- Email: [email protected]
Bone mineral density, calcium intake and general health of a cohort of postmenopausal Filipino women
Abstracts / Bone 44 (2009) S99–S120
317 The MDCT evaluation of human femoral bones symmetry in aging, using QCT and anthropological measurements: A cross-sectional mortuary based study J.L. Hislop-Jambricha, C.D.L. Thomasa, C.A. Briggsb, S. Blauc, C.J. Halld, J.G. Clementa a Dental Science, University of Melbourne, Melbourne, VIC, Australia b Anatomy and Cell Biology, University of Melbourne, Melbourne, VIC, Australia c Forensic Anthropology, Victorian Institute of Forensic Medicine, Melbourne, VIC, Australia d Centre for Synchrotron Science, Monash University, Clayton, VIC, Australia Aim: The aim of this study was to measure gender and agerelated changes, and the degree of symmetry between contra-lateral femora. In order to complete this, it was necessary to evaluate the accuracy and precision of a clinical helical CT unit, used in a mortuary setting, for such measurements. Method: We evaluated bilateral femora from 289 individuals ranging between 15–95 years from both sexes (n = 154 males and 134 females). We used cross sectional data from high-resolution multiple detector-row computed tomography (MDCT) investigations routinely performed at the Victorian Institute of Forensic Medicine (VIFM) in Melbourne, Australia. The study used digital 3D anthropological measurements, adapted from traditional calliper based methods, and quantitative computed tomography (QCT) analysis. Bone mineral density measurements were calibrated by the use of a bone mineral phantom during image acquisition. Individuals were excluded from the study if there were any radiological signs of non-age related bone disease or pathology. Males and females were further divided into age groups representing those ≤ 50 years (n = 73 males and 57 females), and those >50 years (n = 82 males and 77 females) for trend evaluation. Bilateral anthropological and QCT data including values for maximum femoral length and neck of femur volumetric bone density (vBMD) were then obtained. Results: The radiological differences between right and left morphological and quantitative features of the femora are small taking into consideration the precision of the MDCT methods used. Conclusion: This work represents a critical step in the development of bilateral archetypal models of human femoral bone aging in a contemporary urban population using state-ofthe-art 3D radiological imaging techniques.
≤50 >50
Male Female Male Female
Right long femur length (mm)
Left long femur length (mm)
n
mean
Std Deviation
n
Mean
Std deviation
73 57 82 77
469.7 433.7 463.0 425.0
23.1 19.7 25.2 21.2
73 57 82 77
470.9 434.6 453.8 427.0
22.4 19.4 24.9 21.2
Right hip vBMD (gm/cm2) ≤50 >50
Male Female Male Female
Left hip vBMD (gm/cm2)
n
Mean
Std Deviation
n
Mean
Std Deviation
73 57 82 77
295.8 301.1 254.3 231.3
46.7 55.7 47.8 54.6
73 57 82 77
293.3 294.2 254.1 232.5
44.6 55.0 47.2 53.5
doi:10.1016/j.bone.2009.01.233
S107
318 Risk factors for cervical and trochanteric hip fractures— A 10-year follow-up study H. Jokinena, P. Pulkkinena, S. Keinänen-Kiukaanniemib, R. Korpelainena,c, T. Jämsäa a Department of Medical Technology, University of Oulu, Oulu, Finland b Institute of Health Sciences, University of Oulu, Oulu, Finland c Oulu Deaconess Institute, Oulu, Finland The biomechanical origins for cervical and trochanteric hip fractures are different [Pulkkinen et al. (2004) Osteoporos Int 15:274–280, Pulkkinen et al. (2006) JBMR 21:895–901], but there is only limited information on the risk factors for the different types of hip fractures. Our objective was to evaluate the predictive value of calcaneal QUS, radial DXA and clinical risk factors for cervical and trochanteric hip fractures in a 10-year population-based follow-up cohort of elderly women. The study population consisted of 1222 women living at home (70–73 years at baseline). Lifestyle, anthropometric and physical activity data were collected [Korpelainen et al. (2003) Osteoporos Int 14:34–43, Korpelainen et al. (2006) Bone 39:385–91]. Radial BMD was measured by DXA (Osteometer DTX 200). Calcaneal broadband ultrasound attenuation (BUA), speed of sound (SOS) and quantitative ultrasound index (QUI) were assessed (Hologic Sahara). During the 10-year follow-up, 32 cervical and 21 trochanteric hip fractures were observed. The fractured women were taller (p < 0.05) and thinner (p < 0.001) than the non-fractured. They had 9% lower BUA and 7% lower QUI (p < 0.05) than those without fractures. The cervical fracture group had lower BMI and physical activity (p < 0.05) than the women without fractures. The trochanteric fracture group had lower BMI (p < 0.05) and higher coffee consumption (p < 0.05) than those without hip fracture. Multivariate analyses revealed that high BMI protected from all hip fractures (OR 0.87, 95% CI 0.80–0.95), and low physical functioning was a risk factor for fractures (OR 2.72, 1.32–5.61). The risk factors for cervical fractures were BMI (OR 0.86, 0.77–0.96) and low physical activity (OR 3.26, 1.37–7.74), whereas high coffee consumption (> 5 cups per day) was a risk factor for trochanteric fractures (OR 4.49, 1.49–13.49), after adjustment by age, calcium intake and medication. To conclude, BUA and QUI correlated with hip fractures, but other risk factors were more predictive in multivariate analyses. BMI was the primary predictor for cervical but not for trochanteric fractures, whereas high coffee consumption predicted trochanteric fractures. Low physical activity was associated with cervical, but not with trochanteric fractures. Acknowledgement: This study was financially supported by the National Agency for Technology and Innovation (grant nr. 40463/05). (1) Pulkkinen et al. (2004) Osteoporos Int 15:274–280. (2) Pulkkinen et al. (2006) JBMR 21:895–901. (3) Korpelainen et al. (2003) Osteoporos Int 14:34–43. (4) Korpelainen et al. (2006) Bone 39:385–91. doi:10.1016/j.bone.2009.01.234
319 Bone mineral density, calcium intake and general health of a cohort of postmenopausal Filipino women M.C. Krugera, L.M. Schollumb, B. Kuhn-Sherlockb, J.L. Yuc, I. Angeles-Agdeppad, W.H. Chuaa, J.M. Todde a Institute of Food, Nutrition and Human Health, Massey University, Palmerston North, New Zealand b Fonterra Brands Ltd., Palmerston North, New Zealand c Department of Medicine, University of Santo Tomas Hospital, España, Manila, Philippines
S108
Abstracts / Bone 44 (2009) S99–S120
d Department of Science and Technology, Food and Nutrition Research Institute, Taguig City, Philippines e Fonterra Brands Ltd., Auckland, New Zealand
Introduction: Previous bone mineral density (BMD) studies have suggested that Asian women have lower BMD compared with Caucasian women. In the Philippines, use of a Simple Calculation Osteoporosis Risk Estimation (SCORE) (Torralba TP et al. APLAR J Rheumatol 2004; 7: 30–37) aimed to set reference scores for healthy Filipino women suggested that this cohort should not be compared to the Asian data base. The current study aimed to obtain further baseline bone and dietary intake data on a cohort of Filipino women. Objective: To measure bone mineral density, investigate blood biochemistry and assess diet in a subset of Filipino post-menopausal women. Methodology: Bone mineral density was obtained using dual energy x-ray absorptiometry (DXA) (GE Lunar DPX-IQ) and anthropomorphic parameters were measured in a subset of 118 Filipino women at least 5 years post-menopause. Blood samples were taken for blood minerals, haematology, liver and kidney function and nutritional status. Results: Preliminary results indicate that the women had a mean age of 58 ± 4.8 years (range 48–65 years old) and a mean BMI of 24.1 ± 4.13 kg/m2. Very few women reported use of contraceptives or hormone replacement therapy. Mean age of menopause was 48 years (range 45–55) with menarche occurring at age 13 years (range 10– 18). DXA examinations of the femoral neck identified osteoporosis in 4.2% of women (defined as T-score of <− 2.5 SD), and osteopenia in 50.0% (defined as a T-score between − 2.5 to −1.0 SD). Considering BMD at the lumbar spine, 21.2% of women were identified as being osteoporotic and a further 50.8% as osteopenic. Blood minerals were within normal ranges. Several of the women had high blood cholesterol. Serum folate and vitamin B12 levels were normal. Mean daily calcium intake using 24 h recall was estimated to be 372 mg/ day (range 87–883). Conclusion: The preliminary results of this study show an early age of menopause, and a high prevalence of osteoporosis and osteopenia in this cohort of women. These findings may be associated with a low calcium intake as well as other dietary and lifestyle factors. (1) Torralba TP et al. APLAR J Rheumatol 2004; 7: 30–37. doi:10.1016/j.bone.2009.01.235
