Identifying bone-mass-related risk factors for fracture to guide bone densitometry measurements: A systematic review of the literature

Available evidence suggests that fracture prediction with bone densitometry may improve when used on people at high risk of osteoporotic fractures. Th e objectives of this literature review were: (1) to identify risk factors f or fracture that are associated with the development of a low bone mass for both men and women; (2) to describe and assess the relationship between th ese factors and the risk of fracture; and (3) to classify them according to the strength of their association with fracture incidence. Studies were id entified from MEDLINE (1982-1997), HealthSTAR (1975-1997) and The Cochrane Library (1997) databases. Pre-stated inclusion criteria (original analytic studies assessing risk factors for osteoporotic fractures in men and women) and methodologic quality were assessed by two independent investigators. I nformation on the study design and analysis, characteristics of participant s, exposure (risk factor) and outcome measures (relative risk and odds rati os for fracture incidence), control for potential confounding factors and r isk estimates was extracted using a standardized protocol. Qualitative and meta-analytic techniques were used for data synthesis. As a result, risk fa ctors were classified into three groups according to their strength of asso ciation with fracture: high risk (RR greater than or equal to 2). moderate risk (1 < RR < 2) and no risk or protective (RR less than or equal to 1). O f approximately 80 risk factors identified from 94 cohort and 72 case-contr ol studies, 15% were classified in the high-risk group, including low body weight, loss of weight, physical inactivity, the consumption of corticoster oids or anticonvulsants, primary hyperparathyroidism. diabetes mellitus typ e 1, anorexia nervosa, gastrectomy, pernicious anemia, and aging (> 70-80 y ears). Eighteen percent and 8% of risk factors were classified in the moder ate and no risk group respectively, whereas 60% showed either a lack of sci entific evidence confirming their association with fracture or contradictor y results. An efficient strategy for bone densitometry provision may thus b e its selective use in those individuals who present with several strong or moderate risk factors for fracture related to bone mass loss.