Incidence of Hip Fracture Over 4 Decades in the Framingham Heart Study

Importance Age-adjusted hip fracture incidence is decreasing in the US. The decrease has been attributed to osteoporosis treatment, but the cause is unknown. Objective To examine the decrease in hip fracture incidence over the past 40 years in the US. Design, Setting, and Participants A population-based cohort study using participants in the Framingham Heart Study was conducted. A total of 4918 men and 5634 women were followed up prospectively for the first hip fracture between January 1, 1970, and December 31, 2010. Data were analyzed from May 1, 2019, to May 30, 2020. Main Outcomes and Measures Incidence of hip fracture and contemporaneous prevalence of risk factors for hip fractures analyzed with age-period-cohort models. Results The study contained more than 105000 person-years in 10552 individuals with a gradual shift toward the offspring participants in the 1980s and 1990s. Women represented more than 55% of the study sample over the years. Adjusted for age, the incidence of hip fracture decreased by 4.4% (95% CI, 6.8%-1.9%) per year from 1970 to 2010. Both period associations (P < .001) and birth cohort associations (P < .001) were statistically significant. For example, in persons aged 85 to 89 years, the incidence of hip fracture was 759 per 100 000 person-years in the offspring group compared with 2018 per 100 000 person-years in the original cohort. The decrease in hip fracture incidence was coincident with a decrease