thin women and bone fracture

Helping thin women reduce their fracture risk

The saying,  “You can never be too rich or too thin” is definitely not true when it comes to bone health! It’s well established that women with low body weight have lower bone density and are at increased risk for many types of fracture.

Let’s better understand this link between body weight and fracture risk and then look at the many steps thinner women can take to start strengthening their bones.

 Underweight women…

  • Experience twice the rate of hip fracture as do “healthy weight” women.  (See chart below.)
  • Have lower hip bone density, lower cross-sectional bone area, and less bone bending strength than “normal” weight women.
  • Experience more vertebral and wrist fractures (but fewer lower leg fractures).
  • Tend to lose more bone during the menopause transition than do heavier women.

So just who is included in this “underweight” category?

The “underweight” designation is determined by body mass index (BMI) using weight and height. A BMI of 18.5 or less (which would translate into a 5’3” women weighing 105 lbs or less, or a 5’5” person weighing 115 lbs or less) is considered underweight.

While the “underweight” category includes only very thin folks, there exists a weight–bone gradient link whereby lighter weight individuals have both decreased bone density and increased risk of various fractures.  Those falling into the “underweight” category are at highest risk, but slender individuals (that is, those whose BMI is 18.6–21.5) are often reported to be at increased fracture risk, too, particularly if they also have low muscle mass.

How can underweight or slender women reduce their fracture risk?

This is indeed a complicated topic, which I can only begin to address here. As always, at the Center for Better Bones we look for the root cause of the problem and seek a solution with this in mind. Being significantly underweight likely indicates a serious imbalance within the system, such as digestive, emotional, or disease-related issues:

  • Low body weight is often associated with weak digestion, food allergies, or food intolerances. Addressing these issues is central to improving your metabolism. Check out our 10 steps to stronger digestion and try a simple elimination diet.
  • Clinically, I also see low body weight associated with a tendency towards anxiety, nervousness, and at times even straight out emotional distress and fear. While uprooting these negative emotional responses can take some time and good guidance, a good place to begin is with our free e-book, 7 secrets to reducing stress.
  • If you’re an “eat-and-run” person or you regularly skip meals, discipline yourself to sit down, relax, and consume three tasty, wholesome meals every day.
  • Try not to get extra calories from simple carbohydrates like sugars, pastas, and flours. Instead, increase your intake of root crops and wholesome fats like avocado, nuts, seeds, and olive oil.
  • Remember, bone and muscle are built together — so include some weight-bearing, muscle-building exercise in your weekly routine.

As you can see, there’s a lot that a thin, small-framed person can do to strengthen bone and reduce their fracture risk.  Being aware of your risk is the important first step!

Take this survey to help us see how body mass relates to fracture incidence among the Better Bones, Better Body Community. We’ll report back on what we find!

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Johansson, H. et al. A meta‐analysis of the association of fracture risk and body mass index in women. J Bone Miner Res., 2014;29: 223-233. doi:10.1002/jbmr.2017

Søgaard AJ, et al. Abdominal obesity increases the risk of hip fracture. A population‐based study of 43 000 women and men aged 60–79 years followed for 8 years. Cohort of Norway. J Intern Med. 2015;277: 306–317.

Compston, J. E., et al. Relationship of weight, height, and body mass index with fracture risk at different sites in postmenopausal women: The Global Longitudinal Study of Osteoporosis in Women (GLOW). J Bone Miner Res. 2014;29: 487-493. doi:10.1002/jbmr.2051

5 ways to prevent a second fracture

Make Your First Fracture Your Last Fracture

Low-trauma fracture, rather than low bone density, is what indicates bone weakness — so if you’ve had a fracture, it’s a sign you need to take substantial, comprehensive steps to support your bones. Even a simple fracture of the wrist after stumbling tells a story — and what’s been shown over and over by research is that a person who’s had a previous fracture is at higher risk of future fractures (Johansson et al. 2017; Ferrari 2017; Gehlbach et al 2012).

Many international osteoporosis organizations have also reached this conclusion and have begun to recommend intervention after the first low-trauma fracture. The International Osteoporosis Foundation has developed the Europe-wide “Capture the Fracture” promotion, and Osteoporosis Canada a few years ago identified a significant post-fracture care gap. Both agencies, unfortunately, focus on moving fracture patients into a system of bone drug treatment.

