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Obesity Is Not Protective against Fracture in Postmenopausal Women: GLOW

      Abstract

      Objective

      To investigate the prevalence and incidence of clinical fractures in obese, postmenopausal women enrolled in the Global Longitudinal study of Osteoporosis in Women (GLOW).

      Methods

      This was a multinational, prospective, observational, population-based study carried out by 723 physician practices at 17 sites in 10 countries. A total of 60,393 women aged ≥55 years were included. Data were collected using self-administered questionnaires that covered domains that included patient characteristics, fracture history, risk factors for fracture, and anti-osteoporosis medications.

      Results

      Body mass index (BMI) and fracture history were available at baseline and at 1 and 2 years in 44,534 women, 23.4% of whom were obese (BMI ≥30 kg/m2). Fracture prevalence in obese women at baseline was 222 per 1000 and incidence at 2 years was 61.7 per 1000, similar to rates in nonobese women (227 and 66.0 per 1000, respectively). Fractures in obese women accounted for 23% and 22% of all previous and incident fractures, respectively. The risk of incident ankle and upper leg fractures was significantly higher in obese than in nonobese women, while the risk of wrist fracture was significantly lower. Obese women with fracture were more likely to have experienced early menopause and to report 2 or more falls in the past year. Self-reported asthma, emphysema, and type 1 diabetes were all significantly more common in obese than nonobese women with incident fracture. At 2 years, 27% of obese women with incident fracture were receiving bone protective therapy, compared with 41% of nonobese and 57% of underweight women.

      Conclusions

      Our results demonstrate that obesity is not protective against fracture in postmenopausal women and is associated with increased risk of ankle and upper leg fractures.

      Keywords

      Fractures are a major cause of morbidity and mortality in postmenopausal women, and incur huge economic costs for health services. One in 3 women aged ≥50 years will sustain ≥1 fracture during her remaining lifetime, with an estimated annual cost of €30 billion in Europe and $17 billion in the US.
      • Becker D.J.
      • Kilgore M.L.
      • Morrisey M.A.
      The societal burden of osteoporosis.
      • Burge R.
      • Dawson-Hughes B.
      • Solomon D.H.
      • et al.
      Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025.
      • Kanis J.A.
      • Johnell O.
      Requirements for DXA for the management of osteoporosis in Europe.
      The social and economic burden resulting from fractures is predicted to increase at least 2-fold in the next few decades as a result of demographic changes in the population.
      • Cooper C.
      • Campion G.
      • Melton 3rd, L.J.
      Hip fractures in the elderly: a world-wide projection.
      • Nearly 1 in 4 postmenopausal women with clinical fracture is obese, a finding that has major public health implications in view of the rapidly rising incidence of obesity.
      • Obesity is a risk factor for ankle and upper leg fractures.
      • Increased risk of falls and reduced physical mobility are likely to be important pathogenetic factors in fractures in obese individuals.
      Low body mass index (BMI) is an important risk factor for fractures in postmenopausal women—an effect mediated predominantly, although not exclusively, through low bone mineral density (BMD).
      • De Laet C.
      • Kanis J.A.
      • Oden A.
      • et al.
      Body mass index as a predictor of fracture risk: a meta-analysis.
      In contrast, obesity is widely believed to be protective against fracture because of higher BMD and reduced impact of falls as a result of increased soft-tissue padding.
      • Albala C.
      • Yanez M.
      • Devoto E.
      • et al.
      Obesity as a protective factor for postmenopausal osteoporosis.
      • Felson D.T.
      • Zhang Y.
      • Hannan M.T.
      • Anderson J.J.
      Effects of weight and body mass index on bone mineral density in men and women: the Framingham study.
      However, in a recent audit of postmenopausal women presenting to a Fracture Liaison Clinic, 27.7% of women presenting with a fracture had a BMI ≥30 kg/m2.
      • Premaor M.O.
      • Pilbrow L.
      • Tonkin C.
      • et al.
      Obesity and fractures in postmenopausal women.
      This suggests that fractures in obese women may contribute significantly to the overall fracture burden in the postmenopausal population.
      The Global Longitudinal study of Osteoporosis in Women (GLOW)—a prospective, multinational, observational, population-based study of postmenopausal women—provides an ideal setting in which to investigate the epidemiology and pathogenesis of fractures in obese postmenopausal women.
      • Hooven F.H.
      • Adachi J.D.
      • Adami S.
      • et al.
      The Global Longitudinal Study of Osteoporosis in Women (GLOW): rationale and study design.
      The aim of this study was to document the prevalence of clinical fractures in obese women in the GLOW cohort at baseline, and to establish the incidence of fractures in this population after 2 years of follow-up. Further aims were to examine the skeletal sites of fracture and underlying risk factors in obese women, and to compare these with corresponding data in nonobese and underweight women with fractures.

      Methods

      GLOW is a prospective cohort study involving 723 physician practices at 17 sites in 10 countries (Australia, Belgium, Canada, France, Germany, Italy, Netherlands, Spain, UK, and US). The study methods have been described previously.
      • Hooven F.H.
      • Adachi J.D.
      • Adami S.
      • et al.
      The Global Longitudinal Study of Osteoporosis in Women (GLOW): rationale and study design.
      In brief, practices typical of each region were recruited through primary care networks organized for administrative, research, or educational purposes, or by identifying all physicians in a geographic area. Each site obtained local ethics committee approval to participate in the study. The practices provided the names of women aged ≥55 years who had been seen by their physician in the past 24 months. Approximately 3000 women were sought at each site. Self-administered questionnaires (baseline surveys) were mailed to 140,416 subjects between October 2006 and February 2008, with a 2:1 oversampling of women aged ≥65 years. Nonresponders were followed-up with a series of postcard reminders, a second questionnaire, and telephone interviews. After appropriate exclusions, 60,393 women agreed to participate in the study. Follow-up questionnaires were mailed 1 and 2 years later to women who had participated in the baseline survey. Women without both 1 and 2 years of follow-up (lost to follow-up or died) and women with incomplete BMI data were excluded from the analysis.

