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Competing Interests: Intérêts concurrents : Lora Giangregorio déclare avoir reçu des honoraires d’Amgen Inc. pour une conférence donnée sur l’exercice physique, hors du cadre du présent manuscrit, sans mention de médicaments. La Dre Giangregorio est également membre du conseil consultatif scientifique d’Ostéoporose Canada et coresponsable du Groupe d’intérêt spécial sur la fracture vertébrale du Fragility Fracture Network. Sandra Kim déclare qu’Ostéoporose Canada lui a offert le soutien d’une personne spécialiste de la méthodologie GRADE (Grading of Recommendations, Assessment, Development and Evaluations) à l’Université McMaster au cours de l’étude. De 2017 à 2020, la Dre Kim a aussi été membre bénévole du conseil d’administration d’Ostéoporose Canada. Nancy Santesso déclare avoir reçu une rémunération versée à son établissement (Université McMaster) afin d’apporter son expertise de l’outil GRADE à l’élaboration des lignes directrices et à la préparation de contenus au cours de l’étude. La Dre Santesso a aussi reçu du soutien d’Ostéoporose Canada pour se rendre aux réunions sur les lignes directrices. Heather McDonald-Blumer déclare avoir reçu des honoraires de consultation d’Eli Lilly et de Novartis pour sa présence à des conseils consultatifs, sans lien avec les présents travaux. Rowena Ridout est membre du conseil d’administration d’Ostéoporose Canada depuis 2020 (aucune rémunération perçue). Neil Binkley déclare avoir reçu une subvention de recherche (versée à son établissement) de Radius, ainsi que des frais de consultation et des honoraires d’Amgen. Angela Cheung a reçu des honoraires d’Amgen et des Laboratoires Paladin à titre de consultante. La Dre Cheung a aussi été membre du comité des lignes directrices cliniques de l’Endocrine Society, coprésidente du programme de santé postménopause de l’American College of Obstetrics and Gynecology et vice-présidente et coresponsable de la Conférence de prise de position 2023 de la Société internationale de densitométrie clinique. Robert Josse déclare avoir reçu des frais de consultation d’Amgen Canada, des Laboratoires Paladin et d’Alexion, ainsi que des honoraires d’Amgen et d’Alexion. Le Dr Josse a aussi participé à des comités consultatifs pour Amgen, Paladin, Alexion et Ultragenyx. Aliya Khan a reçu des subventions de recherche d’Alexion, d’Amgen Canada, de Takeda, d’Ascendis, de Chugai, de Radius, d’Amolyt et d’Ultragenyx, ainsi que des honoraires de conférencière d’Amgen, d’Alexion, d’Ascendis, de Takeda et d’Ultragenyx. La Dre Khan a également participé à des comités consultatifs pour Amgen Canada, Alexion, Amolyt, Ascendis et Takeda. E. Lynn Izumi Nash déclare que le Collège des médecins de famille de l’Ontario lui a versé des honoraires pour la conception d’ateliers de formation médicale continue sur l’ostéoporose. La Dre Nash est aussi membre du conseil consultatif scientifique d’Ostéoporose Canada (à titre bénévole). Zahra Bardai déclare avoir reçu des honoraires en tant que membre du comité de planification scientifique de Pri-Med Canada depuis 2011 et en tant que créatrice du Programme d’apprentissage basé sur la pratique en petit groupe de la Fondation pour l’éducation médicale continue, à l’Université McMaster. La Dre Bardai est aussi membre bénévole du conseil consultatif scientifique d’Ostéoporose Canada. Suzanne Cadarette déclare avoir reçu des subventions de recherche (versées à son établissement) en tant que cochercheuse principale pour des projets financés par les Instituts de recherche en santé du Canada et les National Institutes of Health. Heather Frame a siégé au conseil d’administration d’Ostéoporose Canada jusqu’en novembre 2020. Kaleen Hayes déclare avoir reçu des subventions de recherche à l’initiative des chercheurs du National Institute on Aging, d’Insight Therapeutics, de Genentech et de Sanofi (versées directement à son établissement), et des honoraires de consultation de l’Agence canadienne des médicaments et des technologies de la santé. Alexandra Papaioannou a fait partie d’un comité consultatif et de services de conférenciers et conférencières et a reçu des honoraires d’Amgen Canada. Christine Thomas a été membre du conseil d’administration d’Ostéoporose Canada à différentes périodes.

