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Original research
The intersectional role of social stress in fracture risk: results from the Women’s Health Initiative
  1. Shawna Follis1,
  2. Yann C Klimentidis2,3,
  3. Jennifer Bea4,5,
  4. Chengcheng Hu2,
  5. David Garcia6,
  6. Jean Wactawski-Wende7,
  7. Lindsay Kohler2,6,
  8. Aladdin H Shadyab8,
  9. Melissa Flores9,
  10. Hilary A Tindle10,11,
  11. Zhao Chen2
  1. 1 Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California, USA
  2. 2 Department of Epidemiology and Biostatistics, The University of Arizona, Tucson, Arizona, USA
  3. 3 BIO5 Institute, The University of Arizona, Tucson, Arizona, USA
  4. 4 The University of Arizona Cancer Center, The University of Arizona, Tucson, Arizona, USA
  5. 5 Department of Nutritional Sciences, The University of Arizona, Tucson, Arizona, USA
  6. 6 Mel and Enid Zuckerman College of Public Health, Department of Health Promotion Sciences, The University of Arizona, Tucson, Arizona, USA
  7. 7 Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York, USA
  8. 8 Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, USA
  9. 9 Center for Border Health Disparities, Health Sciences, The University of Arizona, Tucson, Arizona, USA
  10. 10 Medical Center, Vanderbilt University, Nashville, Tennessee, USA
  11. 11 Geriatric Research Education and Clinical Centers, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
  1. Correspondence to Dr Shawna Follis, Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California, USA; sfollis{at}stanford.edu

Abstract

Background The biological consequences of stress from the social environment pattern health outcomes. This study investigated whether social stress is prospectively associated with fracture incidence among racially and ethnically diverse, postmenopausal women.

Methods Data from 160 709 postmenopausal women in the Women’s Health Initiative was analysed using Cox proportional hazards regression models to examine prospective associations of social stress with time to total and hip fracture incidence. Self-reported questionnaires measuring social strain, social functioning and social support were used to assess social stress.

Results Age and race/ethnicity modified associations between social stress and total and hip fractures. HRs for the associations between higher social support (indicating lower social stress) and total fractures among those age 50–59 years were 0.92 (95% CI: 0.90 to 0.94); HR=0.94 (95% CI: 0.93 to 0.95) for those age 60–69 years and HR=0.96 (95% CI: 0.95 to 0.98) for those age 70–79 years. Higher social strain was associated with greater hip fracture incidence among Native American women (HR=1.84, 95% CI: 1.10 to 3.10), Asian women (HR=1.37, 95% CI: 1.01 to 1.86) and white women (HR=1.04, 95% CI: 1.01 to 1.08).

Conclusion Identifying population patterns of fracture incidence as biological expressions of social environments reveals how race/ethnic specific social environmental factors influence disparities in fractures.

  • fractures
  • bone
  • social epidemiology
  • stress
  • ageing

Data availability statement

Data may be obtained from a third party and are not publicly available. Data may be obtained from the Women’s Health Initiative (www.whi.org) and are not publicly available.

https://doi.org/10.1136/jech-2020-216354

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    Data availability statement

    Data may be obtained from a third party and are not publicly available. Data may be obtained from the Women’s Health Initiative (www.whi.org) and are not publicly available.

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    Footnotes

    • Twitter @shawnafollis

    • Contributors All authors contributed to the study design, interpretation of data, preparation of the manuscript and the final approval of the manuscript. SF drafted the initial manuscript, acquired the data, performed statistical analysis. YCK, JB, CH and ZC contributed to study concept and critically revised the initial manuscript. Final approval of the version to be published was given by all authors. SF is the guarantor and she had full access to all the data in the study, takes responsibility for the work and conduct of the study, and controlled the decision to publish. The corresponding author attests that all listed authors meet the authorship criteria and that no others meeting the criteria have been omitted. All authors agree to be accountable for all aspects of the work.

    • Funding The WHI programme is funded by the National Heart, Lung, and Blood Institute, National Institutes of Health, U.S. Department of Health and Human Services through contracts HHSN268201600018C, HHSN268201600001C, HHSN268201600002C, HHSN268201600003C and HHSN268201600004C.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.