 The participants are coming in so great. So welcome everyone. My name is Jennifer Boyko. I'm the manager of scientific operations with the Canadian longitudinal study on aging or CLSA for short. Thank you for joining us for one of our first webinar of the new academic school year entitled an update of the prevalence of osteoporosis fracture risk factors and medication use among community developing older adults in CLSA. Again, I want to acknowledge that the CLSA National Coordinating Center and McMaster University are located on the traditional territories of the Mississauga and Haudenosaunee Nations and within the lands protected by the dish with one spoon wampum agreement. All of the university is located in the Mi'kmaqi, the ancestral and unceded territory of the Mi'kmaq. These lands are bound by the spirit and intent of the peace and friendship treaty. We are all treaty people. As attendees of this webinar, I encourage you to learn more and acknowledge the original inhabitants of the lands where we currently have the privilege to do research, live and work wherever that may be. Before we really get started, let's review a couple of our housekeeping points which we always do at the beginning of our webinars. Everyone but the presenters will be muted throughout the session. If you need to change or test your audio during the webinar, you can click audio settings that on the left of the bottom toolbar. At the end of the presentation, there will be a question and answer period. If you have a question about the webinar then or at any time you can post the question by typing it into the Q&A box located in the bottom toolbar. The questions will be addressed at the very end of the webinar. Some questions will be visible to all attendees. If you have any technical trouble concerning the webinar, please use the chat box to communicate with our webinar team. So post your questions in the Q&A box and any technical issues in the chat box. A feedback survey will be launched at the end of the webinar and we invite you to complete this after exiting your Zoom session. This brief survey provides us with some important feedback that can help us plan future webinars like this one. Now on to today's webinar. Again, the title is an update of the prevalence of osteoporosis, factor with factors and medication use among community dwelling older adults in the CLSA, and it's being presented by Caitlin MacArthur. Dr. MacArthur is an assistant professor in the School of Physiotherapy at Dalhousie University in Halifax. Dr. MacArthur's research focuses on improving the effectiveness of access to rehab for people living with chronic health conditions across the continuum of care, particularly home and long-term care. She is interested in fall and proctor prevention and improving functional mobility with a passion to improve mobility and quality of life of clinically complex older adults. Dr. MacArthur is a lead instructor of the Continuing Education course Bone Fit, which is trademarked, hosted by osteoporosis Canada, which teaches exercise professionals about safe movements, physical activity, and exercise for people with osteoporosis. And now I will pass it on to Caitlin. Welcome. Great. Okay, let me just get my screen shared here so that we're ready to go. All right. Thank you everybody for joining me today. I'm really excited to be here to talk about this project that we did within the CLSA. So we're going to be talking today about osteoporosis. So just so that we're all on the same page about what we mean by osteoporosis, we are talking about a disease characterized by compromised bone strength that also has an increased risk for fractures. And this disease also has a significant morbidity, mortality, and economic burden. So just to give you a few examples of that, after hip fracture, about 25% of people will require institutionalization. So for example, moving into a long-term care home, and over 30% will die within a year of the fracture. So it can be quite a devastating event for somebody. And in terms of the economic burden in Canada in 2011, the aggregate cost of osteoporosis attributable factor, fractures. Sorry, I'll say that again. The aggregate cost of osteoporosis attributable fractures was $4.6 billion. So it costs the health care system quite a lot of money. The resource planning for fracture prevention treatment relies on accurate prevalence estimates of osteoporosis and fracture risk factors. And so that was kind of the impetus behind the study, because we want to know how many people are living with osteoporosis. So we can make plans to ensure that we can try to prevent those fractures and also take care of the people living with it. So previous studies have estimated the prevalence of osteoporosis in Canada, and the rates really ranged depending on the study. And it kind of also depended on the type of data that was used to develop these estimates. So the rates listed here are some of the most recent rates that have been estimated. So anywhere from 15.8% of women and 6.6% of men, 5.6 to 10.5% of people over the age of 50, 10.1% for adults over the age of 40. And so again, it kind of depended where the data came from for this particular estimate as to what the range was. So it could be from administrative data. So looking at hospital records and drug records to see what type of medication people are taking. It could be from clinical data. So looking at how many people have had an osteoporotic fracture over time, or self-reported data. So asking people if they've received a diagnosis of osteoporosis. So you can see why that rate, the rate may range quite a bit depending on how the data are collected. However, these though these are the most kind of recent estimates, these studies are now, you know, becoming older, so 10 to 20 years old. And we know that the aging population is rapidly growing. So these estimates that we developed with this study help us ensure that resource planning kind of keeps pace with the increasing aging population. So we know that we're going to have more older adults. We know that that population, that portion of the population is rapidly growing. So we want to