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SummaryBisphosphonates reduce fractures in randomized controlled trials (RCT); however, there is less information from real life. In our population including 14,990 women and 13,239 men, use of bisphosphonates reduced risk of fractures in hip and forearm in women. The magnitude of the effect was comparable to results from RCT.IntroductionThe objective was to examine if treatment with bisphosphonates (BPs) was associated with reduced risk of fractures in the hip and forearm in women and men in the general population.MethodsIn a cohort study based on data from the third wave of the population-based HUNT Study (HUNT3), the fracture registry in Nord-Trøndelag, and the Norwegian Prescription Database, 14,990 women and 13,239 men 50–85 years were followed from the date of participating in HUNT3 (2006–2008) until the date of first fracture in the hip or forearm, death, or end of study (31 December 2012). Hazard ratios with 95% confidence intervals for hip and forearm fracture according to use of BPs were estimated using Cox proportional hazards models with time-dependent exposure. Adjustment for individual FRAX® fracture risk assessment scores was included.ResultsBPs, predominantly alendronate, were used by 9.4% of the women and 1.5% of the men. During a median of 5.2 years of follow-up, 265 women and 133 men had a hip fracture, and 662 women and 127 men had a forearm fracture. Compared with non-users of BPs, the hazard ratios with 95% confidence interval for a fracture among users of BPs adjusted for age and FRAX® were 0.67 (0.52–0.86) for women and 1.13 (0.50–2.57) for men. Among users of glucocorticoids, the corresponding figures were 0.35 (0.19–0.66) and 1.16 (0.33–4.09), respectively.ConclusionsUse of BPs was associated with reduced risk of fractures in hip and forearm in women, and the magnitude of effect is comparable to results from RCTs.

Summary This population study investigated the association between birth characteristics and fracture risk in 11,099 young adults (aged 19–54 years). Our findings indicate that birth weight, gestational age, and birth weight for gestational age were not associated with fractures in the wrist, humerus, hip, and spine in this population. Purpose Skeletal development starts during fetal life, and it is estimated that most bone formation occurs in the 3rd trimester. This study examined the association between birth characteristics and fractures of the wrist, humerus, hip, and spine, in young adults (19–54 years). Methods 11.099 participants in the 3 rd survey of the HUNT Study (2006–2008) were linked with the Medical Birth Registry of Norway and hospital records. Fractures of the wrist, humerus, hip, and spine were identified using ICD9/10 codes between 1988 and 2021. Follow-up was from date of participation in HUNT until a first fracture, emigration, death, or end of study. Cox regression was used to estimate hazard ratios (HR) of fracture associated with birth characteristics (95% CI), adjusted for birth year, sex, maternal age, and maternal morbidity. In a secondary analysis, follow-up started in 1988. Results During a median follow-up of 14.0 years (153,657 person-years), 290 fractures occurred. Mean age at first fracture was 41.4 years (SD 7.4). Overall, there were no clear associations between birth characteristics and fractures in these data. HR for fracture was 0.43 (0.15–1.24) for those with a birth weight < 2.5 kg (reference birth weight 3.5 − 3.9 kg); 1.04 (0.74 − 1.46) for those born small for gestational age (< 10th percentile, reference 10 − 90 th percentile); and 0.63 (0.33 − 1.23) for those born preterm (reference term births). The secondary analysis from 1988, including 539 fractures, gave similar results as the main analysis. Conclusion Birth weight, gestational age, or birth weight for gestational age was not associated with an increased risk of fractures of the wrist, humerus, hip, and spine in young adults.