5 steps to prevent a second fracture

At the Center for Better Bones, our approach to bone fracture prevention is fundamentally different. We view fractures that occur without high impact as very serious warning signs that are worthy of further investigation. We go about the goal of preventing a second fracture in a systematic fashion:

Step 1: Assess bone health

We guide individuals into assessing health and lifestyle factors that might be weakening their bones. A good way to begin this assessment is with our Bone Health Profile.

Step 2. Uncover causes of bone fragility

We encourage everyone who has fractured to ask their doctor for selected medical tests that help uncover hidden medical causes of bone fragility via a comprehensive osteoporosis work-up. The work-up offers direct data on possible health and lifestyle issues that may be contributing to your fracture risk.

Step 3. Address hidden medical issues

We review the results from your doctor’s medical testing, and if any hidden medical causes of bone weakening are uncovered, we help you understand them while your doctor treats these medical concerns.

Step 4.  Reduce or eliminate fracture risk factors 

We work with the client on the lifestyle and nutrition assessments to identify areas of lifestyle, diet, and emotional makeup that could be improved, with the goal of either eliminating these fracture risk factors or reducing their effects on your bones.

Step 5. Create a personalized plan for stronger bones

Based on our full assessment of the individual case and total load of fracture risk factors, we develop a personalized Better Bones, Better Body program to help modify lifestyle and nutritional factors and develop a strong nutrient supplement regimen to support stronger bones and reduce your future fracture risk.

Your bones are as unique as you are

In my experience, carefully evaluating each case and working with the body’s natural processes to regain optimal bone health offers far greater long-term benefits to health and longevity than any quick fix using bone drugs. This natural approach, however, requires a substantial level of commitment and a willingness to change one’s diet, lifestyle, and daily habits. As the old Chinese saying puts it: “If you keep going in the same direction, you will end up right where you are headed.”

There are undoubtedly extreme and severe case where bone drugs are deemed appropriate by both physician and patient, and in these cases, for optimum results we incorporate the complete Better Bones Better Body Program along with the bone drug.

So if you or someone you know has recently had a fracture, take heart — and take action! — to make this first fracture your only fracture.

Ferrari SL. Prevention of fractures in patients with osteoporosis. Lancet 2017; (published online November 9, 2017).

Gehlbach S, Saag KG, Adachi JD, et al. Previous fractures at multiple sites increase the risk for subsequent fractures: The Global Longitudinal Study of Osteoporosis in Women. J Bone Miner Res. 2012;27(3):645–653. doi:10.1002/jbmr.1476.

Johansson H, Siggeirsdóttir K, Harvey NC, et al. Imminent risk of fracture after fracture. Osteoporos Int. 2017;28(3):775–780. doi:10.1007/s00198-016-3868-0.

mind body bone connection

Mind over muscle — how using your brain could help your bones

Perhaps you’ve heard of the “placebo effect” in clinical trials — that strange situation when some people who don’t receive a beneficial intervention see a benefit to their health anyway, for no obvious reason. By way of explanation, most clinical researchers think that when participants believe they will improve because of the “treatment,” their body takes its cue from the mind and responds as if a therapeutic agent is actually being used.

If only we could capture this seemingly magical ability of the mind to direct the body — what could it do for our own ability to heal?

Mental imagery makes a difference

In fact, a few years ago, some researchers showed that we can capture this ability (Clark et al. 2014). They induced muscle weakness in 29 adult volunteers — healthy people who had more or less similar muscle strength at baseline — by immobilizing the hand and wrist of the subjects’ non-dominant arm using a rigid cast (15 other volunteers had nothing done to their arm and served as controls). They trained 14 members of the group with immobilized wrists in a mental imagery program in which they were told to imagine their immobilized hand and wrist was doing specific movements, such as flexing and pushing, without actually activating the muscles. An electromyogram was used to make sure they didn’t actually flex their muscles during the mental imagery sessions. The remaining 15 people whose arms were immobilized were not given mental imagery training.

What they found was startling: In the participants who underwent mental imagery training, the loss of muscle strength associated with immobilization was half that of those who didn’t get training. They also concluded that lack of neurological activity, rather than lack of muscle activity, accounted for almost a one-third of the strength decrease in the immobilized arm. In other words, simply directing the brain’s attention to the nervous system in a specific part of the body provides sufficient stimulus to the musculoskeletal system to make an important difference.

A mind-body-bone connection?

I’ve noted before that bone strength depends on muscle strength, and most of us know that muscle strength is a “use it or lose it” proposition. This study shows how the power of the mind can be brought to bear on muscle strength — and though it didn’t look at bone specifically, if you’re supporting muscle, you’re also supporting bone. I can’t help but wonder whether a study that also looked at the effects on participants’ bone mass might not show a similar improvement in bones! I bet you dollars to donuts it would.