      Data Collection

      Questionnaires were designed to be self-administered and covered domains that included: patient characteristics and risk factors, fracture history, current medication use, and other medical diagnoses. Data on height and weight were collected to allow calculation of BMI. Women were defined as obese if BMI was ≥30 kg/m2, nonobese if BMI was 18.5-29.9 kg/m2, and underweight if BMI was <18.5 kg/m2.
      Information was gathered on previous fractures (fractures that had occurred since the age of 45 years) during the baseline survey and on incident fractures during the 1- and 2-year follow-up surveys. All surveys included report of fracture location, including spine, hip, wrist, and other nonvertebral sites (clavicle, upper arm, rib, pelvis, ankle, upper leg, lower leg, foot, hand, shoulder, knee, and elbow), and occurrence of single or multiple fractures. Self-reports of personal risk factors included: history of parental hip fracture; premature menopause (age ≤45 years); number of falls in the past 12 months; use of arms to assist standing from a sitting position; current use of cortisone; fair or poor general health; current cigarette smoking; and consumption of ≥3 units of alcohol daily. Subjects were considered to be taking anti-osteoporosis medication if they reported current use of alendronate, calcitonin, estrogen, etidronate, ibandronate, pamidronate, recombinant human parathyroid hormone (1-84), raloxifene, risedronate, strontium ranelate, teriparatide, tibolone, or zoledronate. Information also was obtained about other diagnoses, including asthma, emphysema, osteoarthritis, rheumatoid arthritis, colitis, stroke, Parkinson's disease, multiple sclerosis, cancer, and type 1 diabetes.

      Statistical Analysis

      Age was compared across BMI groups using the Kruskal-Wallis test for continuous variables. Fracture rates are reported as rates per thousand women. Only women with complete baseline, 1- and 2-year follow-up surveys were included. We used the Fisher's exact test to make pairwise comparisons of outcomes between BMI categories. To control for multiple pairwise comparisons among the 3 BMI groups, a statistically significant difference between groups was noted when the P value from the Fisher's exact test was <.017. Analyses of characteristics of women by BMI group were limited to those with previous and incident fractures. Logistic regression was used to predict any type of incident fracture and the 10 individual types of incident fracture, in both unadjusted and adjusted models. We adjusted for variables that were significantly associated with the fracture outcomes and which, in our opinion, were not a part of BMI itself: maternal hip fracture, current estrogen use, current cortisone use, current smoker, fair/poor health, age, osteoarthritis, and Parkinson’s disease. All analyses were performed using SAS 9.2 (SAS Institute Inc., Cary, NC).