SummarySelf-perceived health, smoking, and body mass index measured years before the hip fracture predicted excess post-hip fracture mortality, and even hip fracture patients with the most favorable levels of these risk factors had higher mortality than subjects who did not fracture.IntroductionThis study aimed to investigate the impact of pre-fracture self-perceived health, smoking, and body mass index (BMI) on excess post-hip fracture mortality using matched peers without hip fracture as reference.MethodsThe study was based on the Cohort of Norway (CONOR) consisting of 10 regional health studies (1994–2003) and the NOREPOS hip fracture database (1994–2008). A matched cohort design was used to compare survival between hip fracture patients and subjects without fracture (matched on gender, age at participation in CONOR, and study site). Subjects aged ≥60 years were included. Hazard ratios were estimated using stratified Cox regression. Age-standardized mortality was also calculated.ResultsOverall, hip fracture patients (N = 3177) had a 2.26-fold (95 % CI 2.13, 2.40) increased mortality compared to matched subjects (N = 20,282). The highest excess mortality was found in hip fracture patients reporting poor health (HR 4.08, 95 % CI 3.17, 5.26) and daily smoking (HR 3.25, 95 % CI 2.89, 3.66) and in patients with BMI <18.5 (HR 3.07, 95 % CI 2.11, 4.47) prior to the fracture. However, excess mortality was also observed in hip fracture patients in all other categories of BMI, self-perceived health, and smoking.ConclusionsInformation on self-perceived health, smoking, and BMI collected years before hip fracture predicted excess post-hip fracture mortality, and even hip fracture patients with the most favorable levels of these risk factors had higher mortality than the matched subjects who did not fracture. This suggests that both pre-fracture health status and factors related to the hip fracture itself might affect post-hip fracture mortality.

SummaryLow bone mineral density (BMD) gives an increased risk of fractures, which can lead to premature death. Can BMD of the wrist predict mortality? BMD consistent with osteopenia and osteoporosis gave a significantly increased risk of death for both men and women in a general population in Tromsø, Norway.IntroductionTo investigate if bone mineral density (BMD) levels of the distal forearm, consistent with osteopenia and osteoporosis, can predict mortality and if grip strength is an effect modifier.MethodsThe study population constituted 6565 participants aged 50–79 years at baseline in the Tromsø Study wave 4 conducted in 1994–1995. Forearm BMD measured by SXA was categorized as “normal,” “osteopenia,” or “osteoporosis” following WHO’s definition. Cox regression with all-cause mortality as the outcome over 22 years of follow-up was performed for men and women separately, adjusting for health-related factors, as well as BMD by grip strength interaction. A secondary analysis with a 15-year follow-up also adjusted for hip fractures and osteoporotic fractures.ResultsDuring follow-up, 3176 of participants died (47%). Those categorized as osteoporotic had higher mortality hazard ratio (HR) compared to those with normal BMD; men HR = 1.37 (95% confidence interval (CI) 1.19, 1.58) and women HR = 1.32 (1.14, 1.53) were adjusted for age, body mass index, physical activity, smoking habits, education, health status, chronic diseases, and grip strength. Corresponding HRs for osteopenia were men HR = 1.13 (1.00, 1.27) and women HR = 1.17 (1.01, 1.35). Further adjustments for fractures did only marginally attenuate the results, and HRs were still significant. There was no grip strength by BMD interaction.ConclusionMen and women with low distal forearm BMD values, consistent with osteoporosis or osteopenia, had an increased mortality compared to normal BMD participants. High grip strength did not modify this association, and the association remained after adjustment for a range of health-related factors.

SummarySince muscles can influence bone growth and vice versa, we examined if level of physical activity and physical capability tests can predict areal bone mineral density (aBMD). Both high activity level and good test performance were associated with higher aBMD, especially in women.IntroductionMuscle influences bone formation and vice versa. Tests of physical capability and level of physical activity reflect various muscle qualities. We assessed the associations between total hip aBMD and physical activity as well as a range of standardized physical capability tests in an adult general population.MethodsA total of 3 533 women and men aged 40–84 years, participating in the population-based cross-sectional Tromsø study in Norway in 2015–2016, were included. Linear regression was used to assess associations between aBMD and physical activity and the physical capability tests grip strength, Timed Up and Go (TUG), Short Physical Performance Battery (SPPB), and standing balance. Non-linear associations were examined in cubic spline models. Standardized regression coefficients were calculated to compare effect sizes across physical capability measures.ResultsIn fully adjusted models, higher physical activity was positively associated with total hip aBMD in both sexes compared to a sedentary lifestyle. All tests of physical capability were associated with aBMD in women, SPPB showing the strongest association although effect sizes were too small to indicate clinically significant differences (1 point increase corresponded to an aBMD increase of 0.009 g/cm2, CI = 0.005 to 0.012). In men, SPPB and its subtests were associated with aBMD with chair rises showing the strongest association (1 s increase in execution time corresponded to an aBMD decrease of 0.005 g/cm2, CI = 0.008 to 0.002).ConclusionPhysical activity was associated with aBMD, and tests of physical capability can account for some of the aBMD variations in adults aged 40 years and older, especially in women.