make sure that we can keep up and we know kind of what the prevalence of osteoporosis is in Canada for planning purposes. So what about fracture risk? You noticed in my title I talked about osteoporosis as well as fracture risk. So fracture risk basically is how likely someone is to experience a major osteoporotic fracture in a specified time frame. It depends on the tool that you use, what that time frame will be, could be a year, could be two years. Quite often it's 10 years. So we kind of estimate what is the probability that someone's going to have a fracture in the next 10 years. As I mentioned, there are a variety of tools used to assess fracture risk. One is called the fracks. And that's the one I'm going to be talking about today. And we're going to be talking about the fracks that estimates how likely someone is to fracture in the next 10 years. So fracture risk is really important to gather information about, not just having diagnosis of osteoporosis. It's also important to gather that information about fracture risk because many fractures actually happen in the absence of a diagnosis of osteoporosis, either through bone mineral density or other means. So a lot of people will actually have a fracture before they have even been diagnosed with osteoporosis. So, and that might be for a variety of reasons that they haven't been diagnosed. But they might not meet the threshold for an osteoporosis diagnosis just yet. So maybe they have what we call osteopenia, which is slightly more bone mass but still low bone mass in general. So it's really important that we think about how likely someone is to fracture, not just whether they have a diagnosis or not. But many people who are identified as high fracture risk are not offered pharmacological treatment or decide not to take it. And so it's really important to kind of capture how many people are at high fracture risk and whether they're taking pharmacological treatment or not. So if somebody is at high fracture risk, the recommendations for osteoporosis and for high fracture risk is that people would be offered a pharmacological treatment for their to kind of manage and mitigate the risk of having another fracture or having a fracture at first. Another recent study also suggested that it's important to understand the proportion of the general population that is at high fracture risk. And this really helps us with proper surveillance and planning. So both understanding how many people have, you know, diagnosed osteoporosis and then how many people are at high risk because those numbers might be different and are actually different. But it also helps us with proper surveillance, so understanding what the risk level is in the general population, but also planning. So where do we need to have more assessment, where do we need to intervene, and those types of things. So here are some of the established fracture risk factors. And these are the ones that we looked at within this study. So we know that fracture risk, it tends to increase with age so as we get older we tend to have a higher risk for fracture. We also know that sex plays an important role so females tend to be at a much higher risk for fracture than males. So having a low body mass increases the risk for fracture. If somebody's had a fracture already, especially an osteoporotic fracture or what we call a low trauma fracture. So this would be a fracture that happens from falling from standing up to less or the height of two steps or less. Or, you know, sometimes it can also be an insidious fracture so it just happens for no particular event like there's no fall or anything that kind of caused it. If somebody has a history of their parents having a hip fracture, they're more likely to have a fracture. You know there is a genetic component to fracture risk. Smoking also increases the risk for fracture. Someone's recently taken systemic glucocorticoids for, you know, a variety of conditions that can also increase the risk for fracture, as well as having rheumatoid arthritis or living with diabetes, especially particularly type two diabetes. If a female has gone through premature menopause, they are more likely to experience fracture. So that's before the age of 45. And that's because there's changes within estrogen that affects the bone. Heavy alcohol use increases the risk for fracture, as well as low femoral neck bone mineral density, which most people are familiar with that if you have a lower bone mineral density or less bone overall, you're more likely to have a fracture. So these are some of the factors we're going to be talking about in the study. So all of that considered what were the objectives of our study. So we wanted to, within the CLSA data, provide an up-to-date prevalence of the estimate of osteoporosis. And we looked at both self-reported osteoporosis and DEXA confirmed because both of those were available to us within the data. We wanted to look at the prevalence of fracture risk. So what's the proportion of the population that is at high fracture risk? We also wanted to look at the distribution of fracture risk factors and what's the prevalence of those fracture risk factors across the population. And then we also wanted to look at the proportion of older Canadians who are at high fracture risk. We're not taking osteoporosis medications. And why this is important is because, as I mentioned, a lot of fractures will actually happen in the absence of a diagnosis of osteoporosis. And so sometimes looking at high fracture risk is more important. But we also know, as I mentioned as well, that many people who are at high fracture risk are not taking osteoporosis medications or not provided osteoporosis medications. So it identifies a gap in fracture prevention that is something we could target. So in terms of our data, we used data from the CLSA. And these were participants from the baseline comprehensive cohort who completed interviews and the physical assessments. So these were completed between 2011 and 2015. And we only included participants who had DEXA data available. So this was 27,685 participants that we were able to analyze their data because of course