title: Impact of lifestyle factors on fracture risk in older patients with cardiovascular disease: a prospective cohort study of 26,335 individuals from 40 countries.
abstract: BACKGROUND
  fractures are a major health concern among the elderly. People at risk for cardiovascular disease (CVD) are at an increased risk for fractures. The aim of this study was to assess the individual and combined effect of the CVD risk factors of smoking, alcohol consumption and physical activity on fracture risk in a large sample of older individuals with CVD or diabetes with end-organ damage.
  
  
  METHODS
  we analysed data for 26,335 adults, aged 55 years or older, who participated in two large antihypertensive drug treatment trials and who had no previous fracture at baseline. Lifestyle factors were assessed by the standardised questionnaire and their individual and combined effects on incident fracture risk were modelled using Cox proportional hazard regression.
  
  
  RESULTS
  during the 56-month follow-up, 1,079 incident fractures occurred; 508 (6.51%) among women and 571 (3.08%) among men. Smoking [hazard ratio (HR) 1.52, 95% confidence interval (CI) 1.27-1.82] and low physical activity (HR: 1.19, 95% CI: 1.05-1.36) were associated with an increased risk of any fracture, while high alcohol intake showed a directional, but non-significant, relationship with fracture risk (HR: 1.09, 95% CI: 0.64-1.84). Compared with participants with no lifestyle risk factors, those having one, two, or three risk factors had an increased risk of a future fracture (HR: 1.17, 95% CI: 1.03-1.34 for one risk factor; HR: 1.73, 95% CI: 1.38-2.16 for two risk factors; and HR: 2.37, 95% CI: 0.88-6.36 for three risk factors; P for trend <0.001).
  
  
  CONCLUSIONS
  a healthier lifestyle advocated to reduce the risk of CVD is associated with a significant and graded reduction in fracture risk.
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Rasha
authors.initials: R
authors.lastname: Khatib
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Salim
authors.initials: S
authors.lastname: Yusuf
authors.affiliation: Endocrinology, Kaiser Permanente of Georgia and Emory University School of Medicine, Atlanta, Georgia, USA.
authors.forename: Joshua I
authors.initials: JI
authors.lastname: Barzilay
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Papaioannou
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Lehana
authors.initials: L
authors.lastname: Thabane
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
authors.forename: Peggy
authors.initials: P
authors.lastname: Gao
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Philip G
authors.initials: PG
authors.lastname: Joseph
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Koon
authors.initials: K
authors.lastname: Teo
authors.affiliation: Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Mente
mesh_terms: D000367:Age Factors; D000368:Aged; D000428:Alcohol Drinking / Q000009:adverse effects / Q000453:epidemiology; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control; D006801:Humans; D015994:Incidence; D008019:Life Style; D008297:Male; D008875:Middle Aged; D009043:Motor Activity; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012307:Risk Factors; D040242:Risk Reduction Behavior; D057185:Sedentary Behavior; D012907:Smoking / Q000009:adverse effects / Q000453:epidemiology; D011795:Surveys and Questionnaires; D013997:Time Factors
keywords: cardiovascular disease; cohort; fracture risk; international; lifestyle; modifiable; prospective; risk factors