Background: In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older., Methods: This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework., Recommendations: The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized., Interpretation: The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life., Competing Interests: Competing interests: Lora Giangregorio reports receiving an honorarium from Amgen Inc. for a lecture on exercise with no mention of medications, outside the current manuscript. Dr. Giangregorio is also a member of the Scientific Advisory Council of Osteoporosis Canada and co-lead of the Vertebral Fracture Special Interest Group, Fragility Fracture Network. Sandra Kim reports receiving support from Osteoporosis Canada for a Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodologist at McMaster University, during the conduct of the study. Dr. Kim was also a volunteer member of the Osteoporosis Canada Board of Directors from 2017 to 2020. Nancy Santesso reports receiving payment to provide GRADE expertise for guideline development and preparation of materials paid to institution (McMaster University), during the conduct of the study. Dr. Santesso has also received support from Osteoporosis Canada for travel to guideline-related meetings. Heather McDonald-Blumer reports receiving consulting fees from Eli Lilly and Novartis, for attendance on advisory boards, outside the submitted work. Rowena Ridout has been a member of the Osteoporosis Canada Board of Directors since 2020 (no payment received). Neil Binkley reports receiving a research grant (paid to institution) from Radius, and consulting fees and honoraria from Amgen. Angela Cheung has received honoraria for consultancy work from Amgen and Paladin Laboratories. Dr. Cheung has also held the following roles: member of the Clinical Guidelines Committee of the Endocrine Society; co-chair of the postmenopausal health pathway, American College of Obstetrics and Gynecology; and vice-president and co-chair of the 2023 Position Development Conference, International Society for Clinical Densitometry. Robert Josse reports receiving consulting fees from Amgen Canada, Paladin Laboratories and Alexion, and honoraria from Amgen and Alexion. Dr. Josse has also participated on advisory boards for Amgen, Paladin, Alexion and Ultragenyx. Aliya Khan has received research grants from Alexion, Amgen Canada, Takeda, Ascendis, Chugai, Radius, Amolyt and Ultragenyx, and speaker honoraria from Amgen, Alexion, Ascendis, Takeda and Ultragenyx. Dr. Khan has also participated on advisory boards for Amgen Canada, Alexion, Amolyt, Ascendis and Takeda. E. Lynn Izumi Nash reports receivin an honorarium from the Ontario College of Family Physicians for designing continuing medical education workshops on osteoporosis. Dr. Nash is also a member of the Scientific Advisory Council for Osteoporosis Canada (voluntary unpaid position). Zahra Bardai reports receiving honoraria as a member of the Pri-Med Canada Scientific Planning Committee (2011–present) and as an author of the Foundation for Medical Practice Education Small Group Practice–Based Learning Program, at McMaster University. Dr. Bardai is also a volunteer member of the Osteoporosis Canada Scientific Advisory Council. Suzanne Cadarette reports receiving research funds (paid to institution) as co–principal investigator on Canadian Institutes of Health Research and National Institutes of Health project grants. Heather Frame is a former member of the Osteoporosis Canada Board of Directors (term ended November 2020). Kaleen Hayes reports receiving researcher-initiated grants from the National Institute on Aging, Insight Therapeutics, Genentech and Sanofi (all paid directly to institution), and consulting fees from the Canadian Agency for Drugs and Technologies in Health. Alexandra Papaioannou has participated on an advisory board and in speakers’ bureaus and received honoraria from Amgen Canada. Christine Thomas has been a member of the Osteoporosis Canada Board of Directors at various time points. Conflict-of-Interest Oversight Committee: Heather McDonald-Blumer (Chair), Larry Funnell, Rowena Ridout., (© 2023 CMA Impact Inc. or its licensors.)

Unlabelled: A worldwide epidemic of hip fractures has been predicted. Time trends in BMD testing, bone-sparing medications and hip and wrist fractures in the province of Ontario, Canada, were examined. From 1996 to 2001, BMD testing and use of bone-sparing medications increased each year, whereas despite the aging of the population, wrist and hip fracture rates decreased., Introduction: If patients with osteoporosis are being diagnosed and effective treatments used with increasing frequency in the population, rates of hip and wrist fractures will remain stable or possibly decrease. We report here time trends in BMD testing, prescriptions for bone-sparing medications, hip and wrist fracture rates, and population projections of fracture rates to 2005 in the province of Ontario, Canada., Materials and Methods: Ontario residents have universal access to Medicare. To examine time trends in BMD testing, all physician claims for DXA from 1992 to 2001 were selected from the Ontario Health Insurance Plan (OHIP) database. Trends in prescribing were examined from 1996 to 2003 using data from the Ontario Drug Benefit plan, which provides coverage to persons > or = 65 years of age. Actual numbers of hip and wrist fractures were determined for 1992-2000 and population projections for 2001-2005 using time-series analysis. Wrist fractures were identified in the OHIP database and hip fractures through hospital discharge abstracts., Results: From 1992 to 2001, the number of BMD tests increased 10-fold. There has been a steady increase in the number of persons filling prescriptions for antiresorptives (12,298 in 1996 to 225,580 in 2003) and the majority were for etidronate. For women, the rate of decline for wrist fractures is greater than that for hip fractures. The rate of hip fracture was fairly constant around 41 per 10,000 women > or = 50 years between 1992 and 1996. In 1997, the hip fracture rate began to decrease, and the population projections suggest that this downward trend will continue to a rate of 33.1 per 10,000 in 2005., Conclusions: Our findings suggest that fracture rates may be on the decline, despite the aging of the population, because of increased patterns of diagnosis and treatment for osteoporosis.