320 Bone density and calcium intakes in postmenopausal Indonesian women M.C. Krugera, L.M. Schollumb, A. Hestiantoroc, K. Sumaprajac, P. Wijantod, W. Rositawatid, W.H. Chuaa, J.M. Todde a Institute of Food, Nutrition and Human Health, Massey University, Palmerston North, New Zealand b Fonterra Brands Ltd., Palmerston North, New Zealand c Department of Obstetrics and Gynaecology, University of Indonesia, Jakarta, Indonesia d Equilab International and Prodia the CRO Laboratories, Jakarta, Indonesia e Fonterra Brands Ltd., Auckland, New Zealand There are little data available on bone density and dietary calcium intakes for postmenopausal women in Indonesia. In this study we measured bone mineral density (DXA), followed by anthropomorphic measurements, blood collection and a 24 h calcium recall. The study group was a subset of 77 Indonesian women at least 5 years post-menopause. The women had an average age of 58 (range 49–74 years old) and an average BMI of 24.6 (range 17.2–29.8). Ca intakes based on a 24 h
food recall ranged from 38 to 964.6 mg/day, with a mean intake of 218.7 mg/day. This is very low compared to recommended daily intakes (US AI = 1200 mg/day). Ca intake levels will be confirmed with 3 day food frequency diaries at a later date. Serum mineral levels were within normal ranges. DXA examinations of the femoral neck identified 2.6% of women to be osteoporotic (defined as t-score of <− 2.5 SD), and 52% osteopenic (defined as a t-score of − 2.5 to − 1.0 SD). At the lumbar spine, 18.2% of women were identified as being osteoporotic and a further 48.1% as osteopenic. The very high prevalence of osteoporosis and osteopenia may be associated with low calcium intakes among other aspects of lifestyle. Table 1 Anthropometric and bone density data of a subset of 77 postmenopausal Indonesian women Characteristics
Values (range)
Age BMI (kg/m2) (n = 77) 24 h Calcium recall (mg/day) (n = 74) BMD (g/cm2) (n = 77) Femoral neck BMD Femoral neck BMD t-score L1–L4 BMD L1–L4 BMD t-score Femoral neck Osteoporotic (t-score <− 2.5) Osteopenic (t-score between − 2.5 and − 1.0) Normal (t-score >− 1) Lumbar spine Osteoporotic (t-score <− 2.5) Osteopenic (t-score between − 2.5 and − 1.0) Normal (t-score >− 1)
58 (49–74) 24.3 (17.2–30.4) 218.7 (38.0–964.6) 0.771 (0.525–1.032) −3.1–1.1 0.929 (0.654–1.246) − 3.8–1.1 2.6% 53.2% 44.2% 18.2% 48.1% 33.7%
doi:10.1016/j.bone.2009.01.236
321 Failure to perceive increased risk of fracture in women aged 55 years and older. The global longitudinal study of osteoporosis in women R. Lindsaya, P. Sambrookb, J.D. Adachic, N.B. Wattsd, K.G. Saage, J. Compstonf, S. Gehlbachg, A. Wymang, E.S. Sirish a Regional Bone Center, Helen Hayes Hospital, West Haverstraw, USA b University of Sydney-Royal North Shore Hospital, St. Leonards, Sydney, NSW, Australia c St Joseph's Hospital, McMaster University, Hamilton, Canada d Bone Health and Osteoporosis Center, University of Cincinnati, Cincinnati, USA e University of Alabama-Birmingham, Birmingham, USA f University of Cambridge School of Clinical Medicine, Cambridge, UK g UMASS Medical School, Worcester, USA h Columbia University Medical Ctr, New York, USA Aim: To compare self-perceived risk of osteoporotic fracture among women ≥55 years of age with reported risk factors. Methods: GLOW is an observational study of women ≥ 55 recruited by 615 primary physician practices in 10 countries. All non-institutionalized patients who visited the practice within the prior 2 years were eligible. Self-administered questionnaires were mailed (2:1 over-sampling of women ≥65). Respondents rated their perceived risk of fracture vs women of the same age using a 5-point scale from “much lower” to “much higher.” Results: Of the women with no risk factors, 89% believed their risk was the same as or lower than that of women of the same age, whereas the majority of women with risk factors failed to appreciate
