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. Author manuscript; available in PMC: 2020 Oct 27.
Published in final edited form as: J Health Care Poor Underserved. 2016;27(2):644–662. doi: 10.1353/hpu.2016.0085

Bone Mineral Density in Navajo Men and Women and Comparison to Non-Hispanic Whites from NHANES (2005–2008)

Karla Miller 1, Tracy Frech 1, Tom Greene 1, Khe-ni Ma 1, Molly McFadden 1, Lillian Tom-Orme 1, Martha L Slattery 1, Maureen A Murtaugh 1
PMCID: PMC7590421  NIHMSID: NIHMS972441  PMID: 27180701

Abstract

Purpose

To describe bone mineral density (BMD) at the hip and spine and prevalence of low bone mass and osteoporosis in Navajo men and women across age, gender, and body mass index (BMI) compared with non-Hispanic (NH) Whites from NHANES (2005–2008).

Methods

Cross-sectional dual energy x-ray absorptiometry measurements at the hip and spine in 1,097 participants from the Education and Research Towards Health study.

Results

Bone mineral density was lower among younger Navajo than NH-Whites at lower BMI, and in overweight, younger men at lumbar spine and total hip. Spine BMD was lower in Navajo women, across BMI. Prevalence of low bone mass and osteoporosis in Navajo was higher than NH-Whites, particularly among women.

Conclusions

Further research is needed to understand if lower BMD among younger Navajo signals a risk for future fracture, and fracture risk relative to BMD, given the challenges in health care access and fracture morbidity among minorities.

Keywords: Bone mineral density, American Indian, low bone mass, osteoporosis, epidemiology

Few reports examine bone mineral density (BMD) among American Indian populations in the United States and none have specifically addressed BMD among American Indian men. Bone loss is a normal consequence of aging in both men and women after peak bone mass is reached, and is a major contributor to fracture risk.1 Indian Health Services estimates that life expectancy in American Indian people increased nearly 10 years from the early 1970s to 1999–2001 (http://info.ihs.gove/population.asp). Therefore, the impact of bone loss on the quality of life of elder American Indians deserves examination.

Differences in BMD across various racial/ethnic groups in the United States have been described.2–5 A Canadian study showed that calcaneal, and total body BMD were similar in Aboriginal and White women after adjustment for lean to fat mass.6 In the same study, weight was directly related to BMD, and larger bone area (BA) in Aboriginal women seemed to be responsible for differences in BMD.7 Findings of similar bone density at birth among White and First Nation infants suggests that variation may be related to both genetic and environmental factors.8

The Women’s Health Initiative (WHI) reported that BMD and annualized fracture rates in American Indian women were similar to those of Non-Hispanic (NH) White women.9 Reported fragility fracture rates are similar or lower in minority women compared with NH White women, but fracture-related morbidity and mortality may be increased in minority women.10–14 Low bone mass is also an under-recognized problem in men, and some data suggest that men may have higher mortality than women after a hip fracture.15,16 Recent studies have examined differences in BMD across multiple ethnic groups in men, but American Indian populations were not included in these assessments.17,18 Therefore, the purpose of this study was to describe BMD measured by bone densitometry as well as prevalence of low bone mass, and osteoporosis in Navajo men and women participating in the Education and Research Toward Health (EARTH) study.

Methods

Study population

The participants of this bone health study were a randomly selected sub-set of EARTH study participants (N=1,100) selected to fill age and gender groups between November 2007 and January 2010. Simple randomization using a random number table was used. The design and methods from the EARTH study baseline visit have been previously reported.18 Eligibility criteria for EARTH and this sub-study included: American Indian or Alaska Native, eligible for Indian Health Service health care, age 18 years or older, not pregnant, not actively undergoing chemotherapy, physically able to get on and off the dual energy x-ray absorptiometry (DXA) table independently, and mentally able to both understand the consent form and to complete survey instruments. Participants provided information at their EARTH study baseline visit on socioeconomic status, diet, physical activity, lifestyle and cultural practices, medical and reproductive history, and family history of heart disease, and cancer (not included in this study). A computerized data collection and tracking system was developed using audio computer-assisted interview (ACASI) and touch screens.

The bone health sub-study visits were conducted in a single stationary location within the Navajo Nation in New Mexico. This study was approved by the Navajo Nation Human Research Review Board, the Indian Health Service National Institutional Review Board, and the University of Utah Institutional Review Board. Regional, local, and health boards and chapters within local health boards approved and supported the study.

Data collection

Measurements

Dual energy x-ray absorptiometry (DXA) measurements at the left hip, spine, and total body were made by a certified DXA technician on a Discovery W DXA table (Hologic Inc, Waltham, MA). Participants were positioned by the technician according to standard protocol. Quality assurance included daily measurement of the spine phantom to maintain error less than 1% (SD = .004 g/cm2 and = CV = 0.415% for BMD). Bone mineral density (BMD), and its components, bone mineral content (BMC) and bone area (BA), at the femoral neck (g/cm2, spine and whole body were used for the current analysis. The 2005–2008 NHANES data for 20–29 year old White women was used as the reference group to generate T-scores for women. The NHANES reference population for White men (ages 20–29) was used at all sites, and those for both White men and White women ages 20–29 were used as the reference group to generate T-scores for men at the hip. Navajo people aged 18 and 19 were included in the group aged 20 to 29. Data were analyzed in 10-year age groups up to 59. All Navajo individuals over the age of 60 were grouped together and compared with NHANES individuals over 60. Age-adjusted prevalence of low-bone mass and osteoporosis are presented.

Height, weight, and waist and hip circumferences were obtained within one month of the DXA measurement. Measurements were taken in duplicate with the participants wearing loose clothing and no shoes. Weight was measured using Tanita® digital scales (BWP800/BWP627A, Tanita Corporation of America Inc., Arlington Hills, IL). Two measurements were taken (a third was taken if there was greater than a two-pound difference). Standing height was measured with the Road Rod Stadiometer® (Seca, Hamburg, Germany). If the two height measurements differed by more than 1.0 inch, measurements were repeated; the average of the final two measurements was used.

