An audit of current clinical practice in the management of osteoporosis in Nottingham

BACKGROUND: Osteoporosis is now recognized by the World Health Organization and the Department of Health as a major public health problem. In 1994, the Advisory Group on Osteoporosis (AGO), set up by the Department of Health, recommended that Health Authorities and general practitioner fundholders should purchase bone densitometry services for the management of osteoporosis. The aims of this study were to assess the criteria for requests for bone densitometry from primary care in comparison with the AGO recommendations and to compare the numbers of patients referred with a low-trauma osteoporotic fracture with the expected number of fractures in the Nottingham area. METHODS: Patient referral data and requests for bone densitometry were collected by case note review of all new patients referred to the Nottingham Osteoporosis Clinic over a 12 month period and then compared with the AGO recommendations. The patients referred with a history of a low-trauma fracture were then compared with the expected incidence of fractures, calculated using age-sex-specific fracture incidence data applied to the Nottingham population Census statistics. RESULTS: A total of 413 patients were referred to the Osteoporosis Clinic for bone densitometry. Almost two-thirds of the patients had no clinical indicators for requests for scanning, in comparison with the AGO recommendations. Seventy-seven patients were referred with vertebral fracture, 12 hip, 20 colles and 26 other fractures. Using age-sex-specific fracture incidence data applied to the Nottingham population Census statistics, it was estimated that the expected incidence of hip fractures would be 812, distal forearm fractures 514 and vertebral fractures presenting to clinical attention 625. This represents 1.5 per cent of the total hip fractures, 3.9 per cent distal forearm and 12.3 per cent vertebral actually presenting to the Osteoporosis Clinic. CONCLUSION: Bone densitometry was requested in up to 60 per cent of the patients with no clinical risk factors to warrant bone densitometry. Osteoporosis-related fractures remain unrecognized in clinical practice. The majority of patients do not receive specialist assessment despite being at high risk of future fracture. Further steps are necessary to educate health care professionals in primary and secondary care, but more importantly, to direct services more proactively in those at high risk of future fracture.     

Secular trends in the osteoporotic fractures of the distal humerus

Osteoporosis, with its sequelae of fracture, is a major, continuously increasing threat to the health of the elderly, and therefore reliable epidemiological information is needed for assessment of the fracture development in the future and for effective fracture prevention. However, very little population-based information is available concerning the nationwide numbers, incidences and especially secular trends of osteoporotic fractures other than those occurring at the hip. We determined the current trends in the number and incidence of osteoporotic fractures of the distal humerus in Finnish women in 1970–1995 by collecting from the National Hospital Discharge Register all female patients aged 60 years or more who were admitted to our hospitals in 1970–1972, 1974–1975, 1978–1980, 1983–1985 and 1988–1995 for primary treatment of first osteoporotic fracture of the distal humerus. The fracture was defined as osteoporotic if it occurred on individuals aged 60 years or more as a consequence of a moderate or minimal trauma only (a fall from standing height or less). We also predicted the fracture development till the year 2030 by a regression model, a model that took into account the predicted changes in the fracture incidences and population at risk. The number and incidence (per 100,000 women) of osteoporotic fractures of the distal humerus in Finnish women aged 60 years or more increased from 42 (number) and 11 (incidence) in 1970 to 175 and 30 in 1995. The age-adjusted incidence of osteoporotic fractures of the distal humerus also increased, from 12/100,000 women in 1970 to 28/100,000 women in 1995. If this trend continues, the number of these fractures in Finnish women will be almost three-fold in the year 2030 compared with that in 1995. We conclude that the number of osteoporotic fractures of the distal humerus in elderly Finnish women is increasing more rapidly than can be accounted for by the demographic changes alone and therefore effective preventive measures are imperative to keep this problem in control.     

Risk of postmenopausal hip fracture in Mexican American women.

To assess the risk of hip fracture in Mexican Americans, the ethnicity of 80 women aged 50 years and over admitted with hip fractures to a Texas hospital was compared with that of age-matched women hospitalized for other reasons. The risk of fracture for Mexican Americans was only 35 per cent that of Whites (95% CI = 19 per cent, 65 per cent). This finding was confirmed in a chart survey performed in a second hospital population. These results suggest that Mexican American women may receive less potential benefit from preventive measures for hip fracture than Whites.     