we wanted to have DEXA confirmed osteoporosis. So we needed that data in order to include them in our study. So just a quick review of the data source for CLSA and how the sample from CLSA is gathered. So basically there was three sampling frames. So a subset of participants from the Statistics Canada's Canadian Community Health Survey for Healthy Aging, registries of provincial healthcare systems and random digit dialing. And that's how people were recruited into the CLSA. And in the comprehensive cohort, the cohort that we used to attended the interviews in person and did the physical assessments and data collection. So we lived within 25 to 50 kilometers of data collection site. And this excluded people who are living in an institution at baseline, people who are full time members of the Canadian Armed Forces, persons living off federal First Nations reserves and other settlements. So people living in the three northern territories and some other remote regions, those unable to respond in English or French and those who had cognitive impairment at baseline and were unable to participate. So for our data analysis, we really did a descriptive analysis. So we described the prevalence of five different things. We over-reported the prevalence of self-reported osteoporosis. Next of DEXA confirmed osteoporosis. And for this we used the results from the femoral neck DEXA. And we used the World Health Organization definition for our cut points for osteoporosis. So T score less than or minus 2.5 or less was considered osteoporosis. Osteopenia was a T score between minus one and minus 2.5 and normal bone marrow density was a T score more than minus one. We also described the prevalence of each fracture risk factor within the frax and the ones that I had kind of gone through previously. And people who are at high risk according to the frax and the frax was really great is it was already calculated within the CLSA data. So we are able to pull that information from the data that we accessed. So just to give you an idea of what a high risk is within the frax. This is 20% or higher chance of a future fracture within the next 10 years. And we also described the prevalence of people who have osteoporosis and who are at high fracture risk who are not taking osteoporosis medications. So how we identified osteoporosis medications is we defined those using the drug ID number. And Public Health Agency of Canada has an operational structure for which drugs are generally used for osteoporosis. So we use that structure to help identify which are the medications that somebody would be taking for osteoporosis. Within this we did not include over the counter supplements like calcium or vitamin D. We only looked at prescribed medications. We reported prevalence estimates both as a percentage and as cases per 1000 persons. We stratified these prevalence estimates by age and sex because we know that those are two very important factors when we talk about osteoporosis and fracture risk. And as is standard with these analyses we use the sampling weights as defined by the CLSA and apply those to our analysis. All right so let's jump into some results. Our sample, as I mentioned had about 27,000 participants their mean age was 70 with a standard deviation of 10.3 years and 52.5% of our sample were female. We looked at the prevalence of osteoporosis. So this is self reported osteoporosis so that the participants were asked has a physician ever told you that you have osteoporosis. Overall the prevalence with 7.8% of our total sample, but 2.2% of males and 12.7% of females which is what we would expect to see with a higher prevalence for females. When we look at DEXA confirmed we can see that our prevalence is much lower so overall 3.6% had DEXA confirmed osteoporosis 1.2% of males and 5.9% of females and we'll discuss a little bit why we might be seeing that difference between self reported and DEXA confirmed a little bit later. It's also really important to think about fracture history so if somebody's had a fracture in the past I mentioned that having a fracture, a previous fracture puts you at high risk for a future fracture. So when we looked at their self reported lifetime fracture history, we found that 13.8% of our population overall had reported a fracture in the past. So 7.2% of males and 17.1% of females which again is what we would expect to see with a higher prevalence with females. Now I'll just make an important note here that these were all fractures grouped together so just based on the structure of how the CLSA interview guide works, it's hard to disentangle osteoporotic or low trauma fractures from all fractures. Because it doesn't parse out whether it happened from the height of just standing and falling over or because of no trauma, it's just fractures overall. So that's why we've kind of reported it here is lifetime fracture history not as major osteoporotic fracture history as you might expect in research related to osteoporosis. Alright, so let's have a look at our prevalence. And this is stratified by age and sex across the bottom with the yellow bars being female, the green bars being male, and then the kind of more solid with some dots being self reported osteoporosis and the lines being dexaconfirmed osteoporosis. And we are talking here about cases per 1000 persons so we're no longer talking about percentage or proportion, we're looking at the cases cases per 1000 persons. So a few things to kind of pay attention to. One thing is that the prevalence of osteoporosis increased with age, regardless of male or female. We see that there's an increase as we go to the right from 45 to 75 plus. The next important thing to notice is that the highest prevalence of osteoporosis is in females age 75 plus, which again is what we would expect to see. This is interesting and I kind of pointed out on the first slide they're talking about the population is that the prevalence of self reported osteoporosis was always higher. So it didn't matter age or sex. The prevalence of self reported osteoporosis is always higher than dexaconfirmed osteoporosis. We get into the discussion and we'll talk about why we