      Results

      Of 60,393 women enrolled at baseline, 46,443 (76.9%) completed both 1- and 2-year surveys. We further excluded one woman with a BMI of 130 kg/m2 and 1908 women with incomplete information on BMI or fracture history, leaving 44,534 women for further analysis. Among the 57,556 women enrolled at baseline with BMI data, 23.8% were obese, 74.4% were nonobese, and 1.9% were underweight. Of the 44,534 women analyzed, the corresponding figures were 23.4%, 74.9%, and 1.7%, respectively. Average ages (SD) and weights (SD) for obese, nonobese, and underweight women were: 67 (7.9) years and 90 (15.2) kg, 68 (8.6) years and 64 (8.8) kg, and 70 (9.8) years and 46 (6.4) kg, respectively.
      Fracture prevalence at baseline and incidence within 2 years of baseline in obese, nonobese, and underweight women are shown in Table 1 (rates per 1000 women). Both prevalence and incidence of fractures were highest in the underweight group, with similar rates in obese and nonobese women. The difference in prior fracture rates was statistically significant for both obese versus underweight and nonobese versus underweight women (P <.017). Because of the distribution of body weight in the cohort, the number of women with previous or incident fractures was highest in nonobese women (7401 and 2170, respectively), intermediate in obese women (2274 and 633, respectively), and lowest in underweight women (220 and 53, respectively). Incident fracture rates in women with morbid obesity (BMI ≥35 kg/m2) were similar to those in all obese women (BMI ≥30 kg/m2; data not shown). Obese women were similar to their nonobese and underweight counterparts in having a 2-3-fold higher risk of incident fracture if they had a previous fracture. Obese women with previous or incident fracture were significantly younger than nonobese and underweight women with fracture. Mean ages (SDs) in obese women with previous or incident fracture were 70 (8.3) and 69 (8.3) years, respectively, compared with 72 (8.9) and 70 (9.3) years in nonobese women, and 73 (9.8) and 73 (11) years in underweight women (P <.001 for both previous and incident fractures).
      Table 1Previous and Incident Fractures among Obese, Nonobese, and Underweight Women With or Without Previous Fracture
      n=44,534; rates per 1000 women (number of fractures).
      Group 1: Obese (n=10,441)Group 2: Nonobese (n=33,349)Group 3: Underweight (n=744)P Value
      We performed pairwise comparisons among the 3 groups, and report any results where P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      Previous fracture (n=9895)222 (2274)227 (7401)300 (220)1 vs 3, 2 vs 3
      Incident fracture
      Within 2 years of baseline a fracture of clavicle, upper arm, wrist, spine, rib, hip, pelvis, ankle, upper leg, lower leg, hand, foot, elbow, knee, or shoulder.
      (n=2856)
      Some of these women were missing history of previous fracture.
      61.7 (633)66.0 (2170)72.4 (53)
      No history of previous fracture (n=1679)46.3 (362)51.8 (1294)45.3 (23)
      History of previous fracture (n=1114)116.4 (258)114.1 (826)140.8 (30)
      low asterisk n=44,534; rates per 1000 women (number of fractures).
      We performed pairwise comparisons among the 3 groups, and report any results where P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      Within 2 years of baseline a fracture of clavicle, upper arm, wrist, spine, rib, hip, pelvis, ankle, upper leg, lower leg, hand, foot, elbow, knee, or shoulder.
      § Some of these women were missing history of previous fracture.
      Fracture rates per 1000 women by skeletal site are shown in Table 2. Obese women were more likely than others to have experienced previous ankle or lower leg fractures and less likely to have had previous wrist, hip, rib, or pelvis fractures, while underweight women were more likely than the others to have had previous hip or pelvis fractures (P <.017 for all BMI category pairwise comparisons, except for lower leg, where the difference was seen only between obese and nonobese women).
      Table 2Frequency of Fractures by Skeletal Location in Obese, Nonobese, and Underweight Women (Rates per 1000 Women)
      Previous FractureIncident Fracture (Within 2 Years of Baseline)
      Fracture SiteGroup 1: Obese (n=10,441)Group 2: Nonobese (n=33,349)Group 3: Underweight (n=744)P Value
      We performed pairwise comparisons among the 3 groups, and report any results where Fisher's exact test P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      Group 1: Obese (n=10,441)Group 2: Nonobese (n=33,349)Group 3: Underweight (n=744)P Value
      We performed pairwise comparisons among the 3 groups, and report any results where Fisher's exact test P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      Clavicle11.012.521.62.02.31.4
      Upper arm28.926.339.26.16.06.8
      Wrist67.085.71081 vs 2, 1 vs 312.115.417.61 vs 2
      Spine18.620.933.91 vs 35.67.08.1
      Rib35.641.258.01 vs 2, 1 vs 38.19.31.42 vs 3
      Hip11.215.943.31 vs 2, 1 vs 3, 2 vs 33.84.611.01 vs 3
      Pelvis6.010.623.01 vs 2, 1 vs 3, 2 vs 31.92.78.11 vs 3
      Ankle75.355.250.01 vs 2, 1 vs 313.38.56.91 vs 2
      Upper leg9.77.513.53.72.55.4
      Lower leg28.923.027.01 vs 25.33.62.7
      low asterisk We performed pairwise comparisons among the 3 groups, and report any results where Fisher's exact test P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      Incident fracture rates per 1000 women and unadjusted BMI category comparisons also appear in Table 2. Rates were higher for ankle and lower for wrist fractures among obese versus nonobese women, lower for both pelvis and hip fracture among obese versus underweight women, and higher for rib fractures in nonobese versus underweight women (P <.017). After adjusting for maternal hip fracture, current estrogen use, current cortisone use, current smoking, fair/poor health, age, osteoarthritis, and Parkinson’s disease, incident ankle fractures remained more common (adjusted odds ratio [OR] 1.5; 95% confidence interval [CI], 1.2-1.9) and incident wrist fractures less common in obese than nonobese women (OR 0.8; 95% CI, 0.6-1.0), while incident rib fractures remained more common in nonobese than underweight women (OR 7.1; 95% CI, 1.0-50.9). Upper leg fractures were more common in obese than nonobese women in the adjusted analysis (OR 1.7; 95% CI, 1.1-2.5). Unadjusted rates for incident hip and pelvis fractures were no longer statistically significant after covariate adjustment. Although adjusted and unadjusted results for incident lower leg fracture were not statistically significant, these fractures appeared similar to ankle and upper leg fractures with respect to rates in obese versus nonobese women.
      Previous and incident fracture rates per 1000 women by BMI group are shown in Table 3 according to risk factors identified at baseline. Main BMI group differences found were a higher fracture incidence for obese versus nonobese women if a woman experienced early menopause, needed to use her arms to assist in standing from a sitting position (also higher if obese than underweight), reported fair or poor health, or reported ≥2 falls in the past 2 years; and a lower incident fracture rate for nonobese versus underweight women with a prior fracture. Table 4 reports rates of various comorbidities among women with a previous fracture and with an incident fracture within 2 years of baseline, by BMI category. Obese women who fractured tended to have higher rates of comorbidities than others (especially self-reported asthma), but Parkinson’s disease was more common in underweight women who fractured.
      Table 3Frequency of Risk Factors Identified at Baseline among Women with Previous and Incident
      Incident fracture is defined as a fracture of at least one of the following bones: clavicle, upper arm, wrist, spine, rib, hip, pelvis, ankle, upper leg, lower leg, hand, foot, elbow, knee, or shoulder.
      Fractures (Rates per 1000 Women)
      Previous FractureIncident Fracture (within 2 Years of Baseline)
      Risk FactorGroup 1: Obese (n=2274)Group 2: Nonobese (n=7401)Group 3: Underweight (n=220)P Value
      We performed pairwise comparisons among the 3 groups, and report any results where Fisher's exact test P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      Group 1: Obese (n=633)Group 2: Nonobese (n=2170)Group 3: Underweight (n=53)P Value
      We performed pairwise comparisons among the 3 groups, and report any results where Fisher's exact test P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      Previous fracture4163905662 vs 3
      Maternal hip fracture156164162141177159
      Current estrogen use55.973.677.61 vs 257.173.494.3
      Early menopause1941271281 vs 2200139981 vs 2
      Current cortisone use49.338.251.248.249.619.2
      Weight loss ≥10 lb1131032071 vs 3,

      2 vs 3
      132117208
      Current smoker56.679.61521 vs 3,

      2 vs 3
      86.392.3173
      Alcohol >20 units/week1.35.20.01 vs 23.28.30.0
      Arms assist6053593471 vs 2,

      1 vs 3
      5953483271 vs 2,

      1 vs 3
      Fair/poor general health3422403471 vs 2,

      2 vs 3
      3452573211 vs 2
      Falls
       1 in past 2 years270265298256259358
       ≥ 2 in past 2 years2421872341 vs 23082112641 vs 2
      low asterisk Incident fracture is defined as a fracture of at least one of the following bones: clavicle, upper arm, wrist, spine, rib, hip, pelvis, ankle, upper leg, lower leg, hand, foot, elbow, knee, or shoulder.
      We performed pairwise comparisons among the 3 groups, and report any results where Fisher's exact test P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      Table 4Frequency of Comorbidities Identified at Baseline among Women with Previous and Incident
      Incident fracture is defined as a fracture of at least one of the following bones: clavicle, upper arm, wrist, spine, rib, hip, pelvis, ankle, upper leg, lower leg, hand, foot, elbow, knee, or shoulder.
      Fractures (Percentage of Women)
      Previous FractureIncident Fracture (within 2 Years of Baseline)
      Group 1: Obese (n=2274)Group 2: Nonobese (n=7401)Group 3: Underweight (n=220)P Value
      We performed pairwise comparisons among the 3 groups, and report any results where Fisher's exact test P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      Group 1: Obese (n=633)Group 2: Nonobese (n=2170)Group 3: Underweight (n=53)P Value
      We performed pairwise comparisons among the 3 groups, and report any results where Fisher's exact test P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      Asthma2011131 vs 2191241 vs 2,