Self-report health history

The Health, Lifestyle, and Physical Activity questionnaire obtained at the baseline visit included self-report of medical conditions, including high blood pressure, heart disease, high cholesterol, stroke, gallbladder disease, kidney disease, liver disease, thyroid disease, arthritis, asthma, lung disease, diabetes, cataracts, depression, and cancer; family history of medical conditions (not included in the study), including hip fracture, physical activity information and current and past use of tobacco.19 Physical activity was assessed by self report.20 Participants reported the average time spend on household, child, and elder care in a typical week of the last month. Then they reported leisure time activities they participated in for at least 10 minutes at a time over the past year. The questionnaire assessed occurrence of fracture by asking, “Did a doctor or other health care provider ever tell you that you had a bone fracture or break as an adult, that is after age 18?”19 Participants who reported a fracture were asked the age at the time of fracture and the location of the fracture, but were not asked about degree of trauma. Menopausal status was determined by women’s responses to a series of questions including whether they had experienced menopause, had their ovaries removed, or had a period in the last 12 months. If women reported that they did not know whether they had gone through menopause and were age 60 or older, menopause was assumed.

Vitamin D and calcium supplement use was obtained from the dietary history questionnaire (DHQ).21 Briefly, the DHQ is a method of obtaining self-report dietary intake. Participants are asked if they consume a given food 12 or more times per year. When the response is yes, the participant chooses how often (per day, week, month or year) and has the option of portion size. Nutritient content of foods are summed for each participant and expressed per day. Participants reported dietary supplements (multivitamin and individual supplements [e.g., iron and calcium]). When supplement use was affirmative, dose and frequency were obtained. Nutrients from supplement use was summed by the individual; total intake is the sum of individual nutrients from foods and from supplements.

Statistical analysis

Data were analyzed using SAS version 9.4 (SAS Institute, Carey, NC). Significant differences were noted when p values were less than .05, without adjustments for multiple comparisons. Age was assessed in categories younger than 30 years, 30–40 years, 40–50 years, and 50–60, and 60 years and older. Body mass index was also assessed categorically (< 25, 25–30, >30) as few individuals had BMI less than 25. T-scores were interpreted as low bone mass (T-score between −1.0 and −2.5) and osteoporosis (T-score ≤ −2.5) following the World Health Organization (WHO) and International Society for Clinical Densitometry (ISCD) position statements.22,23

Two sets of analyses were performed: 1) comparison of mean BMD levels between the EARTH Navajo study population and the corresponding mean values from the general population mean values from the National Health And Nutrition Examination Survey 2005–6 and 2007–8 combined cycles, and 2) summary of T-scores of EARTH Navajo study population using gender matched NHANES combined 2005–6 and 2007–8 cycles (2005–8) with White 20–29 year olds as the reference.

To perform the first set of analyses, it was necessary first to compute mean levels of BMD, BMC, and BA within the designated age, gender, and race/ethnicity combinations while accounting for the combined NHANES 2005–8 multistage probability sampling design. We followed the analytical guidelines for NHANES data analysis proposed by the CDC24 to account for design effects of clustering (SDPPSU) and stratification (SDPSTR) using the SAS procedure SURVEYMEANS to compute the means and standard errors based on combined NHANES 2005–8 cycles. To combine two cycles of NHANES data the two-year mobile exam weights (WTMEC2YR) for each cycle were rescaled so that the sum of the weights matched the survey population at the midpoint of the given period. We then computed unweighted means and standard errors within the corresponding age/gender/and BMI subgroups within the EARTH Navajo study population, and compared these mean values to the corresponding NHANES means using the large-sample normal approximation.

For the second set of analyses, T-scores for EARTH Navajo study participants’ BMD values were computed relative to the means and standard errors provided for combined NHANES 2005–2008 cycles for gender matched NH-Whites between 20 and 29 years of age.25 The T-scores for EARTH Navajo participants over 50 years of age were then categorized according to the WHO guidelines and ISCD position statements described above and summarized by a frequency table.22,23

Results

Table 1 shows demographic data, education level, tobacco and alcohol use history, activity levels, characteristics, menopause status, and female hormone use for menopause or oral contraception of the study participants. Fewer men than women reported being married or living as married, and more men than women reported having never been married. More men than women reported completing a GED or high school education, but more women than men reported some vocational or college education. Current and former tobacco smoking was higher among men than women, and fewer men reported having never smoked tobacco. Women were more likely to report alcohol intake of less than three units per day, while men were more likely to report alcohol intake of greater than three units per day. Men reported spending more time in activity and more vigorous activity levels than women. Body mass index was higher in women than in men. Estimated calcium intake was higher among men than among women. Reported vitamin D intake was also greater among men than among women (390 ± 395 vs 311 ± 332, p < .001). However, energy adjusted intakes were similar (energy adjusted intakes of calcium for men 341 ± 145 vs 339 ± 166 for women and vitamin D 1.8 ± 1.2 for men and 1.9 ± 1.2 for women). Menopause was reported by 28% of female participants. Few participants reported use of other bone-active medications.

Table 1.

PARTICIPANT DEMOGRAPHICS, SOCIOECONOMIC AND LIFESTYLE HABITS RELATED TO BONE HEALTH

Variables Men N (%) Women N (%) p value for the categorya p value by levelb
Age
 18–29 118 (26.0) 134 (20.8) .186 .162
 30–39 83 (18.3) 128 (19.9) .390
 40–49 111 (24.5) 152 (23.6) .433
 50–59 85 (18.8) 126 (19.6) .442
 60–69 47 (10.4) 83 (12.9) .335
 70–79 8 (1.8) 21 (3.3) .411
Marital Status
 Married/Living as 189 (41.7) 308 (47.8) .186 .094
 Widowed, Divorced, Separated 75 (16.6) 129 (20.0) .269
 Never married 188 (41.5) 203 (31.5) .020
Education level
 <High School 112 (24.7) 128 (19.9) <.001 .182
 High School or GED 174 (38.4) 184 (28.6) .024
 Voc/Tech/Assoc/Some college 156 (34.4) 276 (42.9) .043
 College degree or higher 10 (2.2) 52 (8.1) .231
Tobacco Smoking
 Current 86 (18.9) 69 (10.7) <.001 .071
 Former 24 (5.3) 19 (2.9) .347
 Never 331 (73.1) 535 (83.1) <.001
Alcohol intake
 ≤ 3 units per day 310 (68.4) 583 (90.5) <.001 <.001
 > 3 units per day 125 (27.6) 37 (5.7) <.001
Mean (SD) Mean (SD)
BMI (kg/m2) 30.83 (5.68) 32.08 (6.55) <.001
Height (inches) 67.2 (2.44) 62.3 (2.24) <.001
Weight (pounds) 198.3 (41.00) 176.90 (38.22) <.001
Supplement use
Calcium intake (mg/day) 1890.3 (1547.8) 1638.0 (1614.5) .011
Vitamin D intake (IU/day) 390.0 (395.0) 311.0 (332.0) <.001
BMI (kg/m2) 30.83 (5.68) 32.08 (6.55) <.001
Moderate Activity
 < 3 Hrs. 185 (40.8) 459 (71.3) <.001 <.001
 GE 3 Hrs 247 (54.5) 150 (23.3) <.001
Vigorous Activity
 < 3 Hrs. 257 (56.7) 510 (79.2) <.001 <.001
 GE 3 Hrs 175 (38.6) 99 (15.4) <.001
Female specific variables N (%)
Menopause
 Not Reported 42 (6.5)
 Yes 183 (28.4)
 No 419 (65.1)
Taken female hormones for menopause
 Not Reported 412 (64)
 Yes, currently 17 (2.6)
 Yes, but not now 49 (7.6)
 No 166 (25.8)
Taken birth control pills
 Not Reported 24 (3.7)
 Yes, currently 48 (7.5)
 Yes, but not now 218 (33.9)
 No 354 (55)
Any female hormone use current or pastc
 Yes 345 (53.6)
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a