Lower limb fractures and registration for alcoholism

During two consecutive years 607 individuals with lower limb fractures were diagnosed. Half of the individuals, 315, were women and only 14 of them had an earlier registration for alcoholism. In the 292 men, however, 73 men or 25%, had been registered at the Department of Alcohol Diseases at least once during the 13 years of observation, the highest registration frequency (30%) was noted in the malleolar fractures in men. In males, 30-50 years of age, there were 37 per cent who had a registration for alcoholism, the highest registration (44%) was noted for fracture of the tibial diaphysis. Males with fracture of the proximal end of the femur between 16-80 years of age were registered for alcoholism in 23%.     

The Cost-Effectiveness of Bisphosphonates in Postmenopausal Women Based on Individual Long-Term Fracture Risks

OBJECTIVES: Cost-effectiveness analyses are routinely based on data from group averages, restricting its generalizibility to those with below- or above-average risk. A pharmaco-economic model that used individualized risks for fractures was developed in order to take into account patient heterogeneity. METHODS: Data were obtained from The Health Improvement Network research database of general practitioners, comprising a UK general population of women aged more than 50 years (N = 330,000). Mortality and hip, vertebral, and other osteoporotic fracture risks for each individual were estimated by age, body mass index (BMI), smoking, and other clinical risk factors. Estimates on costs, EuroQol (EQ-5D) utilities, and treatment efficacy were obtained from a UK national report (the National Institute for Clinical Excellence) and outcomes were simulated over a 10-year period. RESULTS: It was found that the cost per quality-adjusted life-year (QALY) gained was lower in elderly women and in women with fracture history. There was a large variability in the cost-effectiveness with baseline fracture risk and with clinical risk factors. Patients with low BMI (<20) had considerable better cost-effectiveness than patients with high BMI (>or=26). Using a cost-acceptability ratio of 30k pounds per QALY gained, bisphosphonate treatment became cost-effective for patients with a 5-year risk of 9.3% (95% confidence interval [CI] 8.0-10.5%) for osteoporotic fractures and of 2.1% (95% CI 1.5-2.7%) for hip fractures. Including bone mineral density in the risk assessment, the cost per QALY gained was 35k pounds in women at age 60 with a fracture history and a T-score of -2.5 (at age 80, this was 3k pounds). CONCLUSION: A pharmacoeconomic model based on individual long-term risks of fracture improves the selection of postmenopausal women for cost-effective treatment with bisphosphonates.     

Osteoporotic fractures in the elderly

The epidemiology of injuries is a significant factor in the structure of mortality and causes of hospitalization of elderly people. Epidemiologically, consequences of injury, i.e. their complications, from reduced mobility, sores, contractures, infections, all over to mortality from hypostatic pneumonia, are strongly emphasized in the elderly. In 2005, more than 17.0% of Croatian population were older than 65 years of age, and 27.0% of the population were over 60. Osteoporotic bone fractures are frequent among the elderly; 5,489 hip fracture cases were registered in Croatia during 2005, and 382 of them died from fracture complications. In total, 97.38% of the dead patients were over 65 years of age. Besides hip fractures, other typical osteoporotic fractures are fractures of vertebral bodies, distal part of the radius, humerus, pelvic bones, etc. Regardless of conservative or surgical treatment for osteoporotic fracture, it is essential to stress out that after the care of fractured bone has been provided, appropriate diagnostic examinations and pharmacological treatment of osteoporosis should also be done. Orthopedic and traumatic surgeons all over the world have to understand that conservative or surgical treatment of osteoporotic fracture of any localization is just one link in this complex chain of managing the disease - osteoporotic treatment.     

Associations between fracture incidence and use of depot medroxyprogesterone acetate and anti-epileptic drugs in women with developmental disabilities

PURPOSE: We sought to evaluate any association between incidence of osteoporotic fractures and use of depot medroxyprogesterone acetate (DMPA) and/or anti-epileptic drugs (AEDs) among women and girls with developmental disabilities. METHODS: Cross-sectional population-based observational study of all noninstitutionalized females with developmental disabilities age >/=13 who received fee-for-service Medicaid in Washington State during 2002 (n = 6,773), using administrative data. MAIN FINDINGS: In a sample of 6,773 females, 140 women (2%) had an osteoporotic fracture during 2002. Among 340 users of DMPA, 13 (3.8%) had an osteoporotic fracture with an odds ratio of 2.4 (95% confidence interval [CI], 1.3-4.4) for fracture compared to nonusers. Among 1,909 users of AEDs, 60 (3.1%) had an osteoporotic fracture with an odds ratio of 1.9 (95% CI, 1.3-2.6) for fracture compared to nonusers. We controlled for use of drugs (DMPA or AEDs), age and race (as white or other racial and ethnic groups). CONCLUSIONS: Use of either AEDs or DMPA by women with developmental disabilities is associated with significantly increased incidence of fracture. Women and girls who have developmental disabilities may be poor candidates for DMPA use owing to increased risk of fractures. Further research is indicated to 1) determine the specific risks profile of DMPA for this population, 2) explore alternative means of managing significant menstrual problems and contraceptive needs in this population, and 3) screen current and previous users of DMPA and chronic users of AEDs for osteoporosis risk, regardless of age.     