Better bones affirmations

Better bones affirmations


Clark BC, Mahato NK, Nakazawa M, Law TD, Thomas JS. The power of the mind: the cortex as a critical determinant of muscle mass. J Neurophysiol. 2014;112(12):3219–3226.

5 differences between arthritis and vertebral fracture

Arthritis or fracture? Figuring out what back pain means

It’s an unusual person who gets to middle age without a few aches and pains — a little wear and tear is to be expected after a half century or so. But for those at risk of osteoporotic fractures, back pain is particularly worrisome because you can’t really know whether it’s tired muscles, or arthritis, or a vertebral fracture.

Or can you?

Recent research shows that the pain caused by vertebral fractures is different from other causes, such as arthritis of the spine. As a 2016 study published in Osteoporosis International found, vertebral fractures in women produced a number of distinct pain signposts that weren’t present in women who had arthritis of the spinal column.

Recognizing the signs of vertebral fracture vs. arthritis pain

The study looked at 197 British women between the ages of 67 and 84, asking them to report on their experiences of pain (in the back but elsewhere as well) before initiating a spine x-ray to look for vertebral fractures. They found that about a third of the women had vertebral fractures — and the women with fractures had a number of things in common. They were older (average age of 76.9 years versus 71.7 in the women without fractures), were considerably more likely to have had a previous fracture, or a diagnosis of osteoporosis, or both, and had fairly specific attributes to the pain they experienced that differed from the women with arthritis.

Most notably, women with fractures described their pain as recent and brief in duration but “crushing,” whereas women with arthritis said they had intermittent or periodic pain that they were more likely to call “taut” or “sharp.” Radiation of pain to the legs and association with weather changes were common in the women with arthritis but not the women with vertebral fractures. (See table for full comparison.)

Listening to your body

All of this makes sense. Fractures are an acute injury in the bone, which is very different from the kind of slow, gradual, and chronic inflammatory process that is present in arthritis.

What I take away from this study is that our body will tell us what we need to know — if we listen carefully. To start learning more about your bone health and risk for fracture, I encourage you to take our quick and easy Bone Health Profile.

Table: Women’s experience of vertebral fracture pain

Vertebral fractureArthritis
Risk factors
  • Older age
  • Previous fracture (nonvertebral)
  • Diagnosis of osteoporosis
Duration of painShort-term, recent (occurring within days or weeks of the study); episodes are brief or transient with no apparent patternLong-term (present months or years prior to study); episodes are “periodic” or intermittent
Type of pain“Crushing” but localizedPain description varies but it is ongoing or intermittent and may occur anywhere from neck to legs
  • Relieved by lying down
  • Does not radiate to legs
  • No obvious association to weather or temperature
  • No clear effect on pain of keeping still or moving
  • May radiate to legs
  • Some associations with cold, damp, or changing weather conditions
Vertebral Fracture vs Arthritis

Vertebral Fracture vs Arthritis


Clark EM, Gooberman-Hill R, Peter TJ. Using self-reports of pain and other variables to distinguish between older women with back pain due to vertebral fractures and those with back pain due to degenerative changes. Osteoporos Int 2016;27:1459–1467.

4 tips to free yourself from stress and worry

High perceived stress level increases fracture risk

Do you think you’re a stressed-out person? I certainly think I am — which is one reason I’m so interested in the results of a new Danish study looking at perceived stress and fracture risk.

Not only did the study find that high-stressed participants had a 68% increased risk of hip fracture and a 37% increased risk of any osteoporotic fracture. The research also suggests that it’s not just the stress itself, but our perception of that stress that’s important.

The study determined this with nearly 8,000 Danish adults age 55+ who were categorized according to their self-perceived level of stress. Note that the researchers didn’t try to measure the level or type of stress itself! Instead, they asked the individual participants to describe what their level of stress was — then watched to see who in the cohort experienced an osteoporotic fracture over the next five years.

The one-fourth of people who reported a “high” level of perceived stress had the significantly increased risk of fractures – again a 68% increased risk of hip fracture and a 37% increased risk of any osteoporotic fracture – compared to those who reported “low” perceived stress.

How to free yourself from worry and stress

I’m quick to identify myself with that high-risk cohort. My mother dubbed me her “worry wart” and that personality trait still challenges me today.