hypothesize that might be happening. So that was the prevalence of the different fracture risk factors. So again, female is going to be the yellow bars here and male is going to be the green bars, and then we have our different fracture risk factors on the left hand side, and going across we have the proportion of the sample so again now we've switched back to proportion of the sample. So in here you can see that all of the risk factors were higher for females, except for three more lifestyle factors so alcohol intake, smoking, and diabetes, the prevalence was higher for men. And of course for premature menopause here we've only reported females, but you can see that about 50% females had lived through premature menopause. So you can see that the sex difference is there. All right, so let's switch gears and talk now about high fracture risks. So now we're looking at the prevalence of people within the population who were at high fracture risk according to the facts. So again, now we're looking at cases per 1000 persons. The yellow is going to be female and green is going to be male. So some important things to kind of look at first in the left hand corner there we have the bottom left hand corner. We have the proportion or the percentage of people at high fracture risk so overall of the overall sample is 2.8% 0.3% for males and 5.1% for females. So what we can kind of glean from this figure here is that the prevalence of high risk individuals increases with age, but it's always higher for females. So you can see regardless of male or female we see an increase as we go to the right, but the yellow bars are always higher than those green ones. And just like osteoporosis, the highest prevalence is for females age 75 plus, which again is something we would expect to see. Okay, so now our findings related to fracture risk and medications. So this is now the proportion of the sample or the percentage of the sample, we're at high fracture risk but are not taking an osteoporosis medication. Again, the summary on the left hand side at the bottom for you there, we have 92.7% overall so that's 92.7% of people who are at high fracture risk are not taking medications. For males, it's 97.8% and for females, it's 82.6%. You can see it's quite high overall. So some things to notice from this figure as well is that the prevalence is now kind of the opposite so it's always highest for males. So those the green bars within the same age category, the prevalence of men who are at high fracture risk or males who are at high fracture risk and not taking medication was always higher than females within the same age group. For males age 45 to 54, there were not any males in that age group that were at high risk and that's why that proportion there is zero. And what was also interesting is that prevalence decreased with age. So the prevalence of people who are at high fracture risk were not taking medications decreased with age, but it always remained above 70%. So that's quite a high number. So for all groups at best, at worst I guess 70% were at high fracture risk and not taking medications. So it's quite a high proportion of people. Okay, so let's talk a little bit about some of these results and why we might be seeing what we're seeing. The first thing is that we had a lower prevalence of osteoporosis than previously reported. So overall, our dexa confirmed osteoporosis was 3.6%. And this is lower than the lowest prevalence that's been reported before of 6.6 or, you know, as high as 15.8%. So why we might be seeing this, these differences is first we report dexa confirmed. Whereas the other studies that I mentioned before reported self report or a confirmation of osteoporosis from administrative data. And importantly in our study we found that self report overestimated prevalence of osteoporosis. So if we recall back to the first figure I showed you self reported osteoporosis was always higher than dexa confirmed osteoporosis. So it could be that previous studies that relied on self report for overestimating the prevalence. Because there's this discrepancy between self report and dexa confirmed. Another possibility is we have seen in previous studies that have been done fairly recently that bone mineral density is actually increasing and hip fracture rates are decreasing. And, you know, there's a couple thoughts as to why this is happening. Why we might be seeing this kind of shift over time. There is a higher prevalence of obesity. And if people are living with obesity they're generally at a lower risk for fracture. Now there are people who living with obesity who are at higher risk for fracture for various reasons, perhaps they're living with diabetes as well. But generally we see if you have a lower body mass index or at a higher risk for fracture, but a higher body mass index might actually be at a lower risk for fracture. There's also lower smoking rates and we know that smoking can increase the risk for fracture. As well, though, you know, my data kind of suggests that there's not many people receiving osteoporosis treatment. Over time we have seen some increases in osteoporosis treatment in general. So more people might be getting a receiving treatment so that might be why we're seeing the results we see. The last possibility is that the CLSA cohort could be a healthier cohort than we see in the general population, or that we see in those previous studies that have been done. And I'll talk about this a little bit more in the limitation section, but if they generally the CLSA cohort is a little bit healthier, then we might see lower rates of osteoporosis than in populations that aren't quite as healthy. The next thing that I'd like to just discuss is a significant primary fracture prevention gap. So we found that many, in fact, most people who are at high fracture risk are not on or not receiving an osteoporosis medication. And there's been previous work that has found similar results. So a study was done across 27 European countries, and they found that only 55% of postmenopausal women who are at moderate high and very high fracture risk were untreated with medication. And so this study has