Fracture risk assessment without race/ethnicity information

J Clin Endocrinol Metab. 2012 Oct;97(10):3593-602. doi: 10.1210/jc.2012-1997. Epub 2012 Aug 3.


Context: Dual-energy x-ray absorptiometry-derived bone mineral density (BMD) does not explain interracial differences in fracture risk; thus, BMD-based fracture risk assessment requires patient race/ethnicity information and ethnicity-specific BMD reference databases.

Objective: The objective of the study was to investigate whether composite femoral neck strength indices, which integrate dual-energy x-ray absorptiometry-derived femoral neck size, femoral neck BMD, and body size, will allow fracture risk assessment without requiring race/ethnicity information.

Design: This was a prospective cohort study.

Setting and participants: A total of 1940 community-dwelling women aged 42-53 yr from four race/ethnicity groups (968 Caucasian, 512 African-American, 239 Japanese, and 221 Chinese) were followed up for 9 yr.

Outcome measurements: Self-reported, nondigital, noncraniofacial fractures were measured.

Results: Two hundred and two women (10.4%) sustained fractures and 82 (4.3%) had minimum-trauma fractures. Each sd increment in any of the strength indices was associated with a 34-41% reduction in fracture hazard over 9 yr (each P<0.001). Race/ethnicity predicted fracture hazard independent of BMD (P=0.02) but did not predict fracture hazard independent of any of the composite indices (P=0.11-0.22). Addition of race/ethnicity did not improve risk discrimination ability of the strength indices, but did significantly improve the discrimination ability of BMD. The discrimination ability of BMD with race/ethnicity was not statistically different from that of any of the strength indices without race/ethnicity.

Conclusions: Composite strength indices of the femoral neck can predict fracture risk without race/ethnicity information as accurately as bone mineral density does in combination with race/ethnicity information and therefore would allow risk prediction in people of mixed race/ethnicity and in groups without a BMD reference database.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adult
  • Asian / statistics & numerical data
  • Black or African American / statistics & numerical data
  • Body Size
  • Bone Density / physiology*
  • Databases, Factual / statistics & numerical data
  • Female
  • Femur Neck / physiology*
  • Fractures, Bone / epidemiology*
  • Fractures, Bone / physiopathology*
  • Humans
  • Incidence
  • Middle Aged
  • Models, Biological
  • Predictive Value of Tests
  • Prospective Studies
  • Risk Assessment / methods
  • Risk Factors
  • United States / epidemiology
  • White People / statistics & numerical data