title: Comparison of Bone Mineral Density between Urban and Rural Areas: Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Studies from high income countries (HIC) have generally shown higher osteoporotic fracture rates in urban areas than rural areas. Low bone mineral density (BMD) increases susceptibility to fractures. This review aimed to assess whether urbanicity is consistently associated with lower BMD globally.
  
  
  METHODS
  Ovid MEDLINE, EMBASE, and Global Health (-April 2013) were searched for articles investigating differences in bone mineral content (BMC) or BMD between urban and rural areas. Ratio of means (RoM) of BMD were used to estimate effect sizes in meta-analysis, with an exception for one study that only presented BMC data.
  
  
  RESULTS
  Fifteen articles from eleven distinct populations were included in the review; seven populations from four high income countries and four from three low and middle income countries (LMIC). Meta-analysis showed conflicting evidence for urban-rural difference in BMD; studies from high income countries generally showed higher BMD in rural areas while the results were more mixed in studies from low and middle income countries (HIC RoM = 0.05; 95% CI: 0.03 to 0.06; LMIC RoM = -0.04: 95% CI: -0.1 to 0.01).
  
  
  CONCLUSIONS
  Urban-rural differences of bone mineral density may be context-specific. BMD may be higher in urban areas in some lower income countries. More studies with robust designs and analytical techniques are needed to understand mechanisms underlying the effects of urbanization on bone mass accrual and loss.
authors.affiliation: Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Mika
authors.initials: M
authors.lastname: Matsuzaki
authors.affiliation: Indian Institute of Public Health, Hyderabad, India.
authors.forename: Rashmi
authors.initials: R
authors.lastname: Pant
authors.affiliation: National Institute of Nutrition, Hyderabad, India.
authors.forename: Bharati
authors.initials: B
authors.lastname: Kulkarni
authors.affiliation: Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Kinra
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015519:Bone Density / Q000502:physiology*; D016001:Confidence Intervals; D003906:Developing Countries; D005260:Female; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D012424:Rural Population; D014505:Urban Population; D055815:Young Adult