CBO guideline 'Osteoporosis' (second revision

Risk factors for osteoporotic fractures that can be used for case-finding according to the recent guidelines from the Dutch Institute for Health Care Improvement (CBO) include: a vertebral fracture, a fracture past the age of 50, a positive family history, low body weight, severe immobility and the use of corticosteroids. Measurement of bone mineral density (BMD) is only recommended for case-finding and not for population screening. Measurement of the BMD is advised in women > or = 50 years of age with a fracture, women with a vertebral fracture regardless of age, women > or = 60 years of age with three of the following risk factors, and women > or = 70 years of age with two of the following risk factors: positive family history, low body weight and severe immobility. Persons with less than 1000-1200 mg calcium in their daily food who are using corticosteroids, persons with osteoporotic fractures and persons who are being treated with drugs for osteoporosis are eligible for calcium supplementation. Vitamin D supplementation is recommended for persons who do not come outdoors. For the drug treatment of osteoporosis in the first years after menopause, oestrogens, tibolone and raloxifene may be used. It is recommended that postmenopausal women with one or more osteoporotic vertebral fractures or an increased risk and a T-score below -2.5 be treated with a bisphosphonate. Patients who are expected to be treated with > or = 15 mg prednisolone equivalent per day for more than 3 months and postmenopausal women and older men (> or = 70) who will be treated with > or = 7.5 mg prednisolone equivalent per day should be started on a bisphosphonate as soon as possible. Other patients who will be treated with > or = 7.5 mg prednisolone equivalent per day should take a bisphosphonate if their Z-score is below -1 or their T-score is below -2.5.     

Pharmacologic treatment of osteoporosis--2011

Osteoporosis affects approximately 9% of the population in Hungary resulting in about 100 000 osteoporotic fractures annually. Thirty-five percent of patients with hip fractures due to osteoporosis will die within 1 year. Direct costs of osteoporosis exceed 25 billion forints per year. Apparently, cost-effective reduction of bone loss and consequent fracture risk will add up to not only financial savings but improvement in quality of life, as well. A number of pharmacological modalities are available for this purpose. The mainstay of the treatment of osteoporosis is the bisphosphonate group that includes effective anti-resorptive compounds mitigating bone loss and fragility. The recently registered denosumab exhibits similar efficacy by neutralizing RANK ligand, however, marked differences can be observed between the two drug classes. Strontium has a unique mechanism of action by rebalancing bone turnover, and thus, providing an efficient treatment option for the not fast bone losers who are at high fracture risk. The purely anabolic teriparatide is available for the extremely severe osteoporotic patients and for those who do not respond to other types of therapy. Older treatment options such as hormone replacement therapy, raloxifene, tibolone or calcitonin may also have a restricted place in the management of osteoporosis.     

Pattern, severity and aetiology of injuries in victims of assault.

Although the incidence of assault and other violent crime is increasing in the UK, the cause and overall pattern of injury, and the need for admission have not been defined in adult victims who attend hospital. In a prospective study, all 539 adult victims of assault attending a major city centre Accident & Emergency department in 1986 were therefore interviewed and examined. Facial injury was extremely common: 83% of all fractures, 66% of all lacerations and 53% of all haematomas were facial. The upper limb was the next most common site of injury (14% of all injuries). Twenty-six per cent of victims sustained at least one fracture and nasal fractures were the most frequently observed skeletal injuries (27%) followed by zygomatic fractures (22%) and mandibular body (12%), angle (12%) and condyle (9%) fractures. Seventeen per cent of victims required hospital admission. Overall, the type of injury observed correlated with the alleged weapon used (P = less than 0.001) though 20% of victims who reported attacks with sharp weapons sustained only haematomas or fractures. Injury most often resulted from punching (72% of assaults) or kicking (42% of assaults). Only 6% of victims reported injury with knives but 11% were injured by broken drinking glasses. Those who were kicked were most likely to need hospital admission.     