Chi-square

b

Binomial test of proportions

c

Birth control shots not included

Bone mineral density increased across BMI category in women and men of all age groups at all three sites (Figures 1 and 2). In normal weight Navajo women age 20–29 with BMI <25, BMD was lower than in NH-White women at all sites (Figure 1 and Table 2). These differences dissipated at BMI >30, except at the lumbar spine. Bone mineral density at the lumbar spine was significantly lower in Navajo women, across age and BMI, compared with NH-White women. Bone mineral density at the femoral neck and hip were generally similar. Bone mineral composition was significantly lower in Navajo women at the lumbar spine and to a lesser extent at the femoral neck (Appendix 1). Bone mineral density in Navajo women was largely similar to NH-Whites at the total hip (Figure 1). Bone area was also significantly lower at the lumbar spine, and trended lower at the femoral neck, but not at the total hip in Navajo women compared with NH-Whites (Appendix 1). Interestingly, lower BMC and BA at the femoral neck was more prominent in older Navajo women with higher BMI (Appendix 1).

Figure 1.

Figure 1

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Bone mineral density (g/cm2) in Navajo American women compared with non-Hispanic White women in NHANES (2005–2008) across age groups and BMI.

Figure 2.

Figure 2

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Bone mineral density (g/cm2) in Navajo American men compared with non-Hispanic White men in NHANES (2005–2008) across age groups and BMI.

Table 2.

PREVALENCE OF LOW BONE MASS AND OSTEOPOROSIS IN NAVAJO WOMEN AND MEN

Womena over 50 years
N (%)		 Menb over 50 years
N (%)		 Menc over 50 years
N (%)
Total Hip T-Score
Normal
 ≥ −1 107 (49.8) 84 (62.7) 115 (85.8)
Low Bone Mass
 > −2.5 and < − 1.0 90 (41.9) 42 (31.3) 18 (13.4)
Osteoporosis
 ≤ −2.5 18 (8.4) 8 (6.0) 1 (0.7)
Femoral Neck T-Score
 ≥ −1 74 (34.4) 63 (47.0) 84 (62.7)
 > −2.5 and < − 1.0 119 (55.3) 63 (47.0) 48 (35.8)
 ≤ −2.5 22 (10.2) 8 (6.0) 2 (1.5)
Lumbar Spine T-Score
 ≥ −1 43 (20.0) 98 (73.1) 96 (71.6)
 > −2.5 and < − 1.0 96 (44.7) 33 (24.6) 31 (23.1)
 ≤ −2.5 76 (35.3) 3 (2.2) 7 (5.2)
Total prevalenced
 Normal 31 (14.4) 54 (40.3) 72 (53.7)
 Low Bone Mass 103 (47.9) 71 (53.0) 55 (41.0)
 Osteoporosis 81 (37.7) 9 (6.7) 7 (5.2)
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Notes

a

Women’s T-scores are based on NHANES 2005–2008 White women’s reference data

b

Men’s T-scores are based on NHANES 2005–2008 White men’s reference data

c

Men’s T-scores are based on NHANES 2005–2008 White women’s reference data

d

The total prevalence of osteoporosis is assessed when the T-score in any of the femoral neck or lumbar spine is ≤−2.5. Low bone mass is assessed when at least one of these two T-scores is >−2.5 and <−1.0.

Bone mineral density was significantly lower at all sites in Navajo men age 20–29 with BMI < 25 compared with NH-White men (Figure 2). The same trend was observed in Navajo men age 20–49 with BMI of 25–30, though not consistently at the femoral neck. In Navajo men with BMI >30, BMD was comparable to that of NH-White men. Bone mineral composition was significantly lower in men with BMI 25–30 at all sites and age groups except among the oldest men (Appendix 1). In men over 60, BMC was lower at the spine but not at the hip or femoral neck. Differences in BMC were inconsistent in the other BMI categories (Appendix 1). Bone area was significantly lower in Navajo men at the lumbar spine and femoral neck, but not at the total hip (Appendix 1).

Prevalence of low bone mass and osteoporosis in NA women over the age of 50 were highest at the lumbar spine, and lowest at the total hip (Table 2). In Navajo women over the age of 50, total prevalence of low bone mass was 48% and osteoporosis was 38% while among NH White women in NHANES (2005–2008) the age-adjusted prevalence of osteopenia was 62% and osteoporosis was 15%.26 Among Navajo men the prevalence of low bone mass was highest at the femoral neck and the prevalence of osteoporosis was highest at the lumbar spine. Prevalence of low bone mass in Navajo men over the age of 50 was higher when the men’s referent data was used, compared with when the women’s referent data was used. Total prevalence of low bone mass in Navajo men over the age of 50 using hip or spine BMD measurements was 53%, and osteoporosis was 6.7% when using the men’s reference group, and 41% and 5.2% when using the women’s reference group at the hip. Among NH White men the age-adjusted prevalence of osteopenia was 39% and osteoporosis was 4% using 30 year old NH White women as the reference group.26

Discussion

This report on bone mineral density (BMD) in Navajo men and women in the Southwestern United States is the largest report in American Indian populations, and the first to report on bone mineral density in American Indian men. Bone mineral density decreased with age and menopause, and increased with body mass index (BMI). The exception is at the spine in men where BMD was more stable across age groups. Importantly, prevalence of low bone mass and osteoporosis together (86%) in Navajo women was higher than total prevalence of these disorders measured in the 2005–2008 data from NHANES (77%).26 Prevalence of low bone mass and osteoporosis for Navajo men was between the two comparitor groups, NH White men and NH White women.