Summary The previously reported decline in age-adjusted hip fracture rates in Norway during 1999–2008 continued after 2008. The annual number of hip fractures decreased in women and increased in men. Introduction Norway has among the highest hip fracture incidence rates ever reported despite previously observed declining rates from 1999 through 2008. The aim of the present study was to investigate whether this downward trend continued through 2013, and to compare gender-specific trends in 5 year age-groups during three time periods: 1999–2003, 2004–2008, and 2009–2013. Methods All hip fractures (cervical, trochanteric, and sub-trochanteric) admitted to Norwegian hospitals were retrieved. Annual age-standardized incidence rates of hip fracture per 10,000 person-years by gender were calculated for the period 1999–2013. Time trends were tested by age-adjusted Poisson regression. Results From 1999 through 2013 there were 140,136 hip fractures in persons aged 50 years and above. Age-adjusted hip fracture incidence rates declined by 20.4 % (95 % CI: 18.6–20.1) in women and 10.8 % (95 % CI: 7.8–13.8) in men, corresponding to an average annual age-adjusted decline of 1.5 % in women and 0.8 % in men. Except for the oldest men, hip fracture rates declined in all age-groups 70 years and older. The average annual number of fractures decreased in women (−0.3 %) and increased in men (+1.1 %). Conclusions During the past 15 years, hip fracture rates have declined in Norway. The forecasted growing number of older individuals might, however, cause an increase in the absolute number of fractures, with a substantial societal economic and public health burden.

SummaryThere are geographic variations in hip fracture incidence rates across Norway, with a lower incidence in the coastal areas of the southwest and in the Arctic north, contrary to what may be expected with regard to vitamin D exposure from sunlight. The regional differences have become smaller in recent years.IntroductionTo investigate geographic variation in hip fracture incidence within Norway and regional differences in time trends.MethodsAll hip fractures treated in Norwegian hospitals 2002–2013 were included, and demographic information was obtained from Statistics Norway. Age-standardized incidence rates were calculated separately for 19 counties. Incidence rate ratios with 95% confidence intervals for county differences and time trends were estimated using Poisson regression.ResultsAge-standardized number of hip fractures per 10,000 person-years varied between counties from 69 to 84 in women and from 34 to 41 in men. The highest rates were observed in the southeastern capital city of Oslo, while rates were low in the four northernmost counties. There was an east-west gradient, with lower incidence in the coastal southwest compared with the southeast. Women showed a statistically significant decline during 2002–2013 in almost all counties (up to 31%). In men, only a few counties showed a decline. In both genders, hip fracture rates at age 80 in the combined five counties with the highest rates were significantly higher than in the combined five counties with the lowest rates across the period, although the trends converged over time.ConclusionsIn Norway, the hip fracture incidence was lower in the north compared with the south. In addition, we observed an east-west gradient with the highest incidence in the southeast and lower incidence in the coastal southwest. While there has been an overall declining trend in hip fracture incidence over time, regional differences are still apparent.

SummaryA higher risk of hip fracture was found in areas of Norway at higher elevation and farther from the coast. However, the previously seen county variations could not be explained by these geographical factors.IntroductionNorway is an elongated country extending north of the Arctic Circle with substantial coast-inland variation in topography and climate. Differences in hip fracture incidence between counties and a distinct seasonal variation have previously been shown. The aim of the current study was to explore these variations further by considering associations of height above sea level (elevation) and distance to the coast with hip fracture incidence.MethodsAll patients with hip fractures admitted to Norwegian hospitals in the period 2009–2018 were included. Individual residential elevation and distance to the coast was calculated in Geographic Information Systems and combined with individual-level population data on all Norwegians 50 years of age or older during the observation period, including hospital information on fractures. Age-standardized incidences rate and incidence rate ratios with 95% confidence intervals (IRR, 95% CI) according to elevation and coastal proximity were estimated. The associations were tested using Poisson models adjusting for sex, urban/rural location of residency, country of birth, and season of hip fracture occurrence.ResultsFrom 2009 to 2018, there were 85,776 first hip fractures. There was an increasing risk with higher residential elevation (above versus below mean) for women: IRR = 1.04, 95% CI: 1.02, 1.05), but not for men (IRR = 1.00, 95% CI: 0.97, 1.02). Incidence of hip fracture increased with distance from the coast. Women residing the farthest away from the coast (above versus below mean distance) had a higher age-adjusted incidence of hip fracture compared to those living closer to the coast (IRR = 1.04 (95% CI: 1.02, 1.06), whereas no association was found in men (IRR = 1.00 (95% CI: 1.00, 1.01). Combining elevation and distance to coast showed a higher incidence in women living at high elevation far from the coast compared with women living at low elevation near the coast (IRR = 1.07, 95% CI: 1.04, 1.10). A similar result was found in men but only for hip fractures occurring during March–May (IRR = 1.07, 95% CI: 1.00, 1.15). The previously shown patterns of county differences and seasonal variations were unchanged when considering geography.ConclusionWe found a somewhat higher incidence of hip fracture in inland residents living in areas of high elevation, as compared to those living in more coastal proximity; however, the geographic variation did not explain county and seasonal differences in fracture incidence in Norway. More in-depth analyses on temperature and climate factors may give further clues.

