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Objective: To explore use of bone densitometry in Australia and to identify any sex and geographic differences, as a marker of osteoporosis diagnosis and care., Design and Setting: Analysis of claims data from Medicare Australia in patients aged over 45 years during the period 2001-2005., Main Outcome Measures: Age-standardised rates of bone densitometry use, by sex and by metropolitan, rural or remote classification., Results: Bone densitometry use increased by 26% over the 5 years. Rates were lower for rural and remote populations, with people in capital cities about three times as likely to undergo the investigation as those in remote areas. The sex ratio for the rate of bone densitometry use (women to men) decreased from more than 6 : 1 in 2001 to 4 : 1 in 2005., Conclusion: Although the sex ratio for osteoporotic fracture is close to 2 : 1 (women to men), the sex ratio for testing is much higher, suggesting underuse of bone densitometry in men. Sex and rural inequities in use of the investigation need to be addressed as part of a national approach to reducing minimal trauma fracture.

All women and men with a history of fragility fractures should be considered for treatment of osteoporosis to reduce their risk of future fracture. There is high-level evidence for the anti-fracture efficacy of treatment in women with osteoporosis, particularly if there is prevalent fracture; the evidence is less compelling for women with osteopenia, with or without a fracture, and for men. The rigorously investigated drugs reported to reduce vertebral fractures are the bisphosphonates alendronate and risedronate, the selective oestrogen-receptor modulator raloxifene, the anabolic agent parathyroid hormone and, most recently, strontium ranelate. Only the two bisphosphonates and hormone replacement therapy (HRT) have been reported to reduce hip fractures in community-dwelling women, and calcium plus vitamin D and hip protectors have been reported to reduce these fractures in elderly people in institutions. HRT is not recommended in women for fracture risk reduction alone. Evidence for the anti-fracture efficacy of calcitonin, fluoride, anabolic steroids and active vitamin D metabolites is insufficient to justify their use; lifestyle changes, while not shown to reduce fracture risk, may have a role in maintaining bone strength throughout life.

Osteoporosis is: (1) Underrated. Currently costs about 7 billion dollars annually in Australia. Has high morbidity and 2-3-fold increase in risk of death after any major osteoporotic fracture. Genetic factors contribute highly to risk, modified by lifestyle and hormonal factors. (2) Underdiagnosed. Bone density is a good predictor of subsequent risk. Anyone with a low-trauma fracture has osteoporosis unless proven otherwise. Every individual with a low trauma fracture should be investigated for exclusion of underlying osteoporosis and considered for effective treatment to reduce future fracture risk. More than 75% of women and about 90% of men with a high likelihood of osteoporosis are not investigated. (3) Undertreated. More than 75% of those affected are not treated. Effective treatments (eg, hormone replacement therapy, selective oestrogen receptor modifiers and bisphosphonates) reduce fracture risk by 30%-60%. Simple measures like vitamin D and calcium supplementation and use of hip protectors can reduce hip fractures, particularly in institutionalised and housebound elderly people

Patients with low bone density or any prior low trauma fracture should be considered for therapeutic intervention. Oestrogen replacement therapy remains the first choice for prevention of bone loss in early postmenopausal women with low bone density. In postmenopausal women with existing fractures, the rank order of treatments is firstly alendronate, secondly raloxifene and thirdly less potent bisphosphonates, such as etidronate, or active vitamin D metabolites, such as calcitriol. For men with osteoporosis, if hypogonadism is present, it should be treated with testosterone replacement therapy. Despite limited data, a bisphosphonate should then be considered in conjunction with calcium. Supplementation with simple vitamin D should be considered in elderly patients who are housebound or live in institutions, as they are at risk of vitamin D deficiency and osteomalacia.

Could focused population screening detect osteoporosis earlier and improve the management of this major health care problem? Quantitative ultrasound of the calcaneus is currently being proposed as a suitable screening technique. Correlations between quantitative ultrasound of the calcaneus and dual energy x-ray absorptiometry of bone mineral density of the spine and proximal femur are not high enough to reliably predict bone mineral density at the lumbar spine or proximal femur from the ultrasound results. Some ongoing longitudinal studies suggest that quantitative ultrasound may none the less detect individuals at increased risk of fracture, but its use for mass screening for osteoporosis would be premature.