Bone density tended to increase across BMI groups among both Navajo men and women in this study. This trend has also been reported for American Indian (AI)/Alaska Native and NH-White women participating in other studies, including the Women’s Health Initiative.27,28 Body weight has been shown to be positively associated with BMD in women and men of all ages29 and the AI participants of the North EARTH study.30 Despite the well-documented positive association between BMI and BMD, some studies raise concern that this positive association may dissipate and even decline in the setting of severe obesity, particularly at the lumbar spine.31 Other recent studies have shown an association between high BMI and fragility fractures, irrespective of the positive association between BMI and BMD.32,33 Fragility fractures have yet to be studied among AI people. Our study did indicate lower BMC and BA in older women with higher BMI at the femoral neck compared with White women, but their differences cancelled each other resulting in similar BMD. At the femoral neck differences in BA and BMC were less consistent. We did not have adequate numbers of men or women within in the age groups to consider BMI > 35 or > 40 separately, although future work might address this issue.

Interestingly, BMD was lower at the lumbar spine in Navajo women compared with NH-White women, at any BMI. In contrast, BMD in 148 American Indian (AI)/Alaska Native participants of the Women’s Health Initiative (WHI) was similar compared with NH-White women.9 BMC and BA were also lower at the lumbar spine in Navajo women, and to a lesser extent at the femoral neck. This is in contrast to findings in Canadian Aboriginal women, where BMD and BMC were similar and BA higher compared with NH White women at the lumbar spine.7 Differences in findings among these studies may be multifactorial including differences in sample sizes, ages of the populations studied, and lifestyle habits (e.g., dietary intake and exposure to sunlight) and genetics.

In the present study, we report some statistically significant differences in BMD, as well as BMC and BA, in Navajo men and women compared with corresponding NH-Whites from NHANES (2005–2008). However, the impact of these differences on the risk of fragility fracture and mortality are yet unknown. Hip fracture rates reported for AI were similar to those reported for NH White women by the Women’s Health Initiative.9 In our study, the prevalence of osteoporosis (37.7%) determined by T-scores at the femoral neck and lumbar spine for Navajo women over the age of 50, were higher than the prevalence reported by NHANES (2005–8) (16% osteoporosis) and 2010 estimates from NHANES (51.4% for low bone mass and 15.4% for osteoporosis) for NH-White women.34 This finding is especially sobering given this population’s limited access to some health care services. Therefore, it seems appropriate to follow the current ISCD guideline to use a standard White (not race adjusted) reference database for non-Whites for several reasons including that the relationship between BMD and fracture rate in AI is not well-defined. The evidence further argues for bone density screening among AI women following the current ISCD guidelines until further evidence is available.

Bone mineral density in Navajo men was similar to that reported by NHANES (2005–2008) for NH-White men at BMI >30. BMD in Navajo men remained similar to that of NH-White men, though BA was lower. In men, prevalence outcomes varied according to the whether White men or White women were used as a reference, as expected. Prevalence of osteoporosis and low bone mass in Navajo men lay between prevalence for NH White men and NH White women reported by NHANES (2005–8).26 Fragility fracture risk among American Indian men is as yet unknown. Further study is needed to establish whether morbidity and mortality from fragility fracture is higher among American Indian men as it is among men of other ethnic groups.35–37 At this time, there is inadequate evidence to stray from the ISCD guidelines for bone density screening among men.

There are strengths and limitations to the present study. As mentioned previously, this is the largest study reporting on DXA measured BMD in a U.S. Southwest American Indian population and the first study to report on BMD among American Indian men. The primary recruitment center for study participants was located in northern New Mexico, which limits the generalization of this data to all American Indian populations. These data represent the baseline visit of an observational cohort and therefore, cannot to be used to determine incidence of fragility fractures among this population. Medical and personal history was ascertained by self-reported survey, which may be less precise for some risk factors, compared with review of medical records.38

Limited data exist on the differences in BMD and its components among American Indian populations compared with other ethnicities, particularly data that include men. These data are important to the understanding of metabolic bone disease and fracture risk in these populations, especially in light of the limited access to health care on reservations and the increased fracture morbidity reported among minority groups39–41 and men.35–37 Much remains to be learned about BMD and fracture risk in American Indian men and women, and future studies should focus on larger and more geographically diverse representation in order to optimize bone health in these populations.

Acknowledgments

Funding Source: This study was funded by grants AR052466 from the National Institute for Arthritis and Musculoskeletal and skin Diseases and CA106218, CA88958, CA89139, and CA96095 from the National Cancer Institute. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official view of the National Institute for Arthritis and Musculoskeletal and Skin Diseases or the National Cancer Institute.

Appendix 1

TABLES OF BONE AREA AND BONE MINERAL COMPOSITION FOR NAVAJO WOMEN AND MEN AS COMPARED TO NON-HISPANIC WHITE WOMEN FROM NHANES DATA (2005–2008)a