Fractures and lifestyle: effect of cigarette smoking, alcohol intake, and relative weight on the risk of hip and forearm fractures in middle-aged women

Cigarette smoking, alcohol consumption and low relative weight are often cited as risk factors for osteoporosis. In a prospective cohort study of 96,508 middle-aged nurses 35 to 59 years of age we found that smoking was not a risk factor for hip and forearm fracture. Women who drank more than 15 grams of alcohol per day and whose relative weight was less than 21 kg/m2 were at increased risk of fractures, but these risk factors were not independent. Only the combination of alcohol intake and thinness substantially increased the likelihood of fracture. The low weight women consuming more than one drink per day comprised but 4 per cent of our population of middle-class women and sustained 6 per cent of the fractures.     

Exposure to persistent organochlorine compounds through fish consumption and the incidence of osteoporotic fractures

OBJECTIVES: Animal studies have shown that persistent organochlorine compounds (POC) impair normal bone metabolism and result in increased bone fragility. These findings may have health implications for POC-exposed human populations. The aim of the present study was to assess the impact of POC-contaminated fish on the self-reported fracture incidence of Swedish fishermen and their wives. METHODS: A postal questionnaire was sent to 2096 fishermen and 1602 fishermen's wives from the Swedish east (exposed) coast and 4584 fishermen and 4217 fishermen's wives from the west (unexposed) coast. Self-reported fractures, together with specified current fish consumption and information about potential confounders, were registered. The response rates varied between 50% and 59%. The age distributions of the nonrespondents and respondents were almost identical. Hip, vertebral, and wrist fractures were classified as osteoporotic. The fracture incidence rates for specific skeletal locations were based on allocated fractures and person-years under risk from the age of 25 years until the time of fracture or the end of follow-up. RESULTS: No differences in fracture incidence were observed between the east and west-coast cohorts. East-coast wives with more than one meal of fatty fish from the Baltic Sea per month had, however, an increased fracture incidence as compared with that of the east-coast wives who ate, at most, one such meal per month (age-adjusted incidence rate ratio 1.68, 95% confidence interval 1.00-2.84). No such exposure-response association was found for the fishermen. CONCLUSIONS: The present study only minimally supports an association between POC exposure through contaminated fish and an increased risk of osteoporotic fractures.     

Efficacy of long-term fluoride and calcium therapy in correcting the deficit of spinal bone density in osteoporosis

Long-term fluoride therapy for osteoporosis has been shown to increase the thickness of vertebral trabeculae as seen on spinal radiographs. To determine if this qualitative finding represents a measurable increase in spinal bone density, quantitative computed tomography was utilized to measure trabecular vertebral body density (TVBD) in the lumbar spine of 18 female osteoporotic patients, all of whom had been treated with sodium fluoride, 77 +/- 13 mg/day (mean +/- SD), and calcium, 1000 mg/day, for 57 +/- 24 months. TVBD in these fluoride treated osteoporotic patients (132 +/- 82 mg/cm3) was found to be significantly greater than mean TVBD for an age-matched group of untreated female osteoporotic patients (51 +/- 21 mg/cm3, n = 89, p less than 0.001). The value for TVBD in the long-term fluoride treated osteoporotics was not only similar to previously published values for TVBD (104 +/- 30 mg cm3) in normal females of similar age, but was also above the calculated TVBD "fracture threshold" of 100 mg/cm3 for females. Only one of the 18 fluoride treated osteoporotics continued to have spinal fractures during therapy, accounting for 4 fractures per 87.2 patient years of observation, a value which is significantly lower than the published incidence of 76 fractures per 91 patient years for untreated osteoporotic patients (p less than 0.001). Together, these findings demonstrate that long-term fluoride and calcium therapy for osteoporosis increases TVBD in the majority of patients within a reasonable time frame and significantly reduces the risk for spinal fractures.(ABSTRACT TRUNCATED AT 250 WORDS)     

Invasive pneumococcal disease in Australia, 2001.