      1 vs 3
      Emphysema1410171 vs 2,

      2 vs 3
      161081 vs 2
      Osteoarthritis5145441 vs 2514644
      Rheumatoid arthritis1.31.02.31.31.31.9
      Colitis3.52.41.81 vs 22.92.40.0
      Stroke5.84.73.75.74.21.9
      Parkinson’s disease0.40.82.31 vs 31.31.03.8
      Multiple sclerosis1.00.80.91.01.30.0
      Cancer181615181615
      Type 1 diabetes6.72.71.41 vs 2103.21.91 vs 2
      low asterisk Incident fracture is defined as a fracture of at least one of the following bones: clavicle, upper arm, wrist, spine, rib, hip, pelvis, ankle, upper leg, lower leg, hand, foot, elbow, knee, or shoulder.
      We performed pairwise comparisons among the 3 groups, and report any results where Fisher's exact test P ≤.017 (for example, 1 vs 2 means the difference between group 1 [obese] and group 2 [nonobese] is statistically significant at alpha=.017 level).
      The use of anti-osteoporosis medication was significantly lower in obese women with fracture than in nonobese or underweight women with fracture. Among women with a previous fracture, 21% of obese, 35% of nonobese, and 54% of underweight women received anti-osteoporosis medication at baseline; in the same groups who experienced an incident fracture, rates of baseline anti-osteoporosis medication were 27% of obese, 41% of nonobese, and 57% of underweight (P <.001 for all pairwise comparisons, except for incident fractures, nonobese versus underweight women).