Bone Mineral Concentration
Women L1–L4 Spine Femoral Neck Total Hip
BMI Age NHANES Navajo p value NHANES Navajo p value NHANES Navajo p value
BMI <25 20–29 years 59.4[57.6–61.2] 41.4[38.5–44.2] <.001 4.1[4–4.2] 3.6[3.4–3.8] <.001 29.8[28.8–30.7] 26.8[25.2–28.4] .002
30–39 years 61[58.7–63.3] 44.6[39.1–50.2] <.001 3.9[3.8–4] 3.7[3.3–4] 0.167 29.2[28–30.4] 29.4[25–33.7] .397
40–49 years 60.8[58.6–63] 45.5[41.3–49.7] <.001 3.8[3.7–3.8] 3.4[3.3–3.5] <.001 29.1[28.1–30.1] 27.2[25.1–29.4] .093
50–59 years 54.8[53–56.6] 43.8[39.6–48.1] <.001 3.5[3.3–3.6] 3.5[3.3–3.7] 0.384 27.5[26.4–28.6] 28.2[26.2–30.1] .329
60 years and older 50.9[49.3–52.6] 33.6[26.8–40.4] <.001 3.2[3.1–3.2] 2.9[2.7–3.2] 0.016 25.9[25.3–26.5] 22.9[19.6–26.1] .037
25≤ BMI <30 20–29 years 65.6[63.2–68] 44.6[41.8–47.4] <.001 4.5[4.3–4.6] 3.9[3.8–4] <.001 31.9[30.8–32.9] 28.1[26.9–29.4] <.001
30–39 years 63.2[60.8–65.6] 49.8[47–52.6] <.001 4.2[4.1–4.4] 4[3.8–4.2] 0.035 31.4[30–32.9] 32[30.4–33.6] .345
40–49 years 59.3[57.2–61.3] 48.2[45.5–50.9] <.001 3.9[3.8–4] 3.8[3.7–4] 0.267 29.8[29–30.5] 30.1[28.8–31.4] .363
50–59 years 56.5[53.9–59.1] 41.3[38.9–43.7] <.001 3.8[3.7–3.9] 3.6[3.4–3.7] 0.052 29.2[28.2–30.2] 29.6[27.9–31.2] .365
60 years and older 53.9[52.5–55.2] 37.1[34.6–39.7] <.001 3.5[3.5–3.6] 3.2[3–3.4] <.001 28.4[27.8–29.1] 26.1[24.8–27.5] .004
BMI >=30 20–29 years 62.6[60.7–64.5] 48.9[46.7–51.1] <.001 4.7[4.4–5] 4.5[4.3–4.6] 0.158 33.9[32.4–35.5] 33.6[32.3–35] .381
30–39 years 61.3[59.6–63] 50.9[49.1–52.7] <.001 4.4[4.3–4.5] 4.3[4.2–4.5] 0.279 32.2[31.1–33.3] 34.2[33.1–35.3] .014
40–49 years 64.3[62.3–66.4] 51.3[49.3–53.2] <.001 4.5[4.3–4.6] 4.2[4.1–4.3] 0.003 34.5[33.3–35.8] 34.3[33.4–35.2] .375
50–59 years 60[57.7–62.3] 44.9[42.4–47.4] <.001 4.1[3.9–4.3] 3.8[3.6–3.9] 0.003 32.9[31.5–34.3] 31.3[30.2–32.4] .083
60 years and older 55.9[53.9–57.9] 40.7[38.3–43.2] <.001 3.8[3.7–3.9] 3.4[3.3–3.6] <.001 30.6[29.9–31.3] 29.1[27.5–30.7] .095
Bone Mineral Concentration
Men L1–L4 Spine Femoral Neck Total Hip
BMI Age NHANES Navajo p value NHANES Navajo p value NHANES Navajo p value
BMI <25 20–29 years 71[69.2–72.8] 49.6[46.3–52.8] <.001 5.2[5–5.3] 4.4[4.2–4.6] <.001 42.7[41.9–43.6] 37.2[35.4–39] <.001
30–39 years 68.3[66.1–70.6] 48.3[42.4–54.1] <.001 4.6[4.5–4.8] 4.2[3.7–4.7] 0.071 39.2[37.7–40.7] 36.5[32–41.1] .180
40–49 years 68.7[65.8–71.5] 53.5[47.3–59.8] <.001 4.6[4.4–4.8] 4[3.8–4.3] 0.002 41.5[39.4–43.6] 36.9[34.2–39.6] .007
50–59 years 70.8[67–74.5] 51.9[39.7–64.2] <.001 4.4[4.2–4.6] 3.9[3.4–4.5] 0.033 40.8[39–42.6] 36.1[29.6–42.6] .069
60 years and older 71.2[68.1–74.4] 59.9[50.5–69.3] .007 4.1[4–4.2] 4.1[3.7–4.4] 0.393 39.1[38.1–40] 40.1[34.5–45.8] .358
25≤ BMI <30 20–29 years 72.2[69.6–74.7] 54.7[51.5–57.8] <.001 5.3[5.1–5.5] 5[4.8–5.2] 0.034 44.8[43.3–46.4] 42.1[40–44.1] .035
30–39 years 74.3[71.7–76.9] 56.1[51.6–60.5] <.001 5.1[5–5.3] 4.5[4.3–4.7] <.001 45.3[43.7–47] 42.1[39.8–44.3] .021
40–49 years 74.9[72.7–77] 59.8[56.2–63.4] <.001 5[4.9–5.1] 4.5[4.3–4.8] <.001 45[43.8–46.2] 41.7[39.7–43.7] .007
50–59 years 74.5[72.6–76.5] 60.6[56–65.1] <.001 4.8[4.6–4.9] 4.3[4.1–4.5] <.001 44[42.9–45] 40.3[38–42.7] .007
60 years and older 75.6[73.3–77.9] 65.7[59.8–71.6] .002 4.5[4.4–4.6] 4.3[4–4.5] 0.060 43.1[42.4–43.8] 42.4[39.5–45.2] .352
BMI >=30 20–29 years 72.5[69.6–75.5] 61.4[58.7–64.2] <.001 5.8[5.6–6] 5.5[5.3–5.7] 0.042 46.4[44.5–48.2] 45.4[43.3–47.5] .309
30–39 years 68.9[66.6–71.2] 62.4[59.1–65.7] .002 5.3[5.1–5.4] 5.1[4.9–5.3] 0.192 45.8[44.1–47.5] 46.3[44.4–48.3] .368
40–49 years 72.8[70.2–75.4] 61.6[58.4–64.8] <.001 5.2[5–5.3] 5[4.8–5.2] 0.132 46.5[45.3–47.7] 45.9[44.1–47.8] .346
50–59 years 72.4[70–74.9] 64.9[61.7–68.2] <.001 5[4.9–5.2] 4.7[4.5–4.9] 0.004 46.5[45.4–47.7] 46.5[44.7–48.4] .399
60 years and older 75.5[73–78] 68[64–72] .002 4.9[4.8–5] 4.4[4.2–4.7] 0.002 47.1[46–48.1] 44.2[41.5–46.9] .047