There were 1,681 cases of invasive pneumococcal disease (IPD) notified to the National Notifiable Diseases Surveillance System in Australia in 2001; a rate of 8.6 cases per 100,000 population. The notification rate varied between states and territories and by geographical region with the highest rates in the north of the country. Pneumococcal disease was reported most frequently in children aged less than 5 years (47.3 cases per 100,000 population). Enhanced surveillance for IPD was carried out in the Northern Territory, Western Australia, South Australia, Victoria, Tasmania and metropolitan areas of New South Wales, encompassing 72 per cent of the population and providing additional data on 86 per cent of all notified cases. Enhanced surveillance data revealed high rates of pneumococcal disease in Indigenous Australians. Rates of IPD in Indigenous children aged less than 5 years were as high as 483 cases per 100,000 population in the Northern Territory. The clinical presentation of IPD was most commonly pneumonia (56%) and bacteraemia (36%). There were 125 deaths attributed to IPD resulting in an overall case fatality rate of 8.6 per cent. More than half (54%) of all cases had a recognised risk factor for IPD. Eighty-six per cent of serotypes identified in non-indigenous children compared with only 55% of serotypes in Indigenous children were in the 7-valent vaccine. Antibiotic susceptibility testing showed reduced susceptibility to penicillin in 12 per cent, and to third generation cephalosporins in 5 per cent of isolates. These are the first national data available on IPD in Australia and will assist in evaluating the impact of the newly introduced conjugate vaccine and guide overall pneumococcal vaccine strategies.     

Fracture rates lower in rural than urban communities: the Geelong Osteoporosis Study

BACKGROUND: Urban and rural communities differ in the incidence of several diseases including coronary heart disease and some cancers. Lower hip fracture rates among rural than urban populations have been reported but few studies have compared rural and urban fractures at sites other than the hip. OBJECTIVE: To compare total and site specific fracture rates among adult residents of rural and urban communities within the same population. DESIGN AND SETTING: This is a population based study on osteoporosis in Australia. All fractures occurring in adult residents over a two year period were ascertained using radiological reports. The rural and urban areas are in close proximity, with the same medical, hospital, and radiological facilities permitting uniform fracture ascertainment. MAIN OUTCOME MEASURES: All fracture rates were age adjusted and sex adjusted to the Australian population according to the 1996 census of the Australian Bureau of Statistics and described as the rate per 10 000 person years. The p values refer to the adjusted rate difference. RESULTS: The hip fracture rate (incidence per 10 000 person years) was 32% lower (39 v 57, p<0.001), and the total fracture rate 15% lower (160 v 188, p=0.004) among rural than urban residents, respectively. The lower fracture rates in the rural population were also apparent for pelvic fractures. CONCLUSION: In the older rural population, lower fracture rates at sites typically associated with osteoporosis suggest environmental factors may have a different impact on bone health in this community. If the national rate of hip fracture could be reduced to that of the rural population, the projected increase in hip fracture number attributable to aging of the population could be prevented.     

Die sozioökonomische Bedeutung der Osteoporose

Osteoporosis is a highly abundant disturbance of bone metabolism. The disease has gained significant public health impact, since it has been recognized as a major cause of fragility fractures among the elderly. In Germany, costs directly or indirectly related to osteoporosis are estimated at about 4–5 billion DM per year. 80% of these are due to in hospital treatment of fractures, mostly hip fractures. However, estimates of the socioeconomic burden of osteoporosis as a whole remain difficult. First, in lack of national fracture registries, cost calculations in Germany have to be mainly based on hospital discharge data. Secondly, while hip fractures can be considered a hard endpoint with almost complete capture, this is not true for most other types of osteoporotic fracture. In particular, vertebral fractures have been shown to be subject to mis- or underdiagnosis, although they are probably the most frequently occuring type of osteoporotic fracture. Third, data regarding the longterm outcome among fracture patients are scarce. It is therefore likely that costs of longterm care in nursing or older peoples' homes as a sequelae of osteoporosis are underestimated. Finally, osteoporosis-related loss of quality of life has been hardly taken into consideration so far, as the instruments allowing its assessment have just been developed. Nevertheless, the currently available data indicate that with respect to in hospital care, the socioeconomic burden of hip fracture alone compares to that of cardiovascular events (stroke, heart attack). This mainly results from an exponential increase in hip fracture incidence among women and men after the age of 70–75 years. 75% of cases are women, which is mainly due to a higher average life expectancy among women compared to men. Prevention of hip fractures appears to be a major public health goal, in view of a continuous demographic trend towards an aging population, and a separate, secular trend towards an increase in age-specific hip fracture rates reported from some European countries. As epidemiological data have pointed out the multifactorial pathogenesis of hip fracture, prevention needs to focus upon the prevention of osteoporosis and the prevention of falls among the elderly alike.     

Bisphosphonate treatment prevents hip fractures in 70-79 year old women with osteoporotic vertebral fractures

According to the data of a fracture intervention trial, in women aged 55-80 years with vertebral fractures or osteoporosis diagnosed by bone mineral density measurement, treatment with the bisphosphonate alendronate prevented hip fractures with numbers-needed-to-treat within 5 years of treatment of 46 and 66, respectively. In a large risedronate hip fracture study, this new bisphosphonate only showed a beneficial effect in women aged 70-79 years with moderately severe osteoporosis as judged by femoral neck T-score, when one or more vertebral fractures were present at the start of the treatment. The number-needed-to-treat was 29. However, in women aged over 80 years and who were selected predominantly on the basis of clinical risk factors for hip fracture, no effect was found with this drug on hip fracture rate, suggesting that most were not osteoporotic and/or that the clinical risk factors used did not have the clinical utility in identifying hip fracture risk. Other factors besides osteoporosis may play a more important role in causing hip fracture in this elderly group. Diagnosis of osteoporotic vertebral fractures in women aged 70-79 years is predictive of not only new vertebral fractures but also of hip fractures, and could therefore form an indication for drug treatment.     

Tuberculosis notifications in Australia, 1999.

Australia has one of the lowest incidence of tuberculosis in the world. The crude annual notification rate for tuberculosis (TB) has remained stable at between 5 and 6 per 100,000 population since 1991. In 1999, there were a total of 1,159 TB notifications in Australia of which 1,117 were new TB cases, and 42 were relapsed cases. The corresponding annual notification rate for new and relapsed TB was 5.9 and 0.2 per 100,000 population respectively. People born overseas accounted for 83 per cent of the notified cases. TB notification rates remain highest among overseas-born residents from high prevalence countries, and indigenous Australians. The lowest rates of disease are in the non-indigenous, Australian born population and data from the last 7 years indicate that the rate of tuberculosis in this population is continuing to fall.     

Hospitalisations,admission costs and re‐fracture risk related to osteoporosis in Western Australia are substantial: a 10‐year review

Objective: To quantify hospitalisation costs to Western Australia (WA) for osteoporosis‐related fractures and estimate risk of readmission after incident fracture. Methods: All hospitalisation records for WA residents aged ≥50 years admitted to a WA hospital between 2002 and 2011 due to osteoporotic fractures were extracted from the WA Hospital Morbidity Data System. Data linkage enabled identification of the first (index) fracture admission, determination of subsequent osteoporotic fracture‐related readmissions, and quantification of total admission costs and bed days. Cox proportional hazard models assessed factors influencing first readmission. Results: A total of 5,326 patients were admitted to WA hospitals for an index fracture. Of the 2,037 (38.2%) patients who sustained a re‐fracture requiring readmission, 1,223 (23.0%) had one re‐fracture episode, 453 (8.5%) has two, and 361 (6.8%) has three or more re‐fracture episodes requiring readmission. Cost of index admissions was $57,007,262 while $48,948,623 was associated with readmissions (CPI‐adjusted to 2011/12). Cumulative probability of readmission within six months of the index admission was 20% (males) and 17% (females). Conclusions: Osteoporotic fracture‐related hospitalisations impose a substantial financial impact on WA, exceeding $100 million in a decade. Implications: Considering the large system costs, policy and programs to improve identification of index fractures and initiation of osteoporosis treatments and primary prevention initiatives are justified.     

Milk, dietary calcium, and bone fractures in women: a 12-year prospective study.

OBJECTIVES: This study examined whether higher intakes of milk and other calcium-rich foods during adult years can reduce the risk of osteoporotic fractures. METHODS: This was a 12-year prospective study among 77761 women, aged 34 through 59 years in 1980, who had never used calcium supplements. Dietary intake was assessed with a food-frequency questionnaire in 1980, 1984, and 1986. Fractures of the proximal femur (n = 133) and distal radius (n = 1046) from low or moderate trauma were self-reported on biennial questionnaires. RESULTS: We found no evidence that higher intakes of milk or calcium from food sources reduce fracture incidence. Women who drank two or more glasses of milk per day had relative risks of 1.45 for hip fracture (95% confidence interval [CI] = 0.87, 2.43) and 1.05 for forearm fracture (95% CI = 0.88, 1.25) when compared with women consuming one glass or less per week. Likewise, higher intakes of total dietary calcium or calcium from dairy foods were not associated with decreased risk of hip or forearm fracture. CONCLUSIONS: These data do not support the hypothesis that higher consumption of milk or other food sources of calcium by adult women protects against hip or forearm fractures.