To prospectively assess changes in health-related quality of life (HRQOL) over 10 years, by age and sex, and to compare measured within-person change to estimates of change based on cross-sectional data. Participants in the Canadian Multicentre Osteoporosis Study completed the 36-item short form (SF-36) in 1995/1997 and 2005/2007. Mean within-person changes for domain and summary components were calculated for men and women separately, stratified by 10-year age groups. Projected changes based on published ageand sex-stratified cross-sectional data were also calculated. Mean differences between the two methods were then estimated, along with the 95 % credible intervals of the differences. Data were available for 5,569/9,423 (59.1 %) of the original cohort. Prospectively collected 10-year changes suggested that the four physically oriented domains declined in all but the youngest group of men and women, with declines in the elderly men exceeding 25 points. The four mentally oriented domains tended to improve over time, only showing substantial declines in vitality and role emotional in older women, and all four domains in older men. Cross-sectional estimates identified a similar pattern of change but with a smaller magnitude, particularly in men. Correspondence between the two methods was generally high. Changes in HRQOL may be minimal over much of the life span, but physically oriented HRQOL can decline substantially after middle age. Although clinically relevant declines were more evident in prospectively collected data, differences in 10-year age increments of cross-sectional data may be a reasonable proxy for longitudinal changes, at least in those under 65 years of age. Results provide additional insight into the natural progression of HRQOL in the general population.
Zhou W et al., 2013·J Musculoskelet Neuronal Interact·
Our objective was to study changes in calcium and vitamin D intakes over time, and their cross-sectional and longitudinal associations with bone mineral density (BMD). We followed 9382 women and men aged ≥25 and 899 aged 16-24, for 10 and 2 years respectively. Calcium and vitamin D intakes increased over time in adults, but decreased in women aged 16-18. The increased intakes in adults were largely attributable to the increased use of calcium and/or vitamin D supplements. Both the percentage of supplement users and average dose among users increased over time. There was nevertheless a high prevalence of calcium and vitamin D intake below the estimated average requirement. At baseline, higher calcium and vitamin D intakes were associated with higher total hip and femoral neck BMD in young men, and cumulatively high levels of calcium and vitamin D intakes over time contributed to better BMD maintenance at lumbar spine and hip sites in adult women. Although total intakes, particularly of vitamin D, frequently fell below the Institute of Medicine recommendations despite an increase over time in supplement use, we found some positive associations between total calcium and vitamin D intake and bone health.
Measurement and Statistics · Instrument Development and Validation
Hopman WM et al., 2009·Can J Public Health·
Open Access
Normative data for the SF-36 measure of health-related quality of life (HRQOL) exist for those over 25 years of age, based on data from the population-based Canadian Multicentre Osteoporosis Study (CaMos). CaMos recently recruited a sample of young Canadians aged between 16 and 24 years. The purpose of this study was to develop normative SF-36 data for this age group. After direct standardization to the Canadian population, means, standard deviations (SD), 95% confidence intervals and percentage at floor and ceiling were produced for the eight domain and two summary scores of the SF-36. Domains are scored from 0 (poor) to 100 (excellent). Summary scores are standardized to a mean of 50, with scores over 50 representing better than average and below 50 poorer than average function. Separate analyses were completed for men and women, and for those 16-19 years and 20-24 years. The 1,001 community-based participants consisted of 474 men and 527 women from nine CaMos centres across Canada. Mean Physical Component Summary scores were 53.9 (SD = 6.9) and 53.3 (SD = 5.7) for young men and women, respectively. The equivalent Mental Component Summary scores were 49.3 (SD = 9.7) and 48.8 (SD = 8.9). In general, men scored somewhat higher than women, and younger (16-19 years) women scored higher than older (20-24 years) women, although the differences were small. HRQOL is good in this cohort of young Canadians. Both men and women scored somewhat better on physically than mentally oriented domains. In general, Canadian scores were similar to those of the US, while a comparable Swedish sample scored higher than both countries on most domains. Results underscore the importance of taking country, age and gender into consideration when using normative data. Objectifs: Des données normatives sur la qualité de vie liée à la santé (QVLS) dans le questionnaire sur l’état de santé SF-36 existent déjà pour les personnes de plus de 25 ans grâce aux données représentatives de l’Étude canadienne multicentrique sur l’ostéoporose (CaMos). La CaMos a recruté récemment un échantillon de jeunes Canadiens âgés de 16 à 24 ans. Le but de notre étude était d’élaborer des données normatives SF-36 pour ce groupe