Vigorous physical activity increases fracture risk in children irrespective of bone mass: a prospective study of the independent risk factors for fractures in healthy children

Abstract

Low bone mass is a determinant of fractures in healthy children. Small studies provide limited evidence on the association between ethnicity, birth weight, family size, socioeconomic status, dietary calcium intake, or physical activity and fracture incidence. No studies have investigated whether these determinants of fracture risk act through affecting bone mass or through other mechanisms. The aim of this study was to use a population-based birth cohort to confirm which variables are determinants of fracture risk and to further study which of these risk factors act independently of bone mass. Children from the Avon Longitudinal Study of Parents and Children have been followed up from birth to 11 yr of age. Maternal self-reported data have been collected contemporaneously on early life factors, diet, puberty, and physical activity. These were linked to reported fractures between 9 and 11 yr of age. Multivariable logistic regression techniques were used to assess whether these potential determinants were independent of, or worked through, estimated volumetric BMD or estimated bone size relative to body size measured by total body DXA scan at 9.9 yr of age. A total of 2692 children had full data. One hundred ninety-three (7.2%) reported at least one fracture over the 2-yr follow-up period. Children who reported daily or more episodes of vigorous physical activity had double the fracture risk compared with those children who reported less than four episodes per week (OR, 2.06; 95% CI, 1.21-1.76). No other independent determinants of fracture risk in healthy children were found. In conclusion, reported vigorous physical activity is an independent risk factor for childhood fracture risk. However, the interrelationship between physical activity, bone mass, and childhood fracture risk suggests that the higher bone mass associated with increased physical activity does not compensate for the risk caused by increased exposure to injuries.

FIG. 1

Flow diagram showing the children from ALSPAC included in this analysis.

FIG. 2

Bar charts showing mean ± 95% CI for (A) estimated TBLH vBMD and (B) estimated TBLH bone size relative to body size according to category of reported vigorous physical activity. p values are the test for trend. Results are adjusted for all variables in Tables 1-4.

FIG. 3

Box plots of OR for fracture risk ±95% CI for children who did less than four episodes of vigorous physical activity per week, those who did four to six, and those who did daily or more in (A) children with an estimated TBLH vBMD in the lowest tertile and (B) children with an estimated TBLH vBMD in the highest tertile. p values are the test for trend. Results are adjusted for all variables in Tables 1-4. For box plot A, 27 children had fractures in the less than four episodes of vigorous physical activity per week category, 23 in those who did four to six, and 18 in those who did daily or more. For box plot B, 19 children had fractures in the less than four episodes of vigorous physical activity per week category, 14 in those who did four to six, and 15 in those who did daily or more.

FIG. 4

Proposed relationships between reported vigorous physical activity at 9 yr of age, bone mass at 9.9 yr of age, and fracture risk over the following 2 yr. The higher bone mass associated with increased physical activity does not compensate for the increased exposure to injuries (solid arrows, positive associations; dashed arrows, negative associations).