Objective: To estimate the prevalence of self-reported osteoporotic fractures and use of bone-sparing agents, and to examine if region of residence is associated with fracture or treatment prevalence., Methods: A census of persons aged > or = 55 years residing in 2 regions of Ontario, Canada (East York, a region within Toronto, and Oxford County), was completed between 1995 and 1998. Region was coded by record linkage of residential postal codes to 1996 Canadian Census data into 4 groups: East York (urban core), and Oxford County subdivided into: urban core, small urban, and rural. Respondents were excluded if they resided outside the regions of interest or were missing fracture data (5%)., Results: A total of 26,839 persons (15,541 women) were studied. Nearly 3 times as many women as men reported having had an osteoporotic fracture (14% vs 5%), with 31% and 8%, respectively, taking bone-sparing agents. Controlling for age, a diagnosis of osteoporosis, number of osteoporotic fractures, and height loss, women residing in East York were more likely (OR 1.2, 95% CI 1.0-1.4) to be taking a bone-sparing agent other than estrogen, but less likely to be taking estrogen (OR 0.8, 95% CI 0.7-0.9) compared to those living in rural areas. No regional differences were observed in fracture prevalence, treatment among those with an osteoporotic fracture, or use of a bone-sparing agent among men., Conclusion: Further research into regional differences in osteoporosis screening, treatment, and fractures is warranted. This should examine the appropriateness of possible differences, and separate physician practice patterns from patient characteristics, such as willingness to begin treatment with bone-sparing agents.

The objectives of this study were to determine information needs of family physicians around issues in the management of osteoporosis and preferences for dissemination of this information. A mailed survey was sent to a stratified random sample of 1000 family physicians in Ontario in May 2001. Female physicians and those practicing in rural communities were over-sampled from the College of Family Physicians' database. Among the 505 respondents, 364 were still practicing (182 males and 182 females) and completed the full questionnaire. There were no statistically significant differences in responses by sex or region of practice. Over 80% of family physicians wanted to be more informed about bone density testing and the pharmacological and non-pharmacological management of osteoporosis. The presence of risk factors was one of the most influential factors (72%) for ordering bone density testing. Information in peer-reviewed journals was thought to be the most credible, with 80% rating the CMAJ as very credible compared to 47% for the Osteoporosis Society of Canada (OSC). Sixty-two percent found the OSC guidelines (1996) to be useful even though much of that information is now out of date. Almost 70% had not read the more recently published treatment guidelines from the Ontario Program for Optimal Therapeutics (2000). Over 80% were interested in a decision aid, which incorporates information on risk factors, fracture risk and a treatment algorithm. The perceived need and the lack of availability of clinically useful information on osteoporosis for the family practice setting highlights the failure of the current guideline implementation process and provides insight into where the process has to be improved.

Objective: To explore family physicians' experiences and perceptions of osteoporosis and to identify their educational needs in this area., Design: Qualitative study using focus groups., Setting: Four Ontario sites: one each in Thunder Bay and Timmins, and two in Toronto, chosen to represent a range of practice sizes, populations, locations, and use of bone densitometry., Participants: Thirty-two FPs participated in four focus groups. Physicians were identified by investigators or local contacts to provide maximum variation sampling., Method: Focus groups using a semistructured interview guide were audiotaped and transcribed. The constant comparative method of data analysis was used to identify key words and concepts until saturation of themes was reached., Main Findings: Family physicians order bone densitometry and try to manage osteoporosis appropriately, but lack a rationale for testing and are confused about management. Participants' main concern was clinical management, followed by disease prevention and their educational needs., Conclusion: Family physicians are confused about how to manage osteoporosis. To reduce the burden of illness due to osteoporosis, educational interventions should be tailored to family physicians' needs.