Summary The present study investigated the risk of incident hip fractures according to serum concentrations of vitamin K 1 and 25-hydroxyvitamin D in elderly Norwegians during long-term follow-up. The results showed that the combination of low concentrations of both vitamin D and K 1 provides a significant risk factor for hip fractures. Introduction This case-cohort study aims to investigate the associations between serum vitamin K 1 and hip fracture and the possible effect of 25-hydroxyvitamin D (25(OH)D) on this association. Methods The source cohort was 21,774 men and women aged 65 to 79 years who attended Norwegian community-based health studies during 1994–2001. Hip fractures were identified through hospital registers during median follow-up of 8.2 years. Vitamins were determined in serum obtained at baseline in all hip fracture cases ( n  = 1090) and in a randomly selected subcohort ( n  = 1318). Cox proportional hazards regression with quartiles of serum vitamin K 1 as explanatory variable was performed. Analyses were further performed with the following four groups as explanatory variable: I: vitamin K 1  ≥ 0.76 and 25(OH)D ≥ 50 nmol/l, II: vitamin K 1  ≥ 0.76 and 25(OH)D < 50 nmol/l, III: vitamin K 1  < 0.76 and 25(OH)D ≥ 50 nmol/l, and IV: vitamin K 1  < 0.76 and 25(OH)D < 50 nmol/l. Results Age- and sex-adjusted analyses revealed an inverse association between quartiles of vitamin K 1 and the risk of hip fracture. Further, a 50 % higher risk of hip fracture was observed in subjects with both low vitamin K 1 and 25(OH)D compared with subjects with high vitamin K 1 and 25(OH)D (HR 1.50, 95 % CI 1.18–1.90). The association remained statistically significant after adjusting for body mass index, smoking, triglycerides, and serum α-tocopherol. No increased risk was observed in the groups low in one vitamin only. Conclusion Combination of low concentrations of vitamin K 1 and 25(OH)D is associated with increased risk of hip fractures.

Background Monitoring adherence to the Norwegian food-based dietary guidelines (FBDGs) could provide valuable insight into current and future diet-related health risks. This study aimed to develop and evaluate an index measuring adherence to the Norwegian FBDGs to be used as a compact tool in nutrition surveillance suitable for inclusion in large public health surveys. Methods The Norwegian Dietary Guideline Index (NDGI) was designed to reflect adherence to the Norwegian FBDGs on a scale from 0–100, with a higher score indicating better adherence. Dietary intakes were assessed through 19 questions, reflecting 15 dietary components covered by the Norwegian FBDGs. The NDGI was applied and evaluated using nationally representative dietary data from the cross-sectional web-based Norwegian Public Health Survey which included 8,558 adults.​ Results The population-weighted NDGI score followed a nearly normal distribution with a mean of 65 (SD 11) and range 21–99. Mean scores varied with background factors known to be associated with adherence to a healthy diet; women scored higher than men (67 vs. 64) and the score increased with age, with higher educational attainment (high 69 vs. low 64) and with better self-perceived household economy (good 67 vs. restricted 62). The NDGI captured a variety of dietary patterns that contributed to a healthy diet consistent with the FBDGs. Conclusion The NDGI serve as a compact tool to assess and monitor adherence to the Norwegian FBDGs, to identify target groups for interventions, and to inform priorities in public health policies.​ The tool is flexible to adjustments and may be adaptable to use in other countries or settings with similar dietary guidelines.