seen slightly different results because they included moderate high and very high, whereas we just included high based on fraffs. So that's why you might see some differences there, but we do see that there is still the significant gap in people being high risk and people receiving medication. Now, we weren't able in our data to understand why people might not be taking medication and there's a lot of different reasons. So some of the osteoporosis medications have significant side effects. And so people choose not to take that medication because it can be unpleasant. And they don't want to have those side effects or they're fearful of some of the rare, but serious side effects that can happen with these medications. Financially, there might be some constraints whether medications are covered by drug plans or not. There's a lack of efficacy and I put in brackets perceived lack of efficacy so there's also there's kind of the real lack of efficacy that might be in play, but also people not perceiving that there might not be efficacy related to medication use, as well as medications. So some of the medications, the preparations are changing over time, but some require some specific ways that you take the medication. And so they might choose not to take it because it feels inconvenient at the time, or they just may choose not to take medication for a combination of all of these reasons together. What's important is that previous work suggests most prevention focuses on secondary prevention. What that means is that we focus a lot on preventing fractures after they've happened, which sounds kind of funny. But basically if somebody's had a fracture, that's when we put something into play to try to prevent the next fracture from happening. So there's a lot of screening programs within hospitals where somebody has a fracture and then they will be followed up and they might have a bone marrow density at that time. And then they might be on medication after that or there might be more other kind of prevention strategies put into place after that. So we tend to focus a lot on primary prevention, so trying to prevent the fracture before it even happens. And that's really important because as I've said a couple times now, if somebody's had a fracture before, they're a lot more likely to have a second fracture. So if we can try to prevent that first fracture from happening, it can be really, really important. And fractures result in substantial pain for the person. They can be quite debilitating, have a lot of disability associated with them, they cost the healthcare system, billions of dollars as I mentioned. So fracture prevention really should be optimized. We shouldn't wait till someone has a fracture to try to prevent the next one. I mean, of course we want to still do that, but we will also want to try to prevent that first fracture from happening. And I think the results of the study really point to an opportunity to engage in primary fracture prevention where we try to prevent that first fracture from happening. So I've kind of mentioned a couple times that the prevalence of self reported osteoporosis was higher. And this has also been found in previous work. So it does our work does agree with previous work. So here's a few examples. So only 62% of people in this one study here with DEXA confirmed osteoporosis reported their results correctly. So they said, yes, I have osteoporosis. Some people might have said, oh, they have osteopenia or lower bone mass. They might have said, oh, no, my bone health is fine. Another study found that oftentimes people will report osteoporosis when they are osteopenic. And so that's where things get kind of confused. And that's really just related to the cut off scores that are applied to bone mineral density. We know that if people are osteopenic, of course, it's important to still think about fracture risk, but oftentimes people get confused between the two. So that might be why we're seeing a higher prevalence, self reported osteoporosis, because maybe people were osteopenic and saying they had osteoporosis. We could actually look at this with the data, but we didn't delve into it for this particular study. Another study also found that people often confuse osteoporosis with other conditions that affect our bones like osteoarthritis. And this is quite common. Somebody might think, oh, osteo something, but they're not sure what the something is. And so they confuse the two conditions with each other. Also, it's been found that there's often a poor communication of a diagnosis from a healthcare provider. So it might be that the person didn't understand, but it might also be that the healthcare provider hasn't really provided a good communication of what the person is living with. So looking at the bone mineral density reports, taking everything into consideration, it might not be clear to the person what it is that they're living with. And within this study, they also found that there were some factors associated with accurate reporting of osteoporosis. So they found that females were more likely to accurately report their, their osteoporosis. They found that accuracy varied by race as well as by bone, body mass index. If people were living with poor health or had a history of fractures. And if they were receiving osteoporosis treatment. So that's another kind of interesting thing to take into consideration that it might not be just confusion. It might not be just poor communication, but there's actually some inherent reasons why people might have an understanding of what their health is. So the important thing to kind of take from this is that education about the disease may be needed for people who inaccurately report or people who tend to accurately report. So we need to think about how we improve communication about an osteoporosis diagnosis and how it's different from other disease conditions like osteoarthritis. And the last kind of important finding is that osteoporosis is under treated in males more than females. So we saw that our results were kind of flipped for when we looked at the prevalence of people at high fracture risk were not receiving