d’âge. MÉTHODE: Après avoir effectué une standardisation directe à partir de la population canadienne, nous avons calculé les moyennes, les écarts-types (ET), les intervalles de confiance de 95% et le pourcentage minimum et maximum pour les huit domaines et les deux notes globales du SF-36. Les domaines sont notés de 0 (mauvais) à 100 (excellent). Les notes globales sont standardisées selon une moyenne de 50, les notes de plus de 50 indiquant des fonctions supérieures à la moyenne, et les notes de moins de 50, des fonctions inférieures à la moyenne. Nous avons analysé séparément les hommes des femmes, et le groupe des 16 à 19 ans de celui des 20 à 24 ans. RÉSULTATS: Les 1 001 participants sélectionnés dans la communauté comprenaient 474 hommes et 527 femmes des neuf centres CaMos du Canada. Les notes globales moyennes pour la composante santé physique étaient de 53,9 (ET=6,9) et de 53,3 (ET=5,7) pour les jeunes hommes et les jeunes femmes, respectivement. Les notes équivalentes pour la composante santé mentale étaient de 49,3 (ET=9,7) et de 48,8 (ET=8,9). En général, les hommes ont obtenu des notes un peu meilleures que celles des femmes, et les femmes plus jeunes (16 à 19 ans), de meilleures notes que leurs aînées (20 à 24 ans), mais ces différences étaient faibles. La QVLS est bonne dans cette cohorte de jeunes Canadiens. Tant les hommes que les femmes ont obtenu des notes un peu meilleures pour la santé physique que pour la santé mentale. En général, les notes canadiennes étaient semblables à celles des États-Unis, mais un échantillon suédois comparable a obtenu des notes plus élevées que ces deux pays dans la plupart des domaines. Ces résultats soulignent l’importance de tenir compte du pays, de l’âge et du sexe lorsqu’on utilise des données normatives.
Fractures have largely been assessed by their impact on quality of life or health care costs. We conducted this study to evaluate the relation between fractures and mortality. A total of 7753 randomly selected people (2187 men and 5566 women) aged 50 years and older from across Canada participated in a 5-year observational cohort study. Incident fractures were identified on the basis of validated self-report and were classified by type (vertebral, pelvic, forearm or wrist, rib, hip and "other"). We subdivided fracture groups by the year in which the fracture occurred during follow-up; those occurring in the fourth and fifth years were grouped together. We examined the relation between the time of the incident fracture and death. Compared with participants who had no fracture during follow-up, those who had a vertebral fracture in the second year were at increased risk of death (adjusted hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.1-6.6); also at risk were those who had a hip fracture during the first year (adjusted HR 3.2, 95% CI 1.4-7.4). Among women, the risk of death was increased for those with a vertebral fracture during the first year (adjusted HR 3.7, 95% CI 1.1-12.8) or the second year of follow-up (adjusted HR 3.2, 95% CI 1.2-8.1). The risk of death was also increased among women with hip fracture during the first year of follow-up (adjusted HR 3.0, 95% CI 1.0-8.7). Interpretation: Vertebral and hip fractures are associated with an increased risk of death. Interventions that reduce the incidence of these fractures need to be implemented to improve survival.
Vertebral fractures are the most common osteoporotic fracture, and patients with prevalent vertebral fractures have a greater risk of future fractures. However, radiographically determined vertebral fractures are not identified as a distinct risk factor in the World Health Organization (WHO) fracture risk assessment tool. The objective of this study was to evaluate and compare potential risk factors including morphometric spine fracture status and the WHO risk factors for predicting 5-yr fracture risk. We hypothesized that spine fracture status provides prognostic information in addition to consideration of the WHO risk factors alone. A randomly selected, population-based community cohort of 2761 noninstitutionalized men and women > or =50 yr of age living within 50 km of one of nine regional centers was enrolled in the Canadian Multicentre Osteoporosis Study (CaMOS), a prospective and longitudinal cohort study following subjects for 5 yr. Prevalent and incident spine fractures were identified from lateral spine radiographs. Incident nonvertebral fragility fractures were determined by an annual, mailed fracture questionnaire with validation, and nonvertebral fragility fracture was defined by investigators as a fracture with minimal trauma. A model considering the WHO risk factors plus spine fracture status provided greater prognostic information regarding future fracture risk than a model considering the WHO risk factors alone. In univariate analyses, age, BMD, and spine fracture status had the highest gradient of risk. A model considering these three risk factors captured almost all of the predictive information provided by a model considering spine fracture status plus the WHO risk factors and provided greater predictive information than a model considering the WHO risk factors alone. The use of spine fracture status along with age and BMD predicted future fracture risk with greater simplicity and higher prognostic accuracy than consideration of the risk factors included in the WHO tool.