      Discussion

      Our results challenge the widespread belief that obesity is protective against fracture, and indeed suggest that obesity is a risk factor for certain fractures, particularly those of the ankle and upper leg. In this large, population-based cohort of postmenopausal women, the rates of both previous and incident fracture in obese women were similar to those observed in nonobese women. Although the highest fracture rates occurred in underweight women, the small proportion of women in the underweight group meant that the actual number of fractures in this population was low, and accounted for only 2.2% and 1.9% of the total number of past and incident fractures, respectively. In contrast, fractures in obese women accounted for 23% and 22% of all previous and incident fractures, respectively, in the GLOW population.
      An association between BMI and fracture site was demonstrated, the risk of incident ankle and upper leg fractures being higher in obese versus nonobese women, and of incident fractures of the wrist being lower. Relative protection against hip and pelvis fractures in obese women, as noted for previous fractures, may result from the protective effects of abdominal fat tissue on the impact of falls,
      • Bouxsein M.L.
      • Szulc P.
      • Munoz F.
      • et al.
      Contribution of trochanteric soft tissues to fall force estimates, the factor of risk, and prediction of hip fracture risk.
      while the lower rate of wrist fractures might reflect the direction of falls (possibly more likely to be sideways or backwards as opposed to forwards) in obese individuals. Because of reduced physical mobility, obese women are more likely to fall during activities with little forward momentum, thus protecting the wrist from impact, while the absence of soft tissue padding in the ankle and leg, together with the high impact of the fall, make these sites more vulnerable.
      In other studies, varying associations between obesity and fracture site have been reported. Gnudi et al
      • Gnudi S.
      • Sitta E.
      • Lisi L.
      Relationship of body mass index with main limb fragility fractures in postmenopausal women.
      found that, in 2235 postmenopausal women with fracture, increased BMI was associated with a significantly higher risk of humerus fracture and a lower risk of hip fracture, but no relationship was seen between BMI and either wrist or ankle fractures. In a study of men and women aged 20-80 years, Bergkvist et al
      • Bergkvist D.
      • Hekmat K.
      • Svensson T.
      • Dahlberg L.
      Obesity in orthopedic patients.
      reported that ankle fracture was significantly related to obesity. Finally, Nielson et al
      • Nielson C.M.
      • Marshall L.M.
      • Adams A.L.
      • et al.
      BMI and fracture risk in older men: the osteoporotic fractures in men (MrOS) study.
      have recently reported that obesity was associated with an increased risk of nonspine fractures in men aged ≥65 years, although there was insufficient power to examine the association between BMI and all individual fracture sites. Interestingly, in this study, the risk of hip fracture also was higher in obese men, an effect that was independent of BMD.
      • Nielson C.M.
      • Marshall L.M.
      • Adams A.L.
      • et al.
      BMI and fracture risk in older men: the osteoporotic fractures in men (MrOS) study.
      Data on vertebral fracture in obese individuals are sparse, although in one study in postmenopausal women, obesity appeared to be associated with increased risk.
      • Pirro M.
      • Fabbriciani G.
      • Leli C.
      • et al.
      High weight or body mass index increase the risk of vertebral fractures in postmenopausal osteoporotic women.
      Risk factors for fracture also differed according to BMI in our study. Early menopause was significantly associated with high BMI, rates of 19%-20% being recorded in obese women with either previous or incident fracture, as opposed to rates of 10%-14% in nonobese and underweight women. Whether obesity predisposes to, or is a consequence of, early menopause is unclear. In a recent study, surgical menopause, early hormone replacement therapy, higher serum androgen levels, and lower levels of sex-hormone-binding globulin predicted incident obesity, suggesting that the latter is the case.
      • Sutton-Tyrrell K.
      • Zhao X.
      • Santoro N.
      • et al.
      Reproductive hormones and obesity: 9 years of observation from the Study of Women's Health Across the Nation.
      In the present study, current estrogen use was not more common in obese than in nonobese or underweight women, but past use of estrogen was not documented.
      Obese women with fracture also reported a higher frequency of falls, fair or poor general health, and use of arms to assist standing from a sitting position, suggesting that an increased risk of falls and possibly also impaired protective responses to falling may be important risk factors for fracture associated with obesity. Increased risk of falls and reduced physical function have previously been demonstrated in obese women and men.
      • Corbeil P.
      • Simoneau M.
      • Rancourt D.
      • et al.
      Increased risk for falling associated with obesity: mathematical modeling of postural control.
      • Finkelstein E.A.
      • Chen H.
      • Prabhu M.
      • et al.
      The relationship between obesity and injuries among U.S. adults.
      • Fjeldstad C.
      • Fjeldstad A.S.
      • Acree L.S.
      • et al.
      The influence of obesity on falls and quality of life.
      • Friedmann J.M.
      • Elasy T.
      • Jensen G.L.
      The relationship between body mass index and self-reported functional limitation among older adults: a gender difference.
      We also found that higher BMI was significantly associated with a number of comorbidities, including asthma, emphysema, and type 1 diabetes. These conditions are all associated with obesity and have adverse effects on bone health through a variety of mechanisms, including reduced physical activity, comedications, and increased risk of falls.
      • Arden N.K.
      • Crozier S.
      • Smith H.
      • et al.
      Knee pain, knee osteoarthritis, and the risk of fracture.
      • Berry S.D.
      • Miller R.R.
      Falls: epidemiology, pathophysiology, and relationship to fracture.
      • Compston J.
      Management of glucocorticoid-induced osteoporosis.
      • Conway B.
      • Miller R.G.
      • Costacou T.
      • et al.
      Adiposity and mortality in type 1 diabetes.
      • Dam T.T.
      • Harrison S.
      • Fink H.A.
      • et al.
      Bone mineral density and fractures in older men with chronic obstructive pulmonary disease or asthma.
      • Dixon A.E.
      • Holguin F.
      • Sood A.
      • et al.
      An official American Thoracic Society Workshop report: obesity and asthma.
      • Dormuth C.R.
      • Carney G.
      • Carleton B.
      • et al.
      Thiazolidinediones and fractures in men and women.
      • Gershon A.S.
      • Wang C.
      • Guan J.
      • To T.
      Burden of comorbidity in individuals with asthma.
      • Janghorbani M.
      • Van Dam R.M.
      • Willett W.C.
      • Hu F.B.
      Systematic review of type 1 and type 2 diabetes mellitus and risk of fracture.
      • Klussmann A.
      • Gebhardt H.
      • Nubling M.
      • et al.
      Individual and occupational risk factors for knee osteoarthritis: results of a case-control study in Germany.
      • Mayne D.
      • Stout N.R.
      • Aspray T.J.
      Diabetes, falls and fractures.
      • Petit M.A.
      • Paudel M.L.
      • Taylor B.C.
      • et al.
      Bone mass and strength in older men with type 2 diabetes: the Osteoporotic Fractures in Men Study.
      Obese women with fracture thus had several markers of frailty, possibly explaining the significantly younger age at which incident fracture occurred, compared with nonobese or underweight women.
      While higher BMI is generally associated with higher BMD, there is increasing evidence that the effects of fat on bone mass vary according to its distribution, subcutaneous fat having beneficial effects and visceral fat having adverse effects. This difference may be mediated by the presence of lower levels of leptin and higher levels of adiponectin and pro-inflammatory cytokines in visceral fat.
      • Gilsanz V.
      • Chalfant J.
      • Mo A.O.
      • et al.
      Reciprocal relations of subcutaneous and visceral fat to bone structure and strength.
      • Russell M.
      • Mendes N.
      • Miller K.K.
      • et al.
      Visceral fat is a negative predictor of bone density measures in obese adolescent girls.
      In addition, increased visceral fat is associated with insulin resistance, which also may exert adverse effects on bone.
      • Fulzele K.
      • Riddle R.C.
      • DiGirolamo D.J.
      • et al.
      Insulin receptor signaling in osteoblasts regulates postnatal bone acquisition and body composition.
      • Goodpaster B.H.
      • Krishnaswami S.
      • Resnick H.
      • et al.
      Association between regional adipose tissue distribution and both type 2 diabetes and impaired glucose tolerance in elderly men and women.
      Vitamin D status is inversely related to BMI and to insulin resistance, providing another mechanism by which visceral fat mass might contribute to bone loss.
      • Frost M.
      • Abrahamsen B.
      • Nielsen T.
      • et al.
      Vitamin D status and PTH in young men: a cross-sectional study on associations with bone mineral density, body composition and glucose metabolism.
      • Orwoll E.
      • Nielson C.M.
      • Marshall L.M.
      • et al.
      Vitamin D deficiency in older men.
      In addition, the higher serum parathyroid hormone levels reported in obese individuals could have adverse effects on cortical bone.
      • Bolland M.J.
      • Grey A.B.
      • Ames R.W.
      • et al.
      Fat mass is an important predictor of parathyroid hormone levels in postmenopausal women.
      • Sukumar D.
      • Schlussel Y.
      • Riedt C.S.
      • et al.
      Obesity alters cortical and trabecular bone density and geometry in women.
      The effects of obesity on bone health are therefore complex and require further elucidation.
      The use of bone-protective medication in women with either a previous or incident fracture decreased significantly with increasing BMI. Among obese women, only 27% of those with an incident fracture were receiving treatment, as opposed to 41% and 57% in the nonobese and underweight groups, respectively. The low treatment rate in obese women may reflect the perception that they are protected by their higher BMD and that fractures in this population are therefore not “fragility” or “osteoporotic” fractures. Furthermore, assessment of fracture risk in obese women using algorithms such as FRAX (World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK) will generate lower fracture probabilities than in nonobese or underweight women because of the influence of BMI or BMD in these estimations, and fracture probability is less likely to achieve the intervention thresholds set in guidelines.
      • Compston J.
      • Cooper A.
      • Cooper C.
      • et al.
      Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK.
      • Donaldson M.G.
      • Cawthon P.M.
      • Lui L.Y.
      • et al.
      Estimates of the proportion of older white women who would be recommended for pharmacologic treatment by the new U.S. National Osteoporosis Foundation Guidelines.
      • Kanis J.A.
      • Burlet N.
      • Cooper C.
      • et al.
      European guidance for the diagnosis and management of osteoporosis in postmenopausal women.
      However, higher BMD in people with higher BMI may represent appropriate adjustment of the skeleton to increased body weight and may not necessarily confer greater bone strength for that individual.
      • Henry M.J.
      • Pasco J.A.
      • Sanders K.M.
      • et al.
      Fracture Risk (FRISK) Score: Geelong Osteoporosis Study.
      • Pesonen J.
      • Sirola J.
      • Tuppurainen M.
      • et al.
      High bone mineral density among perimenopausal women.
      • Seeman E.
      • Melton 3rd, L.J.
      • O'Fallon W.M.
      • Riggs B.L.
      Risk factors for spinal osteoporosis in men.
      In a cohort of postmenopausal women in the Study of Osteoporotic Fractures, obese women with incident, nonvertebral fractures had significantly lower BMD and a significantly greater likelihood of previous fracture history than their obese counterparts without fracture, demonstrating that fractures in obese women share some of the characteristics of fragility fractures.
      • Premaor M.O.
      • Ensrud K.
      • Lui L.Y.
      • et al.
      Risk factors for non-vertebral fracture in obese older women.
      Even if fractures in obese postmenopausal women are perceived as fragility fractures, the evidence base for bone protective therapy in this population is weak. Only a minority of obese postmenopausal women with fracture has osteoporosis, and a substantial proportion has normal BMD as defined by a T-score ≥−1.
      • Premaor M.O.
      • Pilbrow L.
      • Tonkin C.
      • et al.
      Obesity and fractures in postmenopausal women.
      In clinical trials of anti-osteoporosis medications, the proportions of obese women have generally been small, and those who have been included have had low BMD. The antifracture efficacy demonstrated in these studies cannot therefore necessarily be extrapolated to obese women with higher BMD, and in one study of the effects of clodronate in postmenopausal women not selected on the basis of low BMD, fracture reduction was lower in women with higher BMI than in those with lower BMI.
      • McCloskey E.V.
      • Johansson H.
      • Oden A.
      • et al.
      Ten-year fracture probability identifies women who will benefit from clodronate therapy—additional results from a double-blind, placebo-controlled randomised study.
      Further studies are therefore required to establish the antifracture efficacy of bone protective interventions in obese women with fracture, including investigation of the possibility that higher doses might be required.