treatment and it was always higher in men, than males. So this is consistent with other literature as well that osteoporosis is traditionally under recognized in males, often thought of as a older women's disease. And so we don't often think about males living with this disease. And males are often not targeted for primary prevention. They often receive secondary prevention of treatment related to secondary osteoporosis. So osteoporosis can develop from many different conditions. For example, rheumatoid arthritis was one example within the facts, but there's some other reasons why people might develop osteoporosis secondary to other treatments or other conditions that they're living with. So a previous study found that the factors associated with osteoporosis care really focused on secondary prevention. So people who are males who received osteoporosis care were more likely to have multiple comorbidities. They were more likely to have received hormonal therapy for prostate cancer, which is a risk factor for osteoporosis. They were more likely to have vertebral or hip fractures and receive glucocorticoid treatment. So I think oftentimes we might think about osteoporosis in the context of secondary condition for males, and we under recognize that kind of primary prevention. So it's really important to think about primary prevention for males and promotion of that and not kind of thinking that osteoporosis only affects females, especially older females. So the strengths of this study are that the CLSA is a population based national cohort with stratified random sampling, and we also applied the sampling weights to minimize sampling bias. So that means that our results should be generalizable to the Canadian population over the age of 45. Some limitations to our study, as I mentioned, we didn't examine the reasons behind not taking medications, but that could certainly be a future study. So we only looked at whether they were taking them yes or no, not why. They might not be taking them, but I think this kind of opens the door for future research into that area. We didn't include lumbar spine T scores because they weren't available to us at the time of our analysis. So sometimes when we look at the prevalence of osteoporosis we look both at femoral neck and lumbar spine T scores, but we didn't have access to those lumbar spine T scores when we did our analysis. However, the femoral neck is really the most extensively validated site for the definition of osteoporosis, and it also provides a higher gradient of fracture risk than many of the other techniques so we felt confident in our results. As I mentioned, the CLSA cohorts may have been healthier than the kind of general population. Indeed, baseline, you know, people with cognitive impairment for who couldn't participate were excluded, and people living in institutions and we know that these two particular populations are at higher fracture risk so really we are results are kind of generalizable to the healthy older population living in the community in Canada. We also couldn't establish a clinical diagnosis of osteoporosis or high fracture risk based on previous fracture. And this is because we weren't able to ascertain whether the fractures were low trauma or not. So as I mentioned when I talked about lifetime fracture history, we couldn't parse out which of those fractures were low trauma. And oftentimes, knowing if somebody has had a low trauma fracture will help us make a clinical diagnosis of osteoporosis, or help establish if somebody is high fracture risk so we just weren't able to look at that. We had to rely on the facts, Dexa and self reported osteoporosis. And finally, our study was cross sectional, and really we're describing a prevalence kind of at that cross section. So we couldn't determine how many people may have experienced a fracture after our assessment so, you know, you know what their fracture is fracture risk is at this one time point but we don't know whether they have experienced it in the future. Again, I think this opens up a door for a previous or for a future study to kind of look at this, this information. So in conclusion, we provide an updated prevalence estimate of osteoporosis for community dwelling older adults age 45 to 85. We found that most community dwelling older adults at high fracture fracture risk are not taking osteoporosis medications, especially males, and this in particular presents an opportunity for primary fracture prevention in the community. So I'd like to take this moment to acknowledge people who have been involved in this project so this project was started at the Jarrah Center for aging research and funded by Catalyst Grant from the CIHR. And I'd really like to thank everyone in Hadjar for helping with the data analysis and for being coauthors and then the other coauthors listed there for their kind of critical feedback and help in designing and carrying out the study. This study has been published in the archives of osteoporosis it's there for you on the right and I believe the link was going to be shared with you. And if you're interested in other work by our group by looking at osteoporosis fractures falls, etc. within the CLSA, we just published this, this study in JBM arts just been accepted, just on September 5. So just a few days ago, but you can look at the associations among cognition frailty and false and self reported incident fractures that there are some interesting finding their findings there as well. Thank you very much for listening to me today. I'm really excited to answer any questions that you have. You can always email me at my email address there or catch me on Twitter as well. Thank you very much. And congratulations on all your recent work. The great exemplar of how to use the CLSA data for very important issues. I know there was, there's a couple questions that came through and, you know, two of them were sort of, I guess, I guess it speaks to the personal nature of this issue. Okay, then maybe I'll let you read the couple comments that were posted but you know I think it speaks to the importance of their needing to be good clinical practice guidelines