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Commentary & Perspective

Commentary on an article by Ruth K. Wilson, MD, et al.: “Male and Non-English-Speaking Patients with Fracture Have Poorer Knowledge of Osteoporosis”

Templeton, Kimberly J., MD*

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doi: 10.2106/JBJS.K.00039
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The presence of a prior fracture is the strongest risk factor for additional fractures, which emphasizes the need for intervention after the index fracture. Intervention includes not only recognition and treatment of bone-health issues by clinicians but also awareness of the risk factors that can be modified. Enhanced knowledge encourages patients to seek out additional information and has been shown to lead to lifestyle changes. Prior studies have demonstrated limited knowledge of osteoporosis risk factors among the general public as well as among those who have already sustained a fracture. The authors of this article sought to determine which demographic and social factors impact the levels of osteoporosis knowledge among patients who were forty years of age or older and who had sustained a fracture. Although this population was somewhat younger than the fracture population typically included in this type of study, this younger age range includes those with potentially decades of risk for additional fractures, making intervention even more crucial.

This study included a broader demographic group of patients as compared with those in other studies, with a substantial percentage of men, those whose primary language is not English, and patients from a range of income levels. This makes the results of the study applicable to most practices. Although more common in women and Caucasians or those of Asian descent, osteoporosis is an important issue for men as well as for individuals from all racial and/or ethnic backgrounds. The incidence of osteoporosis for both sexes and among all races is expected to continue to increase, with consequent increases in the incidence of low-impact fractures. In addition, men have been shown to have a higher mortality rate after sustaining a low-impact fracture. Although prior studies are somewhat conflicting, there has been an indication that those who are unemployed or have a lower income are at greater risk of developing osteoporosis and sustaining low-impact fractures1,2. This may reflect a lack of opportunity to participate in health behaviors known to impact bone, such as weight-bearing exercise or adequate intake of calcium and vitamin D, or may be the result of other health conditions affecting bone. Knowledge of osteoporosis risk factors and modifiable health behaviors is therefore important for all patients who have sustained a fracture, as well as for the general public. Similar to the message in other studies, the need to improve awareness of the impact of osteoporosis among the general public was also noted in this study, in which the most common reason for nonparticipation given by the 21% of eligible patients who declined to participate was that they weren't interested.

In this study, the authors have identified men, those with English as a second language, and those who were unemployed as the groups with the lowest level of osteoporosis knowledge. This may be a result of the fact that most osteoporosis educational efforts up to this point have targeted women and have been delivered in English. Although issues such as exercise and diet are important for both sexes, there are some differences in terms of risk factors for osteoporosis between women and men, and these differences would affect the information that would be presented in an education program. Some osteoporosis education material has been literally translated to reach those who do not speak English or those for whom English is a second language. However, there may be issues with cultural translation that would limit the understanding and applicability of the information provided for this population. For all patients who have already sustained a fracture related to osteoporosis, orthopaedic surgeons have an opportunity to attempt to prevent additional fractures by providing information concerning modifiable risk factors. The study by Wilson et al., however, indicates that current education initiatives should be expanded to target men, the unemployed, and those for whom English is a second language.

* The author received no payments or services, either directly or indirectly (i.e., via her institution), from a third party in support of any aspect of this work. The author, or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena (Zimmer) that could be perceived to influence or have the potential to influence what is written in this work. The author has had no other relationships, or has engaged in no other activities, that could be perceived to influence or have the potential to influence what is written in this work. To view the complete Disclosures of Potential Conflicts of Interest submitted by the author of this work, go to the article citation and click on “Disclosure.”


1. Brennan SL, Pasco JA, Urquhart DM, Oldenburg B, Hanna F, Wluka AE . The association between socioeconomic status and osteoporotic fracture in population-based adults: a systematic review. Osteoporos Int. 2009;20:1487-97.
2. Navarro MC, Sosa M, Saavedra P, Lainez P, Marrero M, Torres M, Medina CD . Poverty is a risk factor for osteoporotic fractures. Osteoporos Int. 2009;20:393-8.
Copyright © 2011 by The Journal of Bone and Joint Surgery, Incorporated