That’s why I took up meditation and have developed various methods to “dial down” my perception of stress. A favorite self-help approach is what I call the “BE FREE” method. Those of you who are also “worry warts” might give it a try.

  • BreathE: Throughout the day, I consciously try to stop what I’m doing and slow down my breathing. Just two or three slow, deep breaths offer a calming chance for the more rational part of my brain to kick in. This exercise is all the more important when I find myself in a stressful situation.
  • Feel: Once I’m quieted down, I focus my attention inward, telling myself to note the emotional response I am feeling—fear, anger, frustration, jealousy, or whatever. I just allow myself to feel that particular energy.
  • RElease: Next, I intentionally release the negative emotion, and the energy behind it dissipates. I can feel my heartbeat slow, and the anxiety-producing stress hormones begin to quiet down.
  • Envision: Still taking deep, conscious breaths, I asked myself, “How do I want to feel?” or “How do I want to be?” Then I envision that desired energy flowing through my body.

If you give it a try, let me know how my “BE FREE” method worked for you. Even more, perhaps you’d like to share some of your personal methods and tips for maintaining resilience amid the ups, downs and of modern life. I would love to hear about them!


Pedersen AB, Baggesen LM, Ehrenstein V, et al. Perceived stress and risk of any osteoporotic fracture. Osteoporosis International, 2016;27:2035–2043.

Wrist fracture and future fracture risk

What your wrist fracture may be telling you

How many of you have fallen and thrown out your hands to catch yourself?  It’s probably happened to most us, and may be one reason that in the U.S., 1 in 10 broken bones is a broken wrist.

But wrist fractures aren’t just due to accidents. Wrist fractures that occur from a fall from standing height are generally a sign of bone weakness and are the most common osteoporotic fractures.

Having seen my grandmother experience first a wrist fracture, then a collarbone fracture, and finally a hip fracture, I suspected that wrist fractures — common in middle-aged and older women — are an important sign that attention should be given to strengthening bone.

Wrist fractures signal increased fracture risk

And there’s a recent study out that confirms this suspicion. In a 2015 study from the Journal of Bone and Mineral Research (Crandall et al., 2015), the study authors looked at long-term data from more than 160,000 women and found that women who’d previously had a wrist fracture were at significantly higher risk of other fractures during the almost 12 years of follow-up — regardless of other osteoporosis risk factors.

The big news . . .  the younger the woman was when she fractured her wrist, the greater her relative risk of having another fracture later on.

I like to say, make your first fracture your last fracture. If you’ve fractured a wrist in the past, be aware that this fracture is your “canary in the coal mine” telling you to pay attention to your bones. You can take the Better Bones Profile to assess the health of your bones and your potential risk of fracture.

Crandall, C. J., Hovey, K. M., Cauley, J. A., Andrews, C. A., Curtis, J. R., Wactawski-Wende, J., Wright, N. C., Li, W., and LeBoff, M. S. Wrist fracture and risk of subsequent fractures: Findings from the Women’s Health Initiative Study. Journal of Bone and Mineral Research 2015;30:2086–2095.

21 drugs that increase fracture risk

Medication use and osteoporotic fracture

Are you taking medications that could increase your risk of osteoporotic fracture? Many people are – even after they’ve suffered a fracture – according to a recent article about osteoporotic fractures and medication use from the Journal of the American Medical Association (JAMA).

Scientists looked at 168,000 Medicare beneficiaries who experienced osteoporotic fractures of the hip, shoulder, or wrist. They found that 75% of these patients had actually been taking one or more medications known to increase fracture risk.

Drugs known to increase fracture risk

In the study, 21 classes of drugs were associated with increased fracture risk. Some of the drugs known to increase fracture risk include:

  • Glucocorticoid steroids (e.g., prednisone)
  • Serotonin re-uptake inhibitors (antidepressants)
  • Antacids (proton pump inhibitors and aluminum-containing antacids)
  • Blood pressure medicines
  • Antipsychotics
  • Thyroid hormone (when dosed in excess of need)
  • Anti-seizure medications
  • Anti-estrogen breast cancer drugs
  • Anti-testosterone prostate cancer drugs
  • DepoProvera
  • Sedatives (benzodiazepines)
  • Opiate pain killers, morphine
  • Acetaminophen if used long term
  • Diabetes medications (thiazolidinediones)
  • Heparin, long term use

What can you do to reduce your bone health risks from medications?