coming out of work such as that's what you're doing. The example that was posted about, you know, a physician not providing or sort of downplaying the medications that were being suggested but perhaps up playing a bone density test. And then, you know, what the other example in the chat is sort of is an example of well, you know, I don't fit within any of what I'm being told what should I do so I'm just wondering, just inside said we can't really sort of touch on personal responses but maybe anything, is there anything from your research that you think could be a contribution to good practice clinical practice guidelines or is it going in that direction at all. Yeah, that's a great question. And I'll just put up a plug for the hospital process Canada's new guidelines will be coming out shortly. Within the next several months. So those will be updated and they have sections on fracture risk, you know that I kind of talked about and medications when they should be, you know, considered and when they should not be considered and how to kind of have that conversation, as well as other lifestyle factors like exercise and nutrition which are certainly important. We didn't focus on them on this study in particular, but we did. So that they are important things to consider as well. So those, those will be coming out very very soon. So I would definitely urge people to kind of look to those as they come out. You can check us to your process Canada's website for updates on those. I think, you know, a lot of the work that we did here supports some of that work just thinking about, you know, when medication might be important, important when other factors might influence decisions about about choosing to use a physician or not. And that's certainly a conversation that you want to have with with your physician. So, yeah, I think, you know, keep your eyes out for the new guidelines that are coming and they have sections on all of the things that I talked about today. And of course, I think it's a reminder always that just because we have these guidelines doesn't mean they're necessarily used in practice. And you know, implementation science and ensuring that these guidelines are used once they're developed is important as well so but that's a whole other topic discussion on knowledge translation. So the another question was why is paternal osteoporosis disregarded as a risk factor in France. And why is paternal oops, I went back a section there. So it's actually just going back here, it's parental hit fracture that is considered. Usually maternal is more relevant because we often have osteoporosis, women often have osteoporosis. And so they might be more likely to fracture their hip. However, I think paternal would be relevant. I think that'd be something that would be interesting to look at in the future is if including paternal would be helpful. It might be that the prevalence of paternal hip fracture is so low so maybe there aren't a lot of paternal hip fractures that it might not play as much of a role, but I think it's worth it would be worth looking into in the future. Can you assess the role of bone intense exercise and preventive preventing factors. Yeah, that's a good question. So we didn't do that in our study. It could potentially be looked at within the CLSA. I think the difficulty would be parsing out what and making sure we're really clear on what the definition of bone intense exercise would be so being able to assess if people are doing resistance training or weight bearing training that would be the most important. So that that could be a future study as well I think it'd be interesting and we just have to think really carefully about how we define the bone intense exercise and what variables we could use within the CLSA. There were kind of waves of data come in because right now we were just looking at baseline but as we look you know to the future fall of one fall of two fall of three and we have those bone mineral density results we can look at changes relative to exercise or nutrition. So it definitely could be a possibility. We didn't do it in our study but especially because we were just looking at baseline at cross section so we wouldn't have been able to really know. And we have a couple questions from Theodora so I'll just read them both at once. Did the death rate in adults over age 75 affect your statistics and can you just briefly review the difference between osteoporosis and osteoarthritis. Sure, so we didn't look at the death rate, but we did have a good, a good population within the age group of 75 and we were at cross section. So we were just looking at baseline. So even if people were lost to follow up one, it wouldn't have affected our results because we were just looking kind of at one time point and not following people up over time. So in our study if I go to the end here, oopsies went way too far. If I go to the end here. This study we actually did look at people and how they changed over time so that's where death rate would come into play but for the study that I presented today, it wouldn't have really affected our results. And then if we think about the difference between osteoporosis and osteoarthritis so osteoporosis affects the amount of bone that we have, as well as kind of how that bone is structured. Whereas osteoarthritis is really affects the bone where it meets another bone so within a joint, and it affects the cartilage within that joint. And you get things like spur bones like osteophytes I should say, which are like bony growths kind of within that joint space. You get less joint space so it affects kind of more the joints and the mobility of those joints and how the two bones interact with each other. Whereas osteoporosis affects kind of the amount of bone that we have. And you'd be at higher risk for breaking a bone because of the amount of bone that you have. Whereas with osteoarthritis might affect things more like mobility, you know, pain, range of motion, those types of things. So osteoporosis can affect mobility and pain and range of motion, but it's usually related to having a fracture, either at the hip or the spine or the wrist, or