A 55-year-old postmenopausal woman comes to the office for a routine health maintenance examination. She feels well. The patient was briefly hospitalized 6 months ago for bronchitis complicated by a rib fracture due to severe coughing. She has no chronic medical conditions or previous surgeries. Her mother was diagnosed with osteopenia at age 70. The patient smoked half a pack of cigarettes daily until age 40 and eats a vegetarian diet. She drinks 2 or 3 cups of coffee every morning and a glass of wine each night. Blood pressure is 120/70 mm Hg, pulse is 84/min, and respirations are 12/min. BMI is 30 kg/m2. Physical examination is unremarkable. Which of the following is the most significant risk factor for bone fracture in this patient?
Osteoporosis risk factors | |
Nonmodifiable |
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Modifiable |
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Osteoporosis is characterized by low bone mass and skeletal disruption, and leads to increased risk of fragility fractures (ie, fractures due to minimal trauma such as falls from a standing height). Major risk factors for osteoporosis include advanced age, postmenopausal status, and low body weight. Significant modifiable risk factors include excessive alcohol intake and sedentary lifestyle. Current smoking also raises the risk, although smoking cessation leads to stabilization of bone density over time and may reduce the risk of fracture.
In patients with osteoporosis, the risk for fragility fracture can be estimated using the FRAX risk calculator. The risk is highest in those with a prior history of fragility fracture; this patient acquired a rib fracture while coughing, which is considered a low-trauma fracture. This is both likely a result of osteoporosis and a risk factor for future bone fracture. Interventions to reduce the risk of fracture include weight-bearing exercise, non-weight-bearing resistance exercise (ie, weight training), adequate intake of calcium and vitamin D, and bisphosphonate therapy.
(Choice A) Excessive alcohol consumption (>2 drinks/day) is associated with an increased risk of fragility fracture. This patient's moderate intake does not confer a significant risk.
(Choice B) Moderate caffeine intake does not increase the risk of osteoporotic fracture, although heavy intake (>4 cups of coffee daily) may carry a small increase in risk.
(Choice C) Low body weight (<58 kg [128 lb]) is associated with an increased risk of fracture, possibly due to a lower peak bone density. This patient, however, is obese.
(Choice D) History of a hip fracture in a first-degree relative is predictive of fracture risk. However, osteopenia is common in elderly women and alone is not a significant familial risk factor.
(Choice F) A strict vegan diet (ie, no intake of any food products of animal origin) is associated with lower bone density. However, it is not clear whether this is due to diet itself or to an increased risk of low body weight in individuals who consume a vegan diet. Current evidence does not show a significant risk of fragility fracture in patients consuming a standard vegetarian diet who do not have low body weight.
Educational objective:
Major risk factors for osteoporosis include advanced age, postmenopausal status, and low body weight. Modifiable risk factors include excessive alcohol intake, sedentary lifestyle, and smoking. In patients with osteoporosis, the risk for fragility fracture is highest in those with a prior history of fragility fracture.