      Strengths and Weaknesses

      Major strengths include the large sample size and prospective nature of the study, enabling examination of the characteristics of both previous and incident fractures. Limitations include the observational nature of the study, which makes it subject to bias, both in terms of the sampling of physicians and the recruitment of participants. Fractures were self-reported and were not confirmed radiologically, and spine fractures were under-represented, as subclinical vertebral deformities were not included. Fractures were not excluded on the basis of how they occurred. While information was collected about activity during fracture, <2% of fractures occurred during a motor vehicle accident. It is possible that some of the fractures may have been pathological in nature, but some clinicians may elect not to treat these fractures. Weight and height, risk factors, medications, and comorbidities also were self-reported; for fractures and medication use there is evidence that self-reports are reasonably reliable,
      • Chen Z.
      • Kooperberg C.
      • Pettinger M.B.
      • et al.
      Validity of self-report for fractures among a multiethnic cohort of postmenopausal women: results from the Women's Health Initiative observational study and clinical trials.
      • Curtis J.R.
      • Westfall A.O.
      • Allison J.
      • et al.
      Agreement and validity of pharmacy data versus self-report for use of osteoporosis medications among chronic glucocorticoid users.
      • Honkanen K.
      • Honkanen R.
      • Heikkinen L.
      • et al.
      Validity of self-reports of fractures in perimenopausal women.
      • Hundrup Y.A.
      • Hoidrup S.
      • Obel E.B.
      • Rasmussen N.K.
      The validity of self-reported fractures among Danish female nurses: comparison with fractures registered in the Danish National Hospital Register.
      • Ismail A.A.
      • O'Neill T.W.
      • Cockerill W.
      • et al.
      Validity of self-report of fractures: results from a prospective study in men and women across Europe EPOS Study Group. European Prospective Osteoporosis Study Group.
      • Nevitt M.C.
      • Cummings S.R.
      • Browner W.S.
      • et al.
      The accuracy of self-report of fractures in elderly women: evidence from a prospective study.
      and comparison of US GLOW data with the National Health And Nutrition Examination Survey (NHANES) III cohort showed that the distribution of risk factors among women in GLOW was broadly similar to that among women enrolled in NHANES.
      • Hooven F.H.
      • Adachi J.D.
      • Adami S.
      • et al.
      The Global Longitudinal Study of Osteoporosis in Women (GLOW): rationale and study design.
      Self-reporting of comorbidities may be less reliable; in particular, type 1 diabetes, which was specified on the questionnaire, may have been confused with type 2 diabetes. However, there is no reason why inaccuracies in self-reports of comorbidity or any of the other characteristics included in this study should vary across the BMI groups. Therefore, any such reporting error would tend to underestimate the effect of BMI on fracture risk. Finally, although this study included diverse geographical regions, no Asian or African countries were included and our results may therefore not be generalizable to these populations.

      Conclusions

      The finding that obesity is not protective against fracture in postmenopausal women and is associated with increased risk of incident upper leg and ankle fractures has major public health implications. The morbidity and economic costs associated with fractures in the obese population are likely to be higher than in nonobese women because of a greater risk of nonunion, postoperative complications, comorbidities, and slower rehabilitation.
      • Green E.
      • Lubahn J.D.
      • Evans J.
      Risk factors, treatment, and outcomes associated with nonunion of the midshaft humerus fracture.
      • King A.R.
      • Moran S.L.
      • Steinmann S.P.
      Humeral nonunion.
      Furthermore, in view of the rapidly rising incidence of obesity,
      Obesity: preventing and managing the global epidemic
      Report of a WHO consultation.
      • Zaninotto P.
      • Head J.
      • Stamatakis E.
      • et al.
      Trends in obesity among adults in England from 1993 to 2004 by age and social class and projections of prevalence to 2012.
      the contribution of fractures in obese women to the global fracture burden will increase significantly over the coming years. Understanding the pathogenesis of these fractures and developing effective strategies for their prevention are important areas for future research.

      Acknowledgment

      We thank the physicians and study coordinators participating in GLOW, the staff at the Center for Outcomes Research, and Linda Chase for secretarial support. Sophie Rushton-Smith coordinated revisions and provided editorial assistance including editing, checking content and language, formatting and referencing.