Maximizing attainment of optimal peak bone mineral density (BMD) is a potential osteoporosis prevention strategy. The main objective of this study was to identify correlates of forearm BMD in young adult women. Population-based data derived from standardized questionnaires administered to healthy women aged 19-35 years in Nord-Trøndelag, Norway (n = 963), were collected in 1995-1997. Forearm BMD was assessed by single x-ray absorptiometry. Multiple linear and logistic regression analyses were used to determine correlates of BMD (g/cm(2)) and lowest quintile of BMD, respectively, at the ultradistal and distal sites. The mean age and weight of the cohort were 29.7 years (standard deviation 4.7) and 68.6 kg (standard deviation 12.5), respectively. Age and weight were positively associated with BMD at both forearm sites. When data were controlled for age and weight, later age at menarche and lack of milk consumption were associated with lower BMD values. In both linear models and logistic models, none of the factors vitamin D intake, physical activity, smoking, alcohol consumption, amenorrhea, oral contraceptive use, number of pregnancies, history of breastfeeding, and family history of osteoporosis were found to be significantly associated with BMD. Prior studies have suggested that calcium supplementation in children is useful for optimizing peak BMD. Further studies exploring the relation between lifestyle factors and BMD are warranted to search for ways to maximize attainment of peak BMD.

Introduction. Evidence of inappropriate bone mineral density (BMD) testing has been identified in terms of overtesting in low risk women and undertesting among patients at high risk. In light of these phenomena, the objective of this study was to understand the referral patterns for BMD testing among Ontario’s family physicians (FPs). Methods. A qualitative descriptive approach was adopted. Twenty-two FPs took part in a semi-structured interview lasting approximately 30 minutes. An inductive thematic analysis was performed on the transcribed data in order to understand the referral patterns for BMD testing. Results. We identified a lack of clarity about screening for osteoporosis with a tendency for baseline BMD testing in healthy, postmenopausal women and a lack of clarity on the appropriate age for screening for men in particular. A lack of clarity on appropriate intervals for follow-up testing was also described. Conclusions. These findings lend support to what has been documented at the population level suggesting a tendency among FPs to refer menopausal women (at low risk). Emphasis on referral of high-risk groups as well as men and further clarification and education on the appropriate intervals for follow-up testing is warranted. [ABSTRACT FROM AUTHOR]

Age-standardized rates of hip fracture in Canada declined during the period 1985 to 2005. We investigated whether this incidence pattern is explained by period effects, cohort effects, or both. All hospitalizations during the study period with primary diagnosis of hip fracture were identified. Age- and sex-specific hip fracture rates were calculated for nineteen 5-year age groups and four 5-year calendar periods, resulting in 20 birth cohorts. The effect of age, calendar period, and birth cohort on hip fracture rates was assessed using age-period-cohort models as proposed by Clayton and Schiffers. From 1985 to 2005, a total of 570,872 hospitalizations for hip fracture were identified. Age-standardized rates for hip fracture have progressively declined for females and males. The annual linear decrease in rates per 5-year period were 12% for females and 7% for males (both p < 0.0001). Significant birth cohort effects were also observed for both sexes ( p < 0.0001). Cohorts born before 1950 had a higher risk of hip fracture, whereas those born after 1954 had a lower risk. After adjusting for age and constant annual linear change (drift term common to both period and cohort effects), we observed a significant nonlinear birth cohort effect for males ( p = 0.0126) but not for females ( p = 0.9960). In contrast, the nonlinear period effect, after adjustment for age and drift term, was significant for females ( p = 0.0373) but not for males ( p = 0.2515). For males, we observed no additional nonlinear period effect after adjusting for age and birth cohort, whereas for females, we observed no additional nonlinear birth cohort effect after adjusting for age and period. Although hip fracture rates decreased in both sexes, different factors may explain these changes. In addition to the constant annual linear decrease, nonlinear birth cohort effects were identified for males, and calendar period effects were identified for females as possible explanations. [ABSTRACT FROM AUTHOR]

Presents letters to the editor. Response to an article about the use of antidepressant medication for chronic tension headaches; Who should be screened for osteoporosis; Discussion of studies regarding violence in children's films and video games; Others.

Abstract: Objective: To examine the validity of both self-report of having had dual-energy x-ray absorptiometry (DXA) and self-reported DXA test results. Methods: Participants were recruited in 2003 and 2004 from a population-based study of women aged 65–90 years examining osteoporosis management in Ontario, Canada (N =871). Women reporting having had a DXA were eligible and asked to report the results of their most recent test. Participant responses were compared against DXA reports obtained from physicians. Results: We obtained 413 (81%) physician records among the 510 women who reported having had a DXA test. Of these, the positive predictive value for self-report of having had a DXA was 93%. The weighted kappa statistic for the agreement between self-report and actual DXA results was 0.42 (95% confidence interval=0.34–0.49). Although 84% of those with normal bone reported this, only 29% of those with osteopenia and 62% with osteoporosis reported their results correctly. Self-report of a clinical diagnosis of osteoporosis was better among those with a low trauma fracture, yet underestimated osteoporosis prevalence by 24%. Conclusion: There is minimal measurement error in self-report of having had a DXA test. Self-report of DXA results will underestimate osteoporosis prevalence and is not a good proxy for clinical diagnosis. [Copyright &y& Elsevier]