Area Women L1–L4 Spine Femoral Neck Total Hip
BMI Age NHANES Navajo p value NHANES Navajo p value NHANES Navajo p value
BMI <25 20–29 years 57.5[56.3–58.8] 46.6[45–48.2] <.001 4.8[4.8–4.9] 4.6[4.5–4.8] 0.007 31.7[31.1–32.2] 31[30–32.1] .238
30–39 years 58.3[57.1–59.5] 47.5[44.1–50.9] <.001 4.8[4.7–4.9] 4.7[4.4–4.9] 0.154 32[31.4–32.7] 32.2[30–34.5] .393
40–49 years 59.2[58–60.4] 48.8[46.6–51.1] <.001 4.9[4.8–5] 4.7[4.5–4.9] 0.012 32.9[32.3–33.5] 32.4[30.6–34.2] .340
50–59 years 58[57–59.1] 50.3[47.9–52.7] <.001 4.9[4.8–5] 5[4.8–5.1] 0.319 33.5[32.7–34.2] 33.9[32–35.8] .365
60 years and older 57.5[56.9–58.1] 48.5[44.4–52.5] <.001 5[5–5.1] 4.9[4.7–5.1] 0.250 34.3[33.9–34.8] 33.4[31.8–35.1] .189
25≤ BMI <30 20–29 years 59.4[57.8–60.9] 46.9[44.9–48.9] <.001 4.9[4.8–5] 4.7[4.6–4.8] 0.012 31.8[31.2–32.5] 31[30–31.9] .118
30–39 years 58.6[56.9–60.3] 49[47.5–50.5] <.001 5[4.9–5.1] 4.8[4.7–5] 0.072 32.5[31.6–33.5] 33.4[32.3–34.4] .204
40–49 years 57.2[56.2–58.2] 49.3[47.7–50.8] <.001 4.8[4.8–4.9] 4.7[4.6–4.8] 0.094 31.9[31.4–32.5] 32.2[31.4–33] .346
50–59 years 56.7[55.7–57.8] 47.3[45.9–48.8] <.001 5[4.9–5.1] 4.7[4.6–4.8] <.001 32.5[31.8–33.3] 32.8[31.8–33.9] .360
60 years and older 57[56.2–57.8] 47.6[45.8–49.4] <.001 5[5–5] 4.8[4.7–4.9] 0.004 34.3[33.9–34.7] 33.9[33–34.7] .254
BMI >=30 20–29 years 56.1[55.2–57] 47.7[46.5–48.9] <.001 4.9[4.8–5] 4.8[4.7–4.8] 0.111 32.3[31.5–33.1] 32.1[31.3–33] .387
30–39 years 56.3[55–57.5] 48.7[47.7–49.7] <.001 4.9[4.8–5] 4.7[4.6–4.8] <.001 31.7[31.1–32.3] 32.8[32.2–33.3] .010
40–49 years 57[56–58] 50.1[49–51.1] <.001 4.9[4.8–4.9] 4.8[4.7–4.9] 0.066 33.1[32.5–33.6] 33.2[32.6–33.9] .367
50–59 years 56.6[55.5–57.7] 48.9[47.8–50] <.001 5[4.9–5] 4.8[4.8–4.9] 0.012 33.8[33.2–34.4] 33.7[33–34.3] .385
60 years and older 56[55–56.9] 47.9[46.5–49.2] <.001 5.1[5–5.1] 4.7[4.6–4.8] <.001 34.3[34–34.7] 33.7[33–34.5] .138
Area Men L1–L4 Spine Femoral Neck Total Hip
BMI Age NHANES Navajo p value NHANES Navajo p value NHANES Navajo p value
BMI <25 20–29 years 68[67–68.9] 53.8[51.9–55.7] <.001 5.6[5.5–5.7] 5.2[5.1–5.4] <.001 41[40.4–41.7] 39.6[38.2–40.9] .043
30–39 years 67.7[66.5–69] 54.5[49.8–59.1] <.001 5.6[5.5–5.7] 5.2[4.9–5.5] 0.008 41.2[40.2–42.2] 39.4[36.1–42.8] .205
40–49 years 68.4[67–69.8] 56.4[52.7–60] <.001 5.7[5.6–5.8] 5.4[5.2–5.6] 0.002 43[41.8–44.1] 41.5[39.2–43.8] .188
50–59 years 69.6[67.4–71.8] 57[50–64.1] <.001 5.7[5.6–5.8] 5.4[5.1–5.7] 0.008 43.1[42.1–44.2] 43.4[39.4–47.3] .396
60 years and older 69.7[68.6–70.9] 62.3[58.5–66.2] <.001 5.7[5.7–5.8] 5.8[5.5–6.1] 0.367 44.4[43.8–45.1] 47.9[42.3–53.4] .115
25≤ BMI <30 20–29 years 67.4[66.1–68.8] 56.4[54.5–58.2] <.001 5.6[5.5–5.7] 5.3[5.2–5.4] <.001 41.6[40.7–42.4] 40.5[39.2–41.9] .182
30–39 years 69[67.5–70.4] 57.4[55.2–59.6] <.001 5.7[5.6–5.8] 5.3[5.2–5.5] <.001 42.9[42–43.8] 41.7[39.9–43.5] .179
40–49 years 70.1[68.9–71.2] 60.1[58.3–61.8] <.001 5.7[5.6–5.8] 5.3[5.2–5.5] <.001 42.9[42.1–43.6] 42[40.8–43.2] .178
50–59 years 69.9[68.9–70.8] 59.7[58–61.3] <.001 5.8[5.7–5.9] 5.3[5.2–5.5] <.001 43.4[42.6–44.2] 42.1[40.7–43.5] .097
60 years and older 70.1[69.2–71] 63.1[60.2–66] <.001 5.8[5.8–5.9] 5.4[5.3–5.6] <.001 44.6[44.2–45.1] 44[42.3–45.8] .312
BMI >=30 20–29 years 66.6[65.1–68.1] 58[56.6–59.5] <.001 5.6[5.6–5.7] 5.4[5.3–5.5] <.001 40.8[39.8–41.8] 41[39.9–42.2] 0376
30–39 years 66.2[65–67.4] 57.9[56.1–59.8] <.001 5.7[5.6–5.8] 5.4[5.3–5.5] 0.004 42.1[40.9–43.2] 42[40.7–43.3] .398
40–49 years 68[67–69] 58.9[57.5–60.4] <.001 5.7[5.7–5.8] 5.5[5.4–5.6] 0.002 43[42.3–43.6] 42.6[41.4–43.7] .332
50–59 years 67.1[66–68.1] 60.3[58.5–62.1] <.001 5.7[5.7–5.8] 5.4[5.3–5.5] <.001 43.7[43–44.3] 43.7[42.7–44.7] .397
60 years and older 67.9[66.8–69] 62.2[59.9–64.5] <.001 5.8[5.8–5.9] 5.4[5.3–5.6] <.001 44.9[44.4–45.4] 43.9[42.5–45.4] .164
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Note:

a

The p values are the result of the z test for mean difference.

Footnotes

Conflicts of interest: None.

References

  • 1.Riggs BL, Wahner HW, Dunn WL, et al. Differential changes in bone mineral density of the appendicular and axial skeleton with aging: relationship to spinal osteoporosis. J Clin Invest. 1981 Feb;67(2):328–35. doi: 10.1172/JCI110039. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Finkelstein JS, Lee ML, Sowers M, et al. Ethnic variation in bone density in pre-menopausal and early perimenopausal women: effects of anthropometric and lifestyle factors. J Clin Endocrinol Metab. 2002 Jul;87(7):3057–67. doi: 10.1210/jcem.87.7.8654. http://dx.doi.org/10.1210/jcem.87.7.8654 http://dx.doi.org/10.1210/jcem.87.7.8480 http://dx.doi.org/10.1210/jcem.87.7.8654 . . http://dx.doi.org/10.1210/jcem.87.7.8480. [DOI] [PubMed] [Google Scholar]
  • 3.Jackson KA, Savaiano DA. Lactose maldigestion, calcium intake and osteoporosis in African-, Asian-, and Hispanic-Americans. J Am Coll Nutr. 2001 Apr;20(2 Suppl):198S–207S. doi: 10.1080/07315724.2001.10719032. [DOI] [PubMed] [Google Scholar]
  • 4.Nelson DA, Barondess DA, Hendrix SL, et al. Cross-sectional geometry, bone strength, and bone mass in the proximal femur in Black and White postmenopausal women. J Bone Miner Res. 2000 Oct;15(10):1992–7. doi: 10.1359/jbmr.2000.15.10.1992. [DOI] [PubMed] [Google Scholar]
  • 5.Snelling AM, Crespo CJ, Schaeffer M, et al. Modifiable and nonmodifiable factors associated with osteoporosis in postmenopausal women: results from the Third National Health and Nutrition Examination Survey, 1988–1994. J Womens Health Gend Based Med. 2001 Jan-Feb;10(1):57–65. doi: 10.1089/152460901750067124. [DOI] [PubMed] [Google Scholar]
  • 6.Leslie WD, Weiler HA, Lix LM, et al. Body composition and bone density in Canadian White and Aboriginal women: the First Nations Bone Health Study. Bone. 2008 May;42(5):990–5. doi: 10.1016/j.bone.2008.01.018. Epub 2008 Feb 13. [DOI] [PubMed] [Google Scholar]
  • 7.Leslie WD, Metge CJ, Weiler HA, et al. Bone density and bone area in Canadian Aboriginal women: the First Nations Bone Health Study. Osteoporos Int. 2006 Dec;17(12):1755–62. doi: 10.1007/s00198-006-0184-0. Epub 2006 Sep 8. [DOI] [PubMed] [Google Scholar]
  • 8.Weiler HA, Fitzpatrick-Wong SC, Schellenberg JM. Bone mass in First Nations, Asian and White newborn infants. Growth Dev Aging. 2008 Summer;71(1):35–43. [PubMed] [Google Scholar]
  • 9.Cauley JA, Wu L, Wampler NS, et al. Clinical risk factors for fractures in multi-ethnic women: the Women’s Health Initiative. J Bone Miner Res. 2007 Nov;22(11):1816–26. doi: 10.1359/jbmr.070713. [DOI] [PubMed] [Google Scholar]
  • 10.Furstenberg AL, Mezey MD. Differences in outcome between Black and White elderly hip fracture patients. J Chronic Dis. 1987;40(10):931–8. doi: 10.1016/0021-9681(87)90142-1. [DOI] [PubMed] [Google Scholar]
  • 11.Jacobsen SJ, Goldberg J, Miles TP, et al. Race and sex differences in mortality following fracture of the hip. Am J Public Health. 1992 Aug;82(8):1147–50. doi: 10.2105/AJPH.82.8.1147. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Ma J, Markides KS, Perkowski LP, et al. Impact of selected medical conditions on self-reported lower-extremity function in Mexican-American elderly. Ethn Dis. 1998 Winter;8(1):52–9. [PubMed] [Google Scholar]
  • 13.Curtis JR, Mcclure LA, Delzell E, et al. Population-based fracture risk assessment and osteoporosis treatment disparities by race and gender. J Gen Intern Med. 2009 Aug;24(8):956–62. doi: 10.1007/s11606-009-1031-8. Epub 2009 Jun 24. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Cauley JA, Lui LY, Ensrud KE, et al. Bone mineral density and the risk of incident nonspinal fractures in Black and White women. JAMA. 2005 May 4;293(17):2102–8. doi: 10.1001/jama.293.17.2102. [DOI] [PubMed] [Google Scholar]
  • 15.Jiang HX, Majumdar SR, Dick DA, et al. Development and initial validation of a risk score for predicting in-hospital and 1-year mortality in patients with hip fractures. J Bone Miner Res. 2005;20(3):494–500. doi: 10.1359/JBMR.041133. Epub 2004 Nov 29. [DOI] [PubMed] [Google Scholar]
  • 16.Forsen L, Sogaard AJ, Meyer HE, et al. Survival after hip fracture: short- and long term excess mortality according to age and gender. Osteoporos Int. 1999;10(1):73–8. doi: 10.1007/s001980050197. [DOI] [PubMed] [Google Scholar]
  • 17.Araujo AB, Travison TG, Harris SS, et al. Race/ethnic differences in bone mineral density in men. Osteoporos Int. 2007 Jul;18(7):943–53. doi: 10.1007/s00198-006-0321-9. Epub 2007 Mar 6. [DOI] [PubMed] [Google Scholar]
  • 18.Sheu Y, Cauley JA, Wheeler VW, et al. Age-related decline in bone density among ethnically diverse older men. Osteoporos Int. 2011 Feb;22(2):599–605. doi: 10.1007/s00198-010-1330-2. Epub 2010 Jun 22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Slattery ML, Schumacher MC, Lanier AP, et al. A prospective cohort of American Indian and Alaska Native people: study design, methods, and implementation. Am J Epidemiol. 2007 Sep;166(5):606–15. doi: 10.1093/aje/kwm109. Epub 2007 Jun 22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Redwood D, Schmacher MC, Lanier AP, et al. Physical activity patterns of American Indian and Alaskan Native people living in Alaska and the Southwestern United States. Am J Health Promot. 2009 Jul-Aug;23(6):388–95. doi: 10.4278/ajhp.071211130. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Slattery ML, Murtaugh MA, Schumacher MC, et al. Development, implementation, and evaluation of a computerized self-administered diet history questionnaire for use in studies of American Indian and Alaskan native people. J Am Diet Assoc. 2008 Jan;108(1):101–9. doi: 10.1016/j.jada.2007.10.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.World Health Organization (WHO) WHO scientific group on the assessment of osteoporosis at primary health care level. Brussels, Belgium: WHO; 2004. Available at: http://www.who.int/chp/topics/Osteoporosis.pdf. [Google Scholar]
  • 23.International Society for Clinical Densitometry (ISCD) 2013 ISCD official positions—adult. Middletown, CT: ISCD; 2013. Available at: http://www.iscd.org/official-positions/2013-iscd-official-positions-adult/ [Google Scholar]
  • 24.National Center for Health Statistics (NCHS) Analytic and reporting guidelines: The Third National Health and Nutrition Examination Survey, NHANES III (1988–94) Hyattsville, MD: NCHS; 1996. Available at: http://www.cdc.gov/nchs/data/nhanes/nhanes3/nh3gui.pdf. [Google Scholar]
  • 25.Centers for Disease Control and Prevention (CDC) National Health and Nutrition Examination Survey (NHANES) 1999–2016 survey content. Atlanta, GA: CDC; 2015. Available at: http://www.cdc.gov/nchs/data/nhanes/survey_content_99_16.pdf. [Google Scholar]
  • 26.Looker AC, Borrud LG, Dawson-Hughes B, et al. Osteoporosis or low bone mass at the femur neck or lumbar spine in older adults: United States, 2005–2008. NCHS Data Breif. 2012 Apr;(93):1–8. [PubMed] [Google Scholar]
  • 27.Perry HM, 3rd, Bernard M, Horowitz M, et al. The effect of aging on bone mineral metabolism and bone mass in Native American women. J Am Geriatr Soc. 1998 Nov;46(11):1418–22. doi: 10.1111/j.1532-5415.1998.tb06010.x. [DOI] [PubMed] [Google Scholar]
  • 28.Baron JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age. Epidemiology. 1996 Nov;7(6):612–8. doi: 10.1097/00001648-199611000-00008. [DOI] [PubMed] [Google Scholar]
  • 29.Travison TG, Chiu GR, McKinlay JB, et al. Accounting for racial/ethnic variation in bone mineral content and density: the competing influences of socioeconomic factors, body composition, health and lifestyle, and circulating androgens and estrogens. Osteoporos Int. 2011 Oct;22(10):2645–54. doi: 10.1007/s00198-010-1520-y. Epub 2011 Jan 6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Supplee JD, Duncan GE, Bruemmer B, et al. Soda intake and osteoporosis risk in post-menopausal American-Indian women. Public Health Nutr. 2011 Nov;14(11):1900–6. doi: 10.1017/S136898001000337X. Epub 2011 Jan 4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Greco EA, Fornari R, Rossi F, et al. Is obesity protective for osteoporosis? Evaluation of bone mineral density in individuals with high body mass index. Int J Clin Pract. 2010 May;64(6):817–20. doi: 10.1111/j.1742-1241.2009.02301.x. [DOI] [PubMed] [Google Scholar]
  • 32.Pirro M, Fabbriciani G, Leli C, et al. High weight or body mass index increase the risk of vertebral fractures in postmenopausal osteoporotic women. J Bone Miner Metab. 2010;28(1):88–93. doi: 10.1007/s00774-009-0108-0. Epub 2009 Jul 4. [DOI] [PubMed] [Google Scholar]
  • 33.Premaor MO, Pilbrow L, Tonkin C, et al. Obesity and fractures in postmenopausal women. J Bone Miner Res. 2010 Feb;25(2):292–7. doi: 10.1359/jbmr.091004. [DOI] [PubMed] [Google Scholar]
  • 34.Wright NC, Looker AC, Saag KG, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res. 2014 Nov;29(11):2520–6. doi: 10.1002/jbmr.2269. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Pande I, Scott DL, O’Neill TW, et al. Quality of life, morbidity, and mortality after low trauma hip fracture in men. Ann Rheum Dis. 2006 Jan;65(1):87–92. doi: 10.1136/ard.2004.034611. Epub 2005 Aug 3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Morin S, Lix LM, Azimaee M, et al. Mortality rates after incident non-traumatic fractures in older men and women. Osteoporos Int. 2011 Sep;22(9):2439–48. doi: 10.1007/s00198-010-1480-2. Epub 2010 Dec 16. [DOI] [PubMed] [Google Scholar]
  • 37.Kannegaard PN, van der Mark S, Eiken P, et al. Excess mortality in men compared with women following a hip fracture. National analysis of comedications, comorbidity and survival. Age Ageing. 2010 Mar;39(2):203–9. doi: 10.1093/ageing/afp221. Epub 2010 Jan 14. [DOI] [PubMed] [Google Scholar]
  • 38.Brownson R, Eyler A, King AC, et al. Reliability of information on physical activity and other chronic disease risk factors among US women aged 40 years or older. Am J Epidemiol. 1999 Feb 15;149(4):379–91. doi: 10.1093/oxfordjournals.aje.a009824. [DOI] [PubMed] [Google Scholar]
  • 39.Graham JE, Chang PF, Berges IM, et al. Race/ethnicity and outcomes following inpatient rehabilitation for hip fracture. J Gerontol A Biol Sci Med Sci. 2008 Aug;63(8):860–6. doi: 10.1093/gerona/63.8.860. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Hoenig H, Rubenstein L, Kahn K. Rehabilitation after hip fracture—equal opportunity for all? Arch Phys Med Rehabil. 1996 Jan;77(1):58–63. doi: 10.1016/S0003-9993(96)90221-X. [DOI] [PubMed] [Google Scholar]
  • 41.Jordan JM, Lawrence R, Kington R, et al. Ethnic health disparities in arthritis and musculoskeletal diseases: report of a scientific conference. Arthritis Rheum. 2002 Sep;46(9):2280–6. doi: 10.1002/art.10480. [DOI] [PubMed] [Google Scholar]

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