other places too but those are the most common. We have a few more questions here so we'll see how many we can get through in the next couple minutes. The next one's about the fracks for and if you know when it was first implemented or might it be updated. That is a good question. I can't tell you the exact date or the exact year. It has been a while, but it is continually updated and there are, there have been a lot of studies where they're looking at adding, for example falls to the fracks and then, you know, how good is it without bone mineral density and with bone mineral density with falls without falls. So I know there there's continually research related to the fracks and the factors that go into it. It's also country specific so there's a fracks calculator tool that you can go to if you just kind of Google fracks, one will pop up and you can choose which country so I think they're always kind of updating it and putting work into figuring out like, are these the best variables that we have? Should we consider other things like falls? Should we look at cognitive impairment, those types of things. So there is lots of work kind of continually going on around it. And this one relates to diabetes and why is diabetes type two more of a risk than type one? It's just related to the disease process and I can't get into the physiology because I don't know it very well, but it's related to the physiology of the disease and how that interacts with the physiology of bones. I'm not sure if you know the answer to this one either, but if patients had a 20% risk factor in most other diseases that would be a matter of concern. Why does the risk have to be 20% over 10 years for this primarily women's disease to be concerned with? Yeah, so that's the cutoff that when they developed fracks that they decided would be the cutoff for high fracture risk. And I can't speak to the reasons why they decided 20%. They, I think it was related to, you know, disability and economic trade off and how all of those things work together. But fracks is one of the tools that can be used. There are others. The reason why a fracks is we used it here is because it is calculated within the CLSA, so we were able to use it, but there's certainly other tools out there that can be used. So there's like the Karak and there's like the Q tool. So there's lots of other fracture risk calculators that can be used. And as I mentioned, they can vary depending on the year that you use. So, or the amount of time so it can be like a one year fracture risk, two years, five years, 10 years. And that's just the one that fracks decided to go with. If you're interested in this, this is a section that is really being updated in the Oscar process candidate guidelines so stay tuned for that. There'll be a really good discussion of different fracture risk tools and decisions around which one to use and when to determine someone's high risk and not. And we have a last question I might be a little bit more can't necessarily interpret if it's a more personal nature or not but generally speaking, if somebody had a bone density test 30 years ago and now perhaps needs a new one is there any guidelines on how often you should get a new bone density test. Yeah, so certainly 30 years is quite a long time so it's yeah 30 years would be a reasonable amount of time. It really depends on a variety of things. It depends on, you know, your risk factors. So if somebody is at high risk but they're younger than it would be warranted but if you're younger, but not at high risk then you might not be warranted at that time. So it, it's, there's kind of an algorithm and a lot of different factors that go into play. And then it depends, you know, are you on a medication, have you had a fracture recently. And all of those things kind of go into deciding when the follow up should be, or, you know, have you had, maybe you had a bone or don't see tests and then, you know, maybe two or five years later you had another one and there was no changes then we might not want to follow up as frequently but if there, you know, there was really big changes then might want to follow up more frequently so it kind of, it's more of an individual decision as to when, when those should happen but I would say 30 years is a long time and things have probably changed over that time. Okay, well I think we will start to wrap up. Thank you very much for the presentation and lots of good questions that came through. We really appreciate your participation in the seminar series as the webinar presenter but also for all of you for participating. For more information, the link to the publication of this webinar is based on is available in the chat it's already been posted, as well as a link to the related approved article, which I believe, I think that was the one that was just published actually that you mentioned. I'd like to remind everyone also that the next deadline for data access application if you're interested is January 18 of 2023. Please visit the CLSA website under data access to review what data is available as well as additional details about the application process. I'd also like to remind everyone to complete their anonymous survey when you exit today's zoom session so that we can learn how to improve these these webinars as well as the topics. For the next CLSA webinar, it will be entitled enhancing the CLSA research platform updates on new initiatives data availability and access, and it will be held on October 31 at noon. So Halloween that webinar will be presented by Dr. Perman de Reina who's the lead principal investigator of the CLSA, as well as Dr. Matilda Saliba who's the data access officer in the CLSA. We hope you'll be able to join join us for that presentation and hopefully we can get our presenters to dress up that day as well. Registration details for that webinar will be posted on our website. That link is also available on the screen. And remember the CLSA does promote the webinar series using the hashtag CLSA webinar, and we invite you to follow us on Twitter at at CLSA underscore ELCV. And that is a wrap for today. So thank you again everyone. Bye bye.