Low bone mineral density (BMD) has long been recognized as an important predictor of fracture risk. Diagnostic criteria for osteoporosis were initially based on how many standard deviations a patient's BMD drops from the mean BMD of a female reference group, specifically young (aged 20-29 years) white women (CDC, 2002). The T-score is the standard deviation from the mean for this reference group. Negative T-scores indicate bone loss. Based on studies of women, a T-score of -2.5 (i.e., 2.5 S.D. below the mean for the reference group) has been defined as the diagnostic cutoff for osteoporosis (World Health Organization, 2003).
Between 1988 and 1994, the U.S. CDC collected BMD data from more than 14,000 U.S. women and men (National Center for Health Statistics, 1994). In 1997, a reference population of young men was used to calculate T-scores for male patients on the basis of healthy male (rather than healthy female) BMD values (Looker, 1997).
Calculating men's T-scores based on a male reference population greatly alters diagnosis rates. The prevalence of osteoporosis in men was estimated as 1%-4% using a female reference population; it has been estimated to be 3%-6% using a male reference population
(Looker, 1997; Cummings, 2002). This practice marks an important gendered innovation (see Method).
The T ≤ -2.5 cutoff (using a male reference population) is a common diagnostic for osteoporosis in men, although this is a matter of debate (Szulc et al., 2012). In a recent study of more than 7,000 men and women age 55 and older, 56% of non-vertebral fractures in women and 79% of non-vertebral fractures in men occurred in participants who were not diagnosed with osteoporosis according to the T ≤ -2.5 cutoff (Schuit et al., 2004). Moreover, there are concerns about the usefulness of T-scores in predicting fracture risk, especially in premenopausal women and men under age 50 (Leslie et al., 2006; Cummings, 2006).
Multiple international models for diagnosing osteoporosis have been established. The Canadian Medical Association, the United Kingdom's National Osteoporosis Guideline Group (NOGG) and Royal College of Physicians, and the German Dachverband Osteologie e.V. (DVO) each endorse different protocols for osteoporosis diagnosis (Papaioannou et al., 2010; Compston et al., 2008; Baum et al., 2008).
Developing a male reference population represented a gendered innovation that led, in turn, to further clinical research—see Designing Health & Biomedical Research. These include:
Researchers studying differences both between and within groups of women and men have identified secondary contributors to osteoporosis and metabolic bone disorders (SECOBs), medical conditions, and treatments that increase the risk of osteoporotic fracture. Understanding SECOBs is especially important in estimating men's fracture risk; men with fragility fractures are more likely than women to have previously diagnosed SECOBs, and when patients are screened after a fracture, new SECOBs are more often found in men (50%) than in women (32%) (Ryan et al., 2011; Tannenbaum et al., 2002). New diagnostics include the following:
In addition to the above, other systems of fracture risk estimation exist; Gimeno et al. describe nine different systems as "most commonly used" (2010).
Clinicians continue to debate the relative advantages and disadvantages of the FRAX, GFRC, and QFracture systems, all of which can be used to estimate a patient's risk of osteoporotic fracture over the next ten years (Bolland et al., 2011; Bennett et al., 2010).
Osteoporosis has been reconceptualized as affecting both women and men. This gendered innovation led to the development of male reference populations, allowing for better evaluation of fracture risk in men. BMD alone, however, is not a good predictor of fracture in women or men. New diagnostics, such as FRAX, GFRC, and QFracture, may predict a patient's fracture risk more accurately than BMD alone by analyzing factors intersecting with sex and gender.
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