317 The MDCT evaluation of human femoral bones symmetry in aging, using QCT and anthropological measurements: A cross-sectional mortuary based study J.L. Hislop-Jambricha, C.D.L. Thomasa, C.A. Briggsb, S. Blauc, C.J. Halld, J.G. Clementa a Dental Science, University of Melbourne, Melbourne, VIC, Australia b Anatomy and Cell Biology, University of Melbourne, Melbourne, VIC, Australia c Forensic Anthropology, Victorian Institute of Forensic Medicine, Melbourne, VIC, Australia d Centre for Synchrotron Science, Monash University, Clayton, VIC, Australia Aim: The aim of this study was to measure gender and agerelated changes, and the degree of symmetry between contra-lateral femora. In order to complete this, it was necessary to evaluate the accuracy and precision of a clinical helical CT unit, used in a mortuary setting, for such measurements. Method: We evaluated bilateral femora from 289 individuals ranging between 15–95 years from both sexes (n = 154 males and 134 females). We used cross sectional data from high-resolution multiple detector-row computed tomography (MDCT) investigations routinely performed at the Victorian Institute of Forensic Medicine (VIFM) in Melbourne, Australia. The study used digital 3D anthropological measurements, adapted from traditional calliper based methods, and quantitative computed tomography (QCT) analysis. Bone mineral density measurements were calibrated by the use of a bone mineral phantom during image acquisition. Individuals were excluded from the study if there were any radiological signs of non-age related bone disease or pathology. Males and females were further divided into age groups representing those ≤ 50 years (n = 73 males and 57 females), and those >50 years (n = 82 males and 77 females) for trend evaluation. Bilateral anthropological and QCT data including values for maximum femoral length and neck of femur volumetric bone density (vBMD) were then obtained. Results: The radiological differences between right and left morphological and quantitative features of the femora are small taking into consideration the precision of the MDCT methods used. Conclusion: This work represents a critical step in the development of bilateral archetypal models of human femoral bone aging in a contemporary urban population using state-ofthe-art 3D radiological imaging techniques.
≤50 >50
Male Female Male Female
Right long femur length (mm)
Left long femur length (mm)
n
mean
Std Deviation
n
Mean
Std deviation
73 57 82 77
469.7 433.7 463.0 425.0
23.1 19.7 25.2 21.2
73 57 82 77
470.9 434.6 453.8 427.0
22.4 19.4 24.9 21.2
Right hip vBMD (gm/cm2) ≤50 >50
Male Female Male Female
Left hip vBMD (gm/cm2)
n
Mean
Std Deviation
n
Mean
Std Deviation
73 57 82 77
295.8 301.1 254.3 231.3
46.7 55.7 47.8 54.6
73 57 82 77
293.3 294.2 254.1 232.5
44.6 55.0 47.2 53.5
doi:10.1016/j.bone.2009.01.233
S107
318 Risk factors for cervical and trochanteric hip fractures— A 10-year follow-up study H. Jokinena, P. Pulkkinena, S. Keinänen-Kiukaanniemib, R. Korpelainena,c, T. Jämsäa a Department of Medical Technology, University of Oulu, Oulu, Finland b Institute of Health Sciences, University of Oulu, Oulu, Finland c Oulu Deaconess Institute, Oulu, Finland The biomechanical origins for cervical and trochanteric hip fractures are different [Pulkkinen et al. (2004) Osteoporos Int 15:274–280, Pulkkinen et al. (2006) JBMR 21:895–901], but there is only limited information on the risk factors for the different types of hip fractures. Our objective was to evaluate the predictive value of calcaneal QUS, radial DXA and clinical risk factors for cervical and trochanteric hip fractures in a 10-year population-based follow-up cohort of elderly women. The study population consisted of 1222 women living at home (70–73 years at baseline). Lifestyle, anthropometric and physical activity data were collected [Korpelainen et al. (2003) Osteoporos Int 14:34–43, Korpelainen et al. (2006) Bone 39:385–91]. Radial BMD was measured by DXA (Osteometer DTX 200). Calcaneal broadband ultrasound attenuation (BUA), speed of sound (SOS) and quantitative ultrasound index (QUI) were assessed (Hologic Sahara). During