Routine bone mineral densitometry (BMD) screening has been recommended for women aged >or=65 yr (Osteoporosis Canada [OC], International Society for Clinical Densitometry [ISCD], Canadian and United States Task Forces on Preventative Healthcare, and National Osteoporosis Foundation) and for men >or=65 yr (OC) or >or=70 yr (ISCD). We estimated the number of older Canadians needed to screen (NNS) by BMD to detect an undiagnosed case of osteoporosis, using prospective, multicenter, population-based data from the Canadian Multicentre Osteoporosis Study (CaMos). We included participants aged >or=65 yr with baseline dual-energy X-ray absorptiometry (DXA) BMDs at the femoral neck and lumbar spine (L1-L4). Osteoporosis was defined by a T-score or=65 yr. The percentage prevalence and 95% confidence intervals were determined. In individuals aged >or=65 yr, the prevalence of osteoporosis was 25.6% in women (95% confidence interval, 24.0%, 27.3%) and 8.9% in men (7.3%, 10.8%). In 652 men aged >or=70 yr, the prevalence of osteoporosis was 11.3% (9.1%, 14.0%). Of the participants with BMD-defined osteoporosis, 76.6% of woman aged >or=65 yr (73.2%, 79.6%; 516 of 674 women), 93.4% of men aged >or=65 yr (86.4%, 96.9%; 85 of 91), and 93.2% of men >or=70 yr (84.9%, 97.0%; 68 of 73) were not aware of it. Thus, the minimum NNS by BMD testing to detect one previously undiagnosed case of osteoporosis in Canada is: 6 women aged >or=65 yr, 13 men aged >or=65 yr, and 10 men aged >or=70 yr.
Limited information exists regarding the natural progression of health-related quality of life (HRQOL) in the general population, as most research has been cross-sectional or has followed populations with specific medical conditions. Such norms are important to establish, because the effect of any intervention may be confounded by changes due to the natural progression of HRQOL over time. Participants were randomly selected from 9 Canadian cities and surrounding rural areas. Changes in the eight domains and 2 summary component scores of the Medical Outcomes Study 36-item short form (SF-36) were examined over a 5 year period (1996/1997-2001/2002). Mean changes were calculated for men and women within 10 year age categories. Multiple imputation was used to adjust for potential selection bias due to missing data. The baseline sample included 6539 women and 2884 men. Loss to follow-up was 17% for women and 23% for men. Mean changes tended to be small, but there was an overall trend towards decreasing HRQOL over time. Changes were more pronounced in the older age groups and in the physically oriented domains. Younger age groups tended towards small mean improvements, particularly in the mentally oriented domains. Large standard errors suggest that on an individual level, large improvements in some participants are balanced by large declines in others. In general, the HRQOL of Canadians appears relatively stable over a 5 year period. However, care should be taken when assessing HRQOL longitudinally in certain age or gender groups, as changes associated with an intervention can potentially be confounded by the natural progression of HRQOL.
The objective of this research was to determine the relative decrement in health-related quality of life, as measured by the health utilities index mark 3 (HUI3), in osteoporosis compared to other chronic medical conditions. The impact of chronic medical conditions other than osteoporosis on HUI3 measurements had been previously established in the 1996/1997 Canadian National Population Health Survey (NPHS). The Canadian Multicentre Osteoporosis Study (CaMos) is a national population-based study in which regional participants were randomly recruited, regardless of presence of osteoporosis. We analyzed data from participants aged > or = 65 years who completed a baseline HUI3 questionnaire and provided information on their medical history (n=3,750). We determined the ageand gender-adjusted mean decrement in HUI3 for several chronic medical conditions, including osteoporosis. The mean changes in HUI3 adjusted for age and gender (with 95% confidence intervals) were as follows: arthritis -0.10 (-0.11, -0.09), chronic obstructive pulmonary disease (COPD) -0.07 (-0.09, -0.05), diabetes mellitus -0.05 (-0.08, -0.03), heart disease -0.06 (-0.08, -0.04), hypertension -0.02 (-0.03, -0.01), and osteoporosis -0.08 (-0.11, -0.06), respectively (model r2=0.17; P<0.0001). These findings were comparable to those observed in the NPHS, with the exception of osteoporosis, which had not been previously studied in this fashion. The decrement in HUI3 score seen in participants with osteoporosis was comparable to that observed in other chronic medical conditions, such as arthritis, COPD, diabetes mellitus or heart disease.
Measurement and Statistics · Instrument Development and Validation
The SF-36 is widely used to assess health-related quality of life (HRQOL), but with few longitudinal studies in healthy populations, it is difficult to quantify its natural history. This is important because any measure of change following an intervention may be confounded by natural changes in HRQOL. This paper assesses mean changes in SF-36 scores over a 3-year period in men and women between the ages of 40 and 59 years at baseline. Subjects were randomly selected from nine Canadian cities. Mean SF-36 changes over a 3-year period (1996/1997-1999/2000) were calculated for each gender within 5-year age categories. Multiple imputation was used to correct for potential bias due to missing data. The baseline cohort included 1,974 women and 975 men between 40 and 59 years. Mean changes in HRQOL tended to be small. Women demonstrated small average declines in 22 of the 32 age and domain groupings (4 age groups, 8 SF-36 domains) while men showed declines in 14/32. Most participants stayed within 10 points of their original baseline score. Interpretation: Mean SF-36 scores change only slightly over three years in middle-aged Canadians, although there is much individual variation. It may be necessary to adjust for the natural evolution of SF-36 scores when interpreting results from longitudinal studies. Contexte: Le SF-36 est un court questionnaire très utilisé pour évaluer la qualité de vie liée à la santé (HRQOL). Toutefois, vu le petit nombre d’études longitudinales menées auprès de populations en bonne santé, il est difficile d’évaluer l’histoire naturelle du SF-36, ce qui est important parce que tout changement noté résultant d’une intervention peut être confondu avec des changements normaux de la qualité de vie liée à la santé. Cet article évalue les changements moyens dans les scores des SF-36 sur une période de trois ans chez les hommes et les femmes qui étaient âgés de 40 à 59 ans lors de leur visite initiale. Méthode: Les sujets ont été choisis au hasard dans neuf villes canadiennes. Les changements moyens dans les résultats du SF-36 sur une période de trois ans (1996–1997 à 1999–2000) ont été calculés par sexe et par groupe d’âge de cinq ans. L’imputation multiple a été utilisée pour corriger tout biais résultant d’informations manquantes. Résultats: La cohorte initiale comportait 1 974 femmes et 975 hommes âgés de 40 à 59 ans. Les changements moyens étaient plutôt légers. Chez les femmes, 22 des 32 groupes d’âge et sous-échelles (quatre groupes d’âge, huit sous-échelles SF-36) présentaient de légères diminutions moyennes, alors que chez les hommes, ce nombre était de 14 groupes sur 32. Le score de la plupart des participants est demeuré en deçà de 10 points du score initial lors de l’entrée dans l’étude. Interprétation: Les scores moyens du SF-36 ne changent que légèrement sur une période de trois ans dans la population canadienne d’âge moyen. Toutefois, il pourrait s’avérer nécessaire de tenir compte de l’évolution naturelle des scores du SF-36 lors de l’interprétation des résultats d’études longitudinales.
Osteoporotic fractures can be a major cause of morbidity. It is important to determine the impact of fractures on health-related quality of life (HRQL). A total of 3,394 women and 1,122 men 50 years of age and older, who were recruited for the Canadian Multicentre Osteoporosis Study (CaMos), participated in this cross-sectional study. Minimal trauma fractures of the hip, pelvis, spine, lower body (included upper and lower leg, knee, ankle, and foot), upper body (included arm, elbow, sternum, shoulder, and clavicle), wrist and hand (included forearm, hand, and finger), and ribs were studied. Participants with subclinical vertebral deformities were also examined. The Health Utilities Index Mark II and III Systems were used to assess HRQL. Past osteoporotic fractures varied in prevalence from 1.2% (pelvis) to 27.8% (lower body) in women and 0.3% (pelvis) to 29.3% (wrist) in men. Multivariate linear regression analyses [parameter estimates and corresponding 95% confidence intervals (CI)] indicated that minimal trauma fractures were negatively associated with HRQL and that this relationship depends on fracture type and gender. The multi-attribute scores for the Mark II system were negatively related to hip (-0.05; 95% CI: -0.09, -0.01), lower body (-0.02; 95% CI: -0.03, -0.000), and subclinical vertebral fractures (-0.02; 95% CI: -0.03, -0.00) for women. The multi-attribute scores for the Mark III system were negatively related to hip (-0.09; 95% CI: -0.14, -0.03) and rib fractures (-0.06; 95% CI: -0.11, -0.00) for women, and rib fractures (-0.06; 95% CI: -0.12, -0.00) for men. In conclusion, this study demonstrates a negative association between osteoporotic fractures and quality of life in both women and men.
Hopman WM et al., 2002·Can J Public Health·
Open Access
Canadian normative data for the Medical Outcomes Study 36-item short form (SF-36) have recently been published. However, there is evidence from other countries to suggest that regional variation in health-related quality of life (HRQOL) may exist. We therefore examined the SF-36 data from nine Canadian centres for evidence of systematic differences. Bayesian hierarchical modelling was used to compare the differences in the eight SF-36 domains and the two summary component scores within each of the age and gender strata across the nine sites. Five domains and the two summary component scores showed little clinically important variation. Other than a small number of exceptions, there was little overall evidence of HRQOL differences across most domains and across most sites. Interpretation: Our finding of only a few small differences suggests that there is no need to develop region-specific Canadian normative data for the SF-36 health survey. Contexte: Les données normatives canadiennes s’appliquant à la version abrégée du questionnaire sur l’évolution médicale comportant 36 questions (SF-36) ont été publiées récemment. Toutefois, les données recueillies dans d’autres pays suggèrent qu’il peut exister des variations régionales au niveau de la qualité de vie reliée à l’état de santé (HRQOL). Nous avons donc étudié les données du SF-36 provenant de neuf centres canadiens pour démontrer les différences systématiques. Méthodes: Un modèle hiérarchique bayésien a été utilisé pour comparer les différences entre les résultats des huit domaines du SF-36 et des deux composantes sommaires pour chaque strate d’âge et de sexe, et ce, pour les neuf centres. Résultats: Les résultats de cinq domaines et des deux composantes sommaires démontraient des différences peu significatives cliniquement. Outre de rares exceptions, il y avait peu d’évidence de variations du HRQOL entre la plupart des domaines et des centres. Interprétation: Les résultats obtenus, ne démontrant que de légères différences, suggèrent qu’il n’est pas nécessaire d’établir des données normatives spécifiques aux régions du Canada pour le questionnaire de santé SF-36.
Health-related quality of life (HRQL) was examined in relation to prevalent fractures in 4816 community-dwelling Canadian men and women 50 years and older participating in the Canadian Multicentre Osteoporosis Study (CaMos). Fractures were of three categories: clinically recognized main fractures, subclinical vertebral fractures and fractures at other sites. Main fractures were divided and analyzed at the hip, spine, wrist/forearm, pelvis and rib sites. Baseline assessments of anthropometric data, medical history, therapeutic drug use, spinal radiographs and prevalent fractures were obtained from all participants. The SF-36 instrument was used as a tool to measure HRQL. A total of 652 (13.5%) main fractures were reported. Results indicated that hip, spine, wrist/forearm, pelvis and rib fractures had occurred in 78 (1.6%), 40 (0.8%), 390 (8.1%), 19 (0.4%) and 125 (2.6%) individuals, respectively (subjects may have had more than one main fracture). Subjects who had experienced a main prevalent fracture had lower HRQL scores compared with non-fractured participants. The largest differences were observed in the physical functioning (-4.0; 95% confidence intervals (CI): -6.0, -2.0) and role-physical functioning domains (-5.8; 95% CI: -9.5, -2.2). In women, the physical functioning domain was most influenced by hip (-14.9%; 95% CI: -20.9, -9.0) and pelvis (-18.1; 95% CI: -27.6, -8.6) fractures. In men, the role-physical domain was most affected by hip fractures (-35.7; 95% CI: -60.4, -11.1). Subjects who experienced subclinical vertebral fractures had lower HRQL scores than those without prevalent fractures. In conclusion, HRQL was lower in the physical functioning domain in women and the role-physical domain in men who sustained main fractures at the hip. Subclinical vertebral fractures exerted a moderate effect on HRQL.