      References

        • Becker D.J.
        • Kilgore M.L.
        • Morrisey M.A.
        The societal burden of osteoporosis.
        Curr Rheumatol Rep. 2010; 12: 186-191
        • Burge R.
        • Dawson-Hughes B.
        • Solomon D.H.
        • et al.
        Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025.
        J Bone Miner Res. 2007; 22: 465-475
        • Kanis J.A.
        • Johnell O.
        Requirements for DXA for the management of osteoporosis in Europe.
        Osteoporos Int. 2005; 16: 229-238
        • Cooper C.
        • Campion G.
        • Melton 3rd, L.J.
        Hip fractures in the elderly: a world-wide projection.
        Osteoporos Int. 1992; 2: 285-289
        • De Laet C.
        • Kanis J.A.
        • Oden A.
        • et al.
        Body mass index as a predictor of fracture risk: a meta-analysis.
        Osteoporos Int. 2005; 16: 1330-1338
        • Albala C.
        • Yanez M.
        • Devoto E.
        • et al.
        Obesity as a protective factor for postmenopausal osteoporosis.
        Int J Obes Relat Metab Disord. 1996; 20: 1027-1032
        • Felson D.T.
        • Zhang Y.
        • Hannan M.T.
        • Anderson J.J.
        Effects of weight and body mass index on bone mineral density in men and women: the Framingham study.
        J Bone Miner Res. 1993; 8: 567-573
        • Premaor M.O.
        • Pilbrow L.
        • Tonkin C.
        • et al.
        Obesity and fractures in postmenopausal women.
        J Bone Miner Res. 2010; 25: 292-297
        • Hooven F.H.
        • Adachi J.D.
        • Adami S.
        • et al.
        The Global Longitudinal Study of Osteoporosis in Women (GLOW): rationale and study design.
        Osteoporos Int. 2009; 20: 1107-1116
        • Bouxsein M.L.
        • Szulc P.
        • Munoz F.
        • et al.
        Contribution of trochanteric soft tissues to fall force estimates, the factor of risk, and prediction of hip fracture risk.
        J Bone Miner Res. 2007; 22: 825-831
        • Gnudi S.
        • Sitta E.
        • Lisi L.
        Relationship of body mass index with main limb fragility fractures in postmenopausal women.
        J Bone Miner Metab. 2009; 27: 479-484
        • Bergkvist D.
        • Hekmat K.
        • Svensson T.
        • Dahlberg L.
        Obesity in orthopedic patients.
        Surg Obes Relat Dis. 2009; 5: 670-672
        • Nielson C.M.
        • Marshall L.M.
        • Adams A.L.
        • et al.
        BMI and fracture risk in older men: the osteoporotic fractures in men (MrOS) study.
        J Bone Miner Res. 2011; 26: 496-502
        • Pirro M.
        • Fabbriciani G.
        • Leli C.
        • et al.
        High weight or body mass index increase the risk of vertebral fractures in postmenopausal osteoporotic women.
        J Bone Miner Metab. 2010; 28: 88-93
        • Sutton-Tyrrell K.
        • Zhao X.
        • Santoro N.
        • et al.
        Reproductive hormones and obesity: 9 years of observation from the Study of Women's Health Across the Nation.
        Am J Epidemiol. 2010; 171: 1203-1213
        • Corbeil P.
        • Simoneau M.
        • Rancourt D.
        • et al.
        Increased risk for falling associated with obesity: mathematical modeling of postural control.
        IEEE Trans Neural Syst Rehabil Eng. 2001; 9: 126-136
        • Finkelstein E.A.
        • Chen H.
        • Prabhu M.
        • et al.
        The relationship between obesity and injuries among U.S. adults.
        Am J Health Promot. 2007; 21: 460-468
        • Fjeldstad C.
        • Fjeldstad A.S.
        • Acree L.S.
        • et al.
        The influence of obesity on falls and quality of life.
        Dyn Med. 2008; 7: 4
        • Friedmann J.M.
        • Elasy T.
        • Jensen G.L.
        The relationship between body mass index and self-reported functional limitation among older adults: a gender difference.
        J Am Geriatr Soc. 2001; 49: 398-403
        • Arden N.K.
        • Crozier S.
        • Smith H.
        • et al.
        Knee pain, knee osteoarthritis, and the risk of fracture.
        Arthritis Rheum. 2006; 55: 610-615
        • Berry S.D.
        • Miller R.R.
        Falls: epidemiology, pathophysiology, and relationship to fracture.
        Curr Osteoporos Rep. 2008; 6: 149-154
        • Compston J.
        Management of glucocorticoid-induced osteoporosis.
        Nat Rev Rheumatol. 2010; 6: 82-88
        • Conway B.
        • Miller R.G.
        • Costacou T.
        • et al.
        Adiposity and mortality in type 1 diabetes.
        Int J Obes (Lond). 2009; 33: 796-805
        • Dam T.T.
        • Harrison S.
        • Fink H.A.
        • et al.
        Bone mineral density and fractures in older men with chronic obstructive pulmonary disease or asthma.
        Osteoporos Int. 2010; 21: 1341-1349
        • Dixon A.E.
        • Holguin F.
        • Sood A.
        • et al.
        An official American Thoracic Society Workshop report: obesity and asthma.
        Proc Am Thorac Soc. 2010; 7: 325-335
        • Dormuth C.R.
        • Carney G.
        • Carleton B.
        • et al.
        Thiazolidinediones and fractures in men and women.
        Arch Intern Med. 2009; 169: 1395-1402
        • Gershon A.S.
        • Wang C.
        • Guan J.
        • To T.
        Burden of comorbidity in individuals with asthma.
        Thorax. 2010; 65: 612-618
        • Janghorbani M.
        • Van Dam R.M.
        • Willett W.C.
        • Hu F.B.
        Systematic review of type 1 and type 2 diabetes mellitus and risk of fracture.
        Am J Epidemiol. 2007; 166: 495-505
        • Klussmann A.
        • Gebhardt H.
        • Nubling M.
        • et al.
        Individual and occupational risk factors for knee osteoarthritis: results of a case-control study in Germany.
        Arthritis Res Ther. 2010; 12: R88
        • Mayne D.
        • Stout N.R.
        • Aspray T.J.
        Diabetes, falls and fractures.
        Age Ageing. 2010; 39: 522-525
        • Petit M.A.
        • Paudel M.L.
        • Taylor B.C.
        • et al.