the 10-year follow-up, 32 cervical and 21 trochanteric hip fractures were observed. The fractured women were taller (p < 0.05) and thinner (p < 0.001) than the non-fractured. They had 9% lower BUA and 7% lower QUI (p < 0.05) than those without fractures. The cervical fracture group had lower BMI and physical activity (p < 0.05) than the women without fractures. The trochanteric fracture group had lower BMI (p < 0.05) and higher coffee consumption (p < 0.05) than those without hip fracture. Multivariate analyses revealed that high BMI protected from all hip fractures (OR 0.87, 95% CI 0.80–0.95), and low physical functioning was a risk factor for fractures (OR 2.72, 1.32–5.61). The risk factors for cervical fractures were BMI (OR 0.86, 0.77–0.96) and low physical activity (OR 3.26, 1.37–7.74), whereas high coffee consumption (> 5 cups per day) was a risk factor for trochanteric fractures (OR 4.49, 1.49–13.49), after adjustment by age, calcium intake and medication. To conclude, BUA and QUI correlated with hip fractures, but other risk factors were more predictive in multivariate analyses. BMI was the primary predictor for cervical but not for trochanteric fractures, whereas high coffee consumption predicted trochanteric fractures. Low physical activity was associated with cervical, but not with trochanteric fractures. Acknowledgement: This study was financially supported by the National Agency for Technology and Innovation (grant nr. 40463/05). (1) Pulkkinen et al. (2004) Osteoporos Int 15:274–280. (2) Pulkkinen et al. (2006) JBMR 21:895–901. (3) Korpelainen et al. (2003) Osteoporos Int 14:34–43. (4) Korpelainen et al. (2006) Bone 39:385–91. doi:10.1016/j.bone.2009.01.234
319 Bone mineral density, calcium intake and general health of a cohort of postmenopausal Filipino women M.C. Krugera, L.M. Schollumb, B. Kuhn-Sherlockb, J.L. Yuc, I. Angeles-Agdeppad, W.H. Chuaa, J.M. Todde a Institute of Food, Nutrition and Human Health, Massey University, Palmerston North, New Zealand b Fonterra Brands Ltd., Palmerston North, New Zealand c Department of Medicine, University of Santo Tomas Hospital, España, Manila, Philippines
S108
Abstracts / Bone 44 (2009) S99–S120
d Department of Science and Technology, Food and Nutrition Research Institute, Taguig City, Philippines e Fonterra Brands Ltd., Auckland, New Zealand
Introduction: Previous bone mineral density (BMD) studies have suggested that Asian women have lower BMD compared with Caucasian women. In the Philippines, use of a Simple Calculation Osteoporosis Risk Estimation (SCORE) (Torralba TP et al. APLAR J Rheumatol 2004; 7: 30–37) aimed to set reference scores for healthy Filipino women suggested that this cohort should not be compared to the Asian data base. The current study aimed to obtain further baseline bone and dietary intake data on a cohort of Filipino women. Objective: To measure bone mineral density, investigate blood biochemistry and assess diet in a subset of Filipino post-menopausal women. Methodology: Bone mineral density was obtained using dual energy x-ray absorptiometry (DXA) (GE Lunar DPX-IQ) and anthropomorphic parameters were measured in a subset of 118 Filipino women at least 5 years post-menopause. Blood samples were taken for blood minerals, haematology, liver and kidney function and nutritional status. Results: Preliminary results indicate that the women had a mean age of 58 ± 4.8 years (range 48–65 years old) and a mean BMI of 24.1 ± 4.13 kg/m2. Very few women reported use of contraceptives or hormone replacement therapy. Mean age of menopause was 48 years (range 45–55) with menarche occurring at age 13 years (range 10– 18). DXA examinations of the femoral neck identified osteoporosis in 4.2% of women (defined as T-score of <− 2.5 SD), and osteopenia in 50.0% (defined as a T-score between − 2.5 to −1.0 SD). Considering BMD at the lumbar spine, 21.2% of women were identified as being osteoporotic and a further 50.8% as osteopenic. Blood minerals were within normal ranges. Several of the women had high blood cholesterol. Serum folate and vitamin B12 levels were normal. Mean daily calcium intake using 24 h recall was estimated to be 372 mg/ day (range 87–883). Conclusion: The preliminary results of this study show an early age of menopause, and a high prevalence of osteoporosis and osteopenia in this cohort of women. These findings may be associated with a low calcium intake as well as other dietary and lifestyle factors. (1) Torralba TP et al. APLAR J Rheumatol 2004; 7: 30–37. doi:10.1016/j.bone.2009.01.235