Objective: To assess measures of postural stability in a large population of persons aged over 60 years in order to compare performance between fallers and non-fallers and relate postural stability to fracture prevalence., Methods: The sensorimotor, visual and balance functions were measured in 1762 ambulatory, community-dwelling patients aged between 60 and 100 years (mean age, 70.1 years) living in a large semi-urban Australian city. A history of recent falls and fractures was recorded at the time of assessment., Results: The prevalence of impairment in all tests increased with age. Men performed significantly better than women in tests of muscle strength, visual field dependence, sway on the floor with eyes open and dynamic balance. In the 12 months before testing, 72.3% of the patients experienced no falls, 18.4% fell only once and 9.3% fell on two or more occasions. Multiple fallers had weaker quadriceps, poorer tactile sensitivity, greater visual field dependence and greater body sway than other patients. Test scores for once-only fallers were mostly between those for non-fallers and multiple fallers. Those who suffered recent fall-related fractures had significantly reduced tactile sensitivity and quadriceps strength and increased body sway. Postural stability was also impaired in patients taking psychoactive and/or anti-hypertensive medications., Conclusion: Tests of postural stability can identify, independently of age, individuals living in the community who are at risk of falls and fall-related fractures.

To investigate whether stress fractures occurring in élite female athletes are related to reductions in bone mineral density (BMD), we measured BMD in nine athletes with such fractures and nine athletes without fractures who were matched for age, weight, height and sport. BMD was measured in three regions: upper limbs (distal radius), axial skeleton (lumbar spine) and lower limbs (femoral neck) by photon absorptiometry. The number of menses per year was significantly less (P less than 0.04) and the age of menarche was significantly delayed (mean +/- SD; 16.1 +/- 0.4 v. 14.4 +/- 1.5 years, P less than 0.02) in the fracture group compared with the non-fracture group. There was no significant difference in BMD between the two groups at any of the measurement sites. Moreover although the fractures occurred mainly in lower limb bones, at sites characterised by predominantly cortical bone, all athletes had femoral neck BMD values within the 95% confidence limits for normal non-athletic women. We conclude that stress fractures in élite female athletes are largely independent of BMD.

Osteoporosis is a major health problem in Australia, as it is in most Western societies. Bone mineral density in the spine and femoral neck are accurate indicators of osteopenia and thus useful indicators of the risk of a fracture. Dual-photon absorptiometry is a non-invasive technique that allows the accurate quantitation of bone mineral density in the lumbar vertebrae and proximal femur with a low radiation exposure. The increasing availability of this technique dictates the requirement for "normal" ranges and quality control. We report here lumbar vertebral and proximal femur bone mineral density as measured by dual-photon absorptiometry in 179 normal Australian women. Forearm bone mineral content in these subjects, as measured by single-photon absorptiometry, is also presented. There was a relative stability of lumbar bone mineral density and forearm bone mineral content before the menopause, after which there was an age-related decline. On the other hand, bone mineral density at all three sites in the proximal femur showed an age-related decline throughout adult life. Intraoperator variability in calculated bone mineral density did not exceed 2.3%. The requirement for correct positioning of the patient is illustrated. The data allow statistical analysis and the development of normal ranges. They provide an Australian base against which individual patient values can now be compared.

The role of calcium in age-related bone loss still is controversial. However, evidence is accumulating to support the hypothesis that an adequate calcium intake early in life, because of its relationship to peak bone mass, may be of greater importance than is the calcium intake in later life. Calcium intake would appear to be declining with age due to the changing food habits that are associated with social and technological change. This is explained partly by the increasing concern about obesity in Western society, with the trend for women to restrict their energy intake, rather than to increase their energy expenditure, to control weight. Thus, low energy intakes and the avoidance of dairy foods have contributed to the declining intakes of calcium and other minerals. Health educational programmes, which are designed to prevent osteoporosis and which identify women who are most at risk of the disease, should provide sensible nutritional advice on an adequate calcium intake and regular weight-bearing exercise among other life-style changes.