        Bone mass and strength in older men with type 2 diabetes: the Osteoporotic Fractures in Men Study.
        J Bone Miner Res. 2010; 25: 285-291
        • Gilsanz V.
        • Chalfant J.
        • Mo A.O.
        • et al.
        Reciprocal relations of subcutaneous and visceral fat to bone structure and strength.
        J Clin Endocrinol Metab. 2009; 94: 3387-3393
        • Russell M.
        • Mendes N.
        • Miller K.K.
        • et al.
        Visceral fat is a negative predictor of bone density measures in obese adolescent girls.
        J Clin Endocrinol Metab. 2010; 95: 1247-1255
        • Fulzele K.
        • Riddle R.C.
        • DiGirolamo D.J.
        • et al.
        Insulin receptor signaling in osteoblasts regulates postnatal bone acquisition and body composition.
        Cell. 2010; 142: 309-319
        • Goodpaster B.H.
        • Krishnaswami S.
        • Resnick H.
        • et al.
        Association between regional adipose tissue distribution and both type 2 diabetes and impaired glucose tolerance in elderly men and women.
        Diabetes Care. 2003; 26: 372-379
        • Frost M.
        • Abrahamsen B.
        • Nielsen T.
        • et al.
        Vitamin D status and PTH in young men: a cross-sectional study on associations with bone mineral density, body composition and glucose metabolism.
        Clin Endocrinol (Oxf). 2010; 73: 573-580
        • Orwoll E.
        • Nielson C.M.
        • Marshall L.M.
        • et al.
        Vitamin D deficiency in older men.
        J Clin Endocrinol Metab. 2009; 94: 1214-1222
        • Bolland M.J.
        • Grey A.B.
        • Ames R.W.
        • et al.
        Fat mass is an important predictor of parathyroid hormone levels in postmenopausal women.
        Bone. 2006; 38: 317-321
        • Sukumar D.
        • Schlussel Y.
        • Riedt C.S.
        • et al.
        Obesity alters cortical and trabecular bone density and geometry in women.
        Osteoporos Int. 2011; 22: 635-645
        • Compston J.
        • Cooper A.
        • Cooper C.
        • et al.
        Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK.
        Maturitas. 2009; 62: 105-108
        • Donaldson M.G.
        • Cawthon P.M.
        • Lui L.Y.
        • et al.
        Estimates of the proportion of older white women who would be recommended for pharmacologic treatment by the new U.S. National Osteoporosis Foundation Guidelines.
        J Bone Miner Res. 2009; 24: 675-680
        • Kanis J.A.
        • Burlet N.
        • Cooper C.
        • et al.
        European guidance for the diagnosis and management of osteoporosis in postmenopausal women.
        Osteoporos Int. 2008; 19: 399-428
        • Henry M.J.
        • Pasco J.A.
        • Sanders K.M.
        • et al.
        Fracture Risk (FRISK) Score: Geelong Osteoporosis Study.
        Radiology. 2006; 241: 190-196
        • Pesonen J.
        • Sirola J.
        • Tuppurainen M.
        • et al.
        High bone mineral density among perimenopausal women.
        Osteoporos Int. 2005; 16: 1899-1906
        • Seeman E.
        • Melton 3rd, L.J.
        • O'Fallon W.M.
        • Riggs B.L.
        Risk factors for spinal osteoporosis in men.
        Am J Med. 1983; 75: 977-983
        • Premaor M.O.
        • Ensrud K.
        • Lui L.Y.
        • et al.
        Risk factors for non-vertebral fracture in obese older women.
        J Clin Endocrinol Metab. 2011 June 15; ([Epub before print])
        • McCloskey E.V.
        • Johansson H.
        • Oden A.
        • et al.
        Ten-year fracture probability identifies women who will benefit from clodronate therapy—additional results from a double-blind, placebo-controlled randomised study.
        Osteoporos Int. 2009; 20: 811-817
        • Chen Z.
        • Kooperberg C.
        • Pettinger M.B.
        • et al.
        Validity of self-report for fractures among a multiethnic cohort of postmenopausal women: results from the Women's Health Initiative observational study and clinical trials.
        Menopause. 2004; 11: 264-274
        • Curtis J.R.
        • Westfall A.O.
        • Allison J.
        • et al.
        Agreement and validity of pharmacy data versus self-report for use of osteoporosis medications among chronic glucocorticoid users.
        Pharmacoepidemiol Drug Saf. 2006; 15: 710-718
        • Honkanen K.
        • Honkanen R.
        • Heikkinen L.
        • et al.
        Validity of self-reports of fractures in perimenopausal women.
        Am J Epidemiol. 1999; 150: 511-516
        • Hundrup Y.A.
        • Hoidrup S.
        • Obel E.B.
        • Rasmussen N.K.
        The validity of self-reported fractures among Danish female nurses: comparison with fractures registered in the Danish National Hospital Register.
        Scand J Public Health. 2004; 32: 136-143
        • Ismail A.A.
        • O'Neill T.W.
        • Cockerill W.
        • et al.
        Validity of self-report of fractures: results from a prospective study in men and women across Europe.
        Osteoporos Int. 2000; 11: 248-254
        • Nevitt M.C.
        • Cummings S.R.
        • Browner W.S.
        • et al.
        The accuracy of self-report of fractures in elderly women: evidence from a prospective study.
        Am J Epidemiol. 1992; 135: 490-499
        • Green E.
        • Lubahn J.D.
        • Evans J.
        Risk factors, treatment, and outcomes associated with nonunion of the midshaft humerus fracture.
        J Surg Orthop Adv. 2005; 14: 64-72
        • King A.R.
        • Moran S.L.
        • Steinmann S.P.
        Humeral nonunion.
        Hand Clin. 2007; 23 (vi): 449-456
        • Obesity: preventing and managing the global epidemic
        Report of a WHO consultation.
        World Health Organ Tech Rep Ser. 2000; 894 (i-xii, 1-253)
        • Zaninotto P.
        • Head J.
        • Stamatakis E.
        • et al.
        Trends in obesity among adults in England from 1993 to 2004 by age and social class and projections of prevalence to 2012.
        J Epidemiol Community Health. 2009; 63: 140-146