320 Bone density and calcium intakes in postmenopausal Indonesian women M.C. Krugera, L.M. Schollumb, A. Hestiantoroc, K. Sumaprajac, P. Wijantod, W. Rositawatid, W.H. Chuaa, J.M. Todde a Institute of Food, Nutrition and Human Health, Massey University, Palmerston North, New Zealand b Fonterra Brands Ltd., Palmerston North, New Zealand c Department of Obstetrics and Gynaecology, University of Indonesia, Jakarta, Indonesia d Equilab International and Prodia the CRO Laboratories, Jakarta, Indonesia e Fonterra Brands Ltd., Auckland, New Zealand There are little data available on bone density and dietary calcium intakes for postmenopausal women in Indonesia. In this study we measured bone mineral density (DXA), followed by anthropomorphic measurements, blood collection and a 24 h calcium recall. The study group was a subset of 77 Indonesian women at least 5 years post-menopause. The women had an average age of 58 (range 49–74 years old) and an average BMI of 24.6 (range 17.2–29.8). Ca intakes based on a 24 h
food recall ranged from 38 to 964.6 mg/day, with a mean intake of 218.7 mg/day. This is very low compared to recommended daily intakes (US AI = 1200 mg/day). Ca intake levels will be confirmed with 3 day food frequency diaries at a later date. Serum mineral levels were within normal ranges. DXA examinations of the femoral neck identified 2.6% of women to be osteoporotic (defined as t-score of <− 2.5 SD), and 52% osteopenic (defined as a t-score of − 2.5 to − 1.0 SD). At the lumbar spine, 18.2% of women were identified as being osteoporotic and a further 48.1% as osteopenic. The very high prevalence of osteoporosis and osteopenia may be associated with low calcium intakes among other aspects of lifestyle. Table 1 Anthropometric and bone density data of a subset of 77 postmenopausal Indonesian women Characteristics
Values (range)
Age BMI (kg/m2) (n = 77) 24 h Calcium recall (mg/day) (n = 74) BMD (g/cm2) (n = 77) Femoral neck BMD Femoral neck BMD t-score L1–L4 BMD L1–L4 BMD t-score Femoral neck Osteoporotic (t-score <− 2.5) Osteopenic (t-score between − 2.5 and − 1.0) Normal (t-score >− 1) Lumbar spine Osteoporotic (t-score <− 2.5) Osteopenic (t-score between − 2.5 and − 1.0) Normal (t-score >− 1)
58 (49–74) 24.3 (17.2–30.4) 218.7 (38.0–964.6) 0.771 (0.525–1.032) −3.1–1.1 0.929 (0.654–1.246) − 3.8–1.1 2.6% 53.2% 44.2% 18.2% 48.1% 33.7%
doi:10.1016/j.bone.2009.01.236
321 Failure to perceive increased risk of fracture in women aged 55 years and older. The global longitudinal study of osteoporosis in women R. Lindsaya, P. Sambrookb, J.D. Adachic, N.B. Wattsd, K.G. Saage, J. Compstonf, S. Gehlbachg, A. Wymang, E.S. Sirish a Regional Bone Center, Helen Hayes Hospital, West Haverstraw, USA b University of Sydney-Royal North Shore Hospital, St. Leonards, Sydney, NSW, Australia c St Joseph's Hospital, McMaster University, Hamilton, Canada d Bone Health and Osteoporosis Center, University of Cincinnati, Cincinnati, USA e University of Alabama-Birmingham, Birmingham, USA f University of Cambridge School of Clinical Medicine, Cambridge, UK g UMASS Medical School, Worcester, USA h Columbia University Medical Ctr, New York, USA Aim: To compare self-perceived risk of osteoporotic fracture among women ≥55 years of age with reported risk factors. Methods: GLOW is an observational study of women ≥ 55 recruited by 615 primary physician practices in 10 countries. All non-institutionalized patients who visited the practice within the prior 2 years were eligible. Self-administered questionnaires were mailed (2:1 over-sampling of women ≥65). Respondents rated their perceived risk of fracture vs women of the same age using a 5-point scale from “much lower” to “much higher.” Results: Of the women with no risk factors, 89% believed their risk was the same as or lower than that of women of the same age, whereas the majority of women with risk factors failed to appreciate