The authors of the study were struck by the fact that even after fracturing, patients did not stop using their bone-damaging medication. One obvious helpful suggestion from this study is for doctors to provide alternative medications that damage bone less. Here are other ideas for creating lifelong bone health:

  • When a drug therapy is recommended, dig a little deeper! Learn more about your health condition and how it’s related to lifestyle and nutrition.
  • Use the medication for the shortest period possible. When you need medication for a chronic condition, work with your doctor to minimize the dose or find a less bone-damaging alternative.
  • Study how others with this ailment have regained health using natural, life-supporting alternatives to drug therapy, including exercise, nutritional strategies, and methods that strengthen the mind–body connection.
  • Look into the more holistic health approaches, such as functional medicine, acupuncture and traditional Chinese medicine, classic homeopathy, chiropractic, and massage.

If you’re concerned about your risk for fracture and other bone health issues, take a moment to learn more about my natural Better Bones Program.



Munson, JC et al. Patterns of prescription drug use before and after fragility fracture. JAMA Intern Med. 2016;176(10):1531-1538.


New data shows omega-3s reduce fracture risk

Getting enough fish oil daily in midlife is associated with lower fracture risk for women later in life, according to a major study from the University of Iceland. And when news about a significant decrease in fracture risk comes from researchers in a country where fracture risk is high, I certainly pay attention.

In the Icelandic study, women who got high daily amounts of polyunsaturated fatty acids from fish-oil consumption during midlife had a 25% lower risk of fracture compared to those who didn’t. The risk of fracture for men who consumed fish oil daily was even less – up to 45% less than those men who had lower levels. For men, getting optimal amounts of fish oil later in life was associated with lower fracture risk.

Are you getting enough omega-3s in your diet?

Closer to home, the average American only gets about 200 mg per day of the most important omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) per day from their diet. The American Heart Association recommends a much higher intake of between 1000–3000 mg.

Good omega-3 food sources

Omega-3s are found in a wide range of foods, including many fish sources. But vegetarians and vegans can also get omega-3s from food, with research showing a diet high in omega-3s from plant sources may be just as effective as those from fish sources.  Here are my favorite choices for omega-3 rich foods:

• Seafood (sources both high in omega-3’s and low in environmental contaminants include anchovies, herring, mackerel, oysters, wild salmon, and sardines)
• Fresh ground flaxseed
• Flaxseed oil
• Hempseed oil
• Canola oil
• Avocados
• Walnuts
• Eggs
• Pumpkin seeds
• Sesame seeds
• Olives

As it sometimes can be difficult to get the full amount of omega-3s from diet alone, many women choose a daily high-quality omega-3 supplement.  I recommend Omega-3s that are molecularly distilled to help you get all of the key benefits for your bones, joints, immune system, heart, skin and more.



Orchard TS. 2013. The association of red blood cell n-3 and n-6 fatty acids with bone mineral density and hip fracture risk in the women’s health initiative. J Bone Miner Res. 2013; doi:10.1002/jbmr.1772.

Harris, TB. 2015 May; Plasma phospholipid fatty acids and fish-oil consumption in relation to osteoporotic fracture risk in older adults: the Age, Gene/Environment Susceptibility Study. Am J Clin Nutr  101(5):947-55. doi: 10.3945/ajcn.114.087502. Epub 2015 Mar 18. ( accessed March 23, 2016)

if I exercise with osteoporosis, will i fracture?

1 minute with Dr. Brown: Will I fracture if I exercise?

Got a minute? Every week I receive dozens of questions from women like you with concerns about their bone health. In my new series, “1 Minute with Dr. Brown,” I will try to answer your most pressing questions. If you have a question, send it in to us at

Question: I have osteoporosis. If I exercise, will I fracture?

how can we tell who will fracture

How can we tell who will fracture? Beyond bone mineral density to the new world of fracture risk assessment

More than twenty-five years ago, I first consulted with several of the individuals who developed the bone density testing machines. The hope was clear — if we could measure bone density we would be able to predict who will experience an osteoporotic fracture. The concept was quite simplistic; it assumed that the most important fracture-determining factor was low bone density. Over the last decades, bone density testing has become widespread; yet the hope for a simple, straight predictor of fracture has faded.

Today, nearly three decades later, we realize that you cannot predict who will fracture from measurements of bone density alone. In fact, recent large studies show that a large percentage of people who do fracture do not have osteoporotic bone density, but actually have only osteopenia or even normal bone density. Furthermore, many people with an osteoporotic bone density never fracture.

Most fractures occur in those who do not have osteoporotic bone density

As early as the mid 1980’s, thoughtful osteoporosis researchers noted that hip fractures could not simply be attributed to low bone mass. As Steven Cummings wrote in 1985, “Patients with hip fractures do not appear to be distinctly more osteoporotic than persons of similar age. Therefore, factors besides bone mass, such as a tendency to fall, may be important determinants of which elderly persons will have fractures; thus, measurements of bone mass might not be a reliable way to identify those at greatest risk of hip fracture.”

Over the last two decades numerous clinical trials have borne out the truth of Dr. Cummings’s early observation. For example, the US Study of Osteoporotic Fractures (SOF) looked at 8,065 women 65 and older, following them for hip fracture incidence over a five year period. Within these five years, 243 hip fractures occurred, 54% of which were in women who did not have an osteoporotic bone density at the start of follow-up. Further reports from this same Study of Osteoporotic Fractures database found that only 10% to 44% of osteoporotic fractures occurred in those with an osteoporotic bone density. As these authors summarize, “Finding effective prevention strategies for fractures in older women will require additional interventions beside [sic] preventions for bone loss, such as prevention of falls and other fracture risk factors.”

The same has been found true in other large studies of osteoporotic fractures, such as the 149,524-women US National Osteoporosis Risk Assessment (NORA) study. Over a one-year period in this large group of women (mean age 64.5), 2,259 new fractures were self-reported, including 393 hip fractures. Of those who fractured, a full 82% had a non-osteoporotic bone density (greater than -2.5 SD T-score) and a full 67% had a T-score greater than -2.0. In total, 6.4% of all women had an osteoporotic bone density. Although fracture rates were highest in this “osteoporotic bone mineral density” group, these women experienced only 18% of all osteoporotic fractures and 26% of all hip fractures.

All in all, many factors are as important, or even more important, indicators of fracture risk than is bone mineral density. For example, fracture after age 40, parental history of hip fracture, low body weight, high rate of bone resorption, deficiencies of vitamins D and K, use of steroid medications, and several other factors are stronger fracture predictors than bone mineral density.

The new fracture assessment tools: multiple risk factor assessment with and without bone density measurements

So a new question arises. How can we tell who will experience an osteoporotic fracture? We now realize that the answer lies not in any single factor like bone density, but rather in assessment of multiple risk factors. What we are already beginning to see is a series of assessment tools which allow individuals and health practitioners to sort out who is likely to fracture according to a series of important variables, not just according to bone mineral density. Further we see that the operative risk factors may vary somewhat by populations studied.

New fracture risk assessment tools: post-menopausal women

One of the best known early fracture assessment tools is the “Fracture Index.” This index was developed using data from the large US Study of Osteoporotic Fractures (SOF). In the SOF, a total of 7,782 US women aged 65 and older were studied over five years.

In the SOF, measurements over time were made of bone density and other variables which were thought to reflect upon bone strength. These variables were compared with actual fracture incidence allowing for the development of a fracture risk screening and assessment tool. With this large data base, researchers identified a seven-variable model which allowed them to make a fairly accurate prediction of the five-year risk of suffering an osteoporotic fracture for any individual.

So what were the factors and variables that seem to determine if one will facture or not? According to the SOF research, the seven most important factors were found to be:

  1. Age
  2. Bone mineral density T-score
  3. Fracture after age 50
  4. Maternal hip fracture after age 50
  5. Weight less than or equal to 125 pounds (57 kg)
  6. Smoking status
  7. Using one’s arms to stand up from chair

According to researchers, this simple seven-factor assessment was shown to be predictive of hip fracture, as well as other non-vertebral fractures. It is also interesting that this risk assessment was shown to be predictive of fracture likelihood with or without incorporating one’s bone density into the assessment. Subjects with the greatest number of risk factors, even without accounting for bone mineral density, had a 14-fold increase risk of fracture as compared to those with the lowest number of risk factors.

In a similar fashion, the large Women’s Health Initiative (WHI) study used its data to develop another five-year fracture risk assessment tool. This 7.6-year trial studied 93,676 women of various ethnic backgrounds, ages 50 to 79 at entry. They found that each year some 1.6% of all women suffered hip fractures. From their analysis they developed a risk assessment tool identifying 11 key risk factors (not including bone density) to predict who would fracture a hip over the next five years. This model, based on these key risk factors, was found to be of similar predictive value as the more expensive bone density tests.

The 11 key risk factors uncovered from the Women’s Health Initiative (WHI) were:

  1. Age
  2. Self-reported health
  3. Weight
  4. Height
  5. Race/ethnicity
  6. Self-reported physical activity
  7. History of fracture after age 54
  8. Parental hip fracture
  9. Current smoking
  10. Current corticosteroid use
  11. Treated diabetes

New fracture risk assessment tools: identifying osteopenic women at risk for fracture

More than half of all low-trauma osteoporotic fractures among women occur in those who do not have an “osteoporotic” bone density; rather, they occur in women with an osteopenic bone density or, even in some cases, a normal bone density. Obviously in these cases we must look beyond bone density in our attempt to assess who is likely to fracture.

Data from the large NORA study attempted to identify those osteopenic women at short-term risk for fracture. In the NORA study, 57,421 post-menopausal women ages 50 to 99 were identified as having osteopenia. That means they had a bone mineral density from -1.0 to -2.5 SD T-score. In this study, bone density was measured at the heel, forearm, or hand. These women had bone density lower than that of young women, but they did not have an “osteoporotic” bone density (-2.5 SD T-score or more). Of the osteopenic women studied, 130 reported new fractures within one year of the bone density measurement.

Four risk factors were found to be the most important for identifying those at highest risk of short-term fracture. These were:

  1. Previous fracture
  2. Bone density T-score of -1.8 or less
  3. Self-rated poor health status
  4. Poor mobility

Women with a previous fracture had a one-year fracture risk of 4.1%, followed by women with T-scores of -1.8 or less or with poor health status. Nearly 2% of the women with poor mobility came to fracture within the year. About 1% of the osteopenic women not identified as being at risk experienced a fracture within the year. This 1% per year fracture incidence is the same as that found among women with normal bone density.

Other interesting findings of this study showed that being younger did not seem to protect the early post-menopausal women.

  • Younger women, aged 50 to 59, who shared a similar risk profile to that of women aged 60 to 69 had a similar 1-year risk of fracture (1.6% as compared to 1.7%).
  • Younger women aged 50 to 59 who were identified to be at increased risk had an absolute fracture risk of 2.6%. This was similar to that of the entire at-risk population of all ages (50 to 99 yrs).
  • Younger women aged 50 to 59 with a history of previous fracture after age 45 had a 4.5% fracture risk. This is similar to the risk for women with an osteoporotic bone density.

New fracture risk assessment tools: the World Health Organization (WHO) master assessment

Over the years the World Health Association (WHO) has analyzed various large population-based studies to develop a fracture risk assessment tool based on clinical factors. This assessment tool is designed to be useful both with and without bone density measurements and indeed, this is important, as much of the world does not have access to bone density measurements. Completed in March 2008, the WHO Fracture Risk Assessment Tool identifies 10 factors found to increase fracture risk independent of bone mineral density. (See The independent risk factors are:

  • Age
  • Sex
  • Weight and height
  • Previous fractures
  • Parental hip fracture history
  • Smoking status
  • Glucocorticoid use
  • Rheumatoid arthritis
  • Secondary disorders linked to osteoporosis, such as type 1 diabetes
  • Drinking three or more alcoholic beverages per day

WHO fracture risk assessment

At age 40, a US Caucasian woman weighing 135 lbs at 5’8” with none of the WHO risk factors has a 2.3% risk of experiencing a major osteoporotic fracture within ten years. The same woman with five of the WHO risk factors has a 15% risk of experiencing a major osteoporotic fracture. At age 65, the same woman with none of the WHO risk factors has a 14% chance of experiencing a major osteoporotic fracture within ten years. This same woman at 65, with five of the WHO risk factors, has a 55% risk of experiencing a major osteoporotic fracture. At age 80, the woman with none of the WHO risk factors has a 28% chance of experiencing a major osteoporotic fracture within ten years. The same 80-year old woman with five of the WHO risk factors has a 71% risk of experiencing a major osteoporotic fracture.

Weight & Height
Number of Additional “WHO” Risk Factors
Risk % for a Major Osteoporotic Fracture within 10 Years
40135 lbs. / 5’8
40135 lbs. / 5’8
65135 lbs. / 5’8
65135 lbs. / 5’8
80135 lbs. / 5’8
80135 lbs. / 5’8

You may want to take this risk assessment yourself. It can be done with or without a bone density measurement. The link is:

Does fracture risk vary by ethnicity?

This is a fascinating question which we have just begun to ask. I am confident the answer will be yes, risk does vary by ethnicity. Even with the little bit of existing research we have on the topic, we know that bone mineral density in Black women does not carry with it the same risk of fracture as it does among Caucasian women. Black women have about 30% fewer fractures at any given bone mineral density than Caucasian women. We also know that overall, Asians experience far fewer fractures than do Caucasians, yet their bone density is significantly lower.

The future of fracture risk assessment

As director of the Better Bones Foundation, I know that multi-variable risk assessments are indeed the tools of the future. I am not sure, however, whether the 7 variable model set forth by the US Study of Osteoporotic Fractures, or the 11-factor model from the Women’s Health Initiative, or even the new WHO assessment will end up being the best risk assessment tool. Yet there are a few things we do know for sure. One is that bone strength is determined by many factors, not just bone density; and many factors contribute to bone weakness. Further, every day we come to understand more about important new fracture risk factors which are yet to be incorporated in these risk assessment tools.

New risk factors: what the future might hold

As new questions are asked and new research unfolds, we are confident that many more new risk factors will become more important than bone mineral density. The new important fracture risk factors I would like to review are:

  • High rates of bone protein matrix breakdown (high bone resorption rates)
  • Low serum levels of vitamin D
  • Low serum levels of vitamin K
  • Use of various additional medications

New risk factor: high rates of bone protein matrix breakdown

Bone can be visualized as a living protein sponge matrix upon which mineral crystals are imbedded. As bone is lost, this living protein matrix breaks down and is excreted in the urine. The more bone protein fragments found in the urine, the higher the rate of bone breakdown. This is known as the rate of bone resorption. High bone resorption generally indicates a high rate of bone loss. Urine tests which measure bone resorption include the NTx, CTx, and the free deoxypryidinoline urine Dpd tests. These urine indices of skeletal turnover are as useful, or nearly as useful, as bone density in predicting fractures. They are fracture risks independent of bone density. Further, the combination of high bone resorption and low bone density is especially predictive of increased fracture risk.

New risk factor: low serum levels of vitamin D

Only recently have we begun to understand the overwhelming importance of vitamin D in fracture prevention. While it is beyond the scope of this article, suffice it to report that the vast majority of hip fractures occur in vitamin D deficient people. Among those who experience an osteoporotic fracture, vitamin D deficiency is the rule, not the exception. For example, a Minnesota hospital study of 82 minimal-trauma fracture patients ages 52-97 found that 97% of the fractures were hip fractures and that all but two of the patients had deficient vitamin D status (less than 30 ng/mL). In a large British study, vitamin D deficiency was found in 95% of hip fracture patients. Further supporting this, 78% of hip fracture patients in a Boston study were vitamin D deficient. Findings such as these have led some researchers to ask if vitamin D level is not the best predictor of fracture risk.

New risk factor: low serum levels of vitamin K

While only limited research attention has been given to the vitamin K-fracture link, the powerful role of this nutrient in fracture prevention is obvious. European researchers have shown that the marker of vitamin K insufficiency (undercarboxylated osteocalcin) strongly predicts fracture. Those with the greatest signs of vitamin K insufficiency were found to have twice the risk of hip fracture, independent of bone density. Further, a combination of low vitamin K status and low bone density increased one’s risk of hip fracture by more than five-and-a-half-fold.

New risk factor: use of various additional medications

It has long been known that the use of corticosteroids like prednisone greatly increase one’s risk of fracture. Now researchers are beginning to uncover links between other medications and fracture risk. For example, a recent British study found that those using higher doses of acid blockers (proton pump inhibitors) for more than a year had a 250% increased risk of hip fracture than non-users. Anti-depressants are another example of medications that increase fracture risk. Recently the large CAMOS 5-year Canadian osteoporosis study found that use of anti-depressants known as serotonin reuptake inhibitors (SSRI’s) was associated with increased fracture risk. Individuals using these medications, such as Prozac, Zoloft, and Paxel, for five years or more, had twice the risk of osteoporotic fracture than those not using these drugs. Further, hip bone density was 4% lower and spinal bone density 2.4% lower in those who used anti-depressants as compared to non-users.

In conclusion

While it is interesting to look at large studies and try to sort out the characteristics of folks at high risk for fracture, it is important to keep in mind that we can only predict relative fracture risk. We cannot foretell who will fracture. As research continues, more fracture risk factors will be uncovered and a relative weighting of their importance outlined. In the meantime, the known cluster of bone-weakening factors now include advancing age, low body weight, inadequacies of vitamins D and K, parental hip fracture, personal low-trauma fracture, selected medications, fragility and poor mobility, poor general health, high bone resorption, and low bone density.