mean FN T-score of −2.49 and a mean LS T-score of −2.93, respectively (33). e, LS QCT BMD of 50 mg/mL among East Asian women is equivalent to 80 mg/mL among Caucasian women, in epidemiology and in sensitivity with vertebral FFx prediction (4,5). f, LS QCT BMD of 50 mg/mL among Chinese men is mainly based on it is to equivalent to LS T-score of −3.2 among Chinese men, and the osteoporosis prevalence of Chinese men (6). g, mainly based on epidemiology (40); OLVFss ≤−1.5 is uncommon among healthy Chinese women (42), but OLVFss ≤−1 is not uncommon among healthy Chinese women (42). h, OLVFss ≤−3.0 is associated with FFx BMD features (Figure 2) (43,44) and leads to a prevalence of 4.5% (i.e., osteoporosis prevalence) (8,33). i, hip FFx in men on average occur at FN T-score 0.6 higher than that in women (2), FN T-score of −2.1 is a natural turning point for higher hip FFx risk (3). j, OLVFss ≤−2.5 is associated with FFx BMD features (Figure 2) (43,44), and leads to a prevalence of 7.9% (i.e., osteofrailia prevalence) (8,33). †, evidence listed in the current letter. ‡, values listed in AJR Expert Panel Narrative Review (45). BMD, bone mineral density; DXA, dual-energy X-ray absorptiometry; FFx, fragility fracture; FN, femoral neck; LS, lumbar spine; OLVFss, osteoporotic-like vertebral fractural deformity sum score; QCT, quantitative computed tomography.

Tentative considerations on LS osteofrailia cutpoint value for Caucasian men

It has been noted that Caucasian men suffer from FFx at higher FN DXA BMD/T-score and higher LS DXA BMD/T-score than women (2,46-48). In Figure 7 (49-64), we re-used the systematic literature research results described in several studies (2,39). Figure 7 shows, though with limited evidence, hip Fx occur at approximately 0.5 LS T-score higher in men (median value: −1.40) than in women (median value: −1.89). Therefore, the same as the definition of FN osteofrailia, it will be meaningful to define a LS osteofrailia T-score cutpoint value of ≤−2.0. According to the description by Faulkner and Orwoll (65), LS T-score ≤−2.0 defines 11% of the USA male population over 50 years which suggests the reasonableness of this cutpoint value for LS osteofrailia (note that, due to degenerative changes of the spine, LS BMD underestimates osteofrailia/osteoporosis prevalence among elderly subjects). It can also be seen that, on average hip Fx occur at 0.6 T-score higher than the osteoporosis LS cutpoint value (i.e., −2.5) for women, and 0.6 higher than the osteofrailia LS cutpoint value (i.e., −2.0) for men (Figure 7), suggesting the difficulty for LS BMD to predict hip Fx.

Figure 7.

Figure 7

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Males suffer from FFx at a higher LS T-score than females (older Caucasian results). Females suffer from a FFx at median T-score higher than the osteoporosis threshold (i.e., LS T-score of −2.5) and males suffer from FFx at a median T-score higher than the tentative osteofrailia threshold (i.e., LS T-score of −2.0). F: females; M: males. F&M1: a mixture of males and females. F1: Wilson et al. (49) (n=68), Yeo et al. (50) (n=91), Schnabel et al. (51) (n=22), Olszewski et al. (52) (n=37). F&M1: Amar et al. (53) (n=314), Heetveld et al. (54) (n=111), Valentini et al. (55) (n=107). M1: Wilson et al. (n=11), Yeo et al. (n=21), Cesme et al. (56) (n=20), Olszewski et al. (n=9). For F1, F&M1, and M1, results were of DXA T-score measured at the timepoint of a hip FFx. All included Caucasian data were from Europe or Turkey. F2: Wong et al. (57) (n=47), M2: Wong et al. (n=16). For F2 and M2 (an Australian study, assumed majority of the study subjects being Caucasians), results were of DXA T-score measured within 12 months of the Fx incident. The data of F2 and M2 are patients with low energy trauma fracture. Low energy traumas are not necessarily osteoporotic Fx. Low energy traumas of the humerus, distal forearm, and spine also commonly occur among young subjects with normal bone strength (42, 58-64). Therefore, the F2 and M2 values are higher than the F1 and M2 values. Note that, the median value of the F1&M1 group lies between those of F1 group and M1 group. BMD, bone mineral density; DXA, dual-energy X-ray absorptiometry; FFx, fragility fracture; Fx, fracture; LS, lumbar spine.

At 78 years old, the mean LS QCT BMD is around 80 mg/mL for Caucasian women, and the mean LS DXA T-score is −2.5; thus, at this age half of the Caucasian women are densitometrically osteoporotic (4,5,24). If we want Caucasian men with osteofrailia to have a similar prevalence as the prevalence of Caucasian women with osteoporosis, then LS QCT BMD being around 100 mg/mL can be the cutpoint value for osteofrailia of Caucasian men (corresponding to 69 mg/mL for Chinese men). At 78 years old, the mean LS QCT BMD is around 100 mg/mL (see Figure 4), thus, half of the Caucasian men would be osteofrailiac.

Limited evidence suggests that this LS QCT BMD osteofrailia cutpoint of 100 mg/mL might be reasonable. In a study based on USA, Odvina et al. (46) reported that vertebral FFx threshold was approximately 25 mg/mL higher for men than for women. In an USA study, Mackey et al. (66) reported LS QCT BMD was 120±40 mg/mL for Caucasian men (mean age: 74.0±2.9 years) and 100±30 mg/mL (age: 73.4±2.6 years) for Caucasian women. For the MrOS USA study, Chalhoub et al. (67) described the baseline demographic information, and the LS QCT BMD was 110±40 mg/mL for older men (mean age: 73.5±5.9 years, 87.7% Caucasians). For a study of British Caucasian men with distal forearm FFx (48), LS QCT BMD was 98.43±26.48 mg/mL for patients with FFx, and 113.60±28.99 for controls without FFx. Kopperdahl et al. (47) described a study with Icelandic females and males. For subjects without incident vertebral FFx during 5 years’ follow-up, the baseline LS QCT BMD was 82.0±32.8 mg/mL for females (mean age: 74.3 years) and 91.6±32.7 for males (mean age: 74.8 years). For subjects with Genant grade-2 and grade-3 incident vertebral FFx during 5 years’ follow-up, the baseline LS QCT BMD was 55.8±22.6 mg/mL for females (mean age: 76.7 years) and 79.0±38.9 for males (mean age: 76.5 years).

There are many limitations for the analyses described in the letter. The arguments are heavily dependent on the initial definition that the LS T-score and QCT BMD osteoporosis cutpoint values were ≤−2.5 and <80 mg/mL, respectively, for Caucasian women. These values may not be optimal for predicting the most important FFx, i.e., hip FFx. LS T-score measurement is contaminated by degenerative changes which artificially increased LS DXA BMD and T-score among older population (68,69). Particularly for Caucasian males, more evidence is needed to substantiate the LS osteofrailia cutpoint values argued in this letter. With QCT, calibration precision, CT parameters, the use of single-slice QCT covering multiple vertebrae or volumetric measurement with spiral CT, region of interest (ROI) placement (which commonly includes trabecular bone while excluding cortex and vertebral posterior elements), etc. will all affect the final QCT reading. Though, studies have demonstrated that the disagreements between various QCT measurements are usually minor, if appropriate calibration is regularly conducted.

Supplementary

The article’s supplementary files as

qims-15-10-10391-coif.pdf (175.7KB, pdf)
DOI: 10.21037/qims-2025-1790

Acknowledgments

None.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Footnotes

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1790/coif). Y.X.J.W. serves as the Editor-in-Chief of Quantitative Imaging in Medicine and Surgery. He is the founder of Yingran Medicals Ltd., which develops medical image-based diagnostics software. The author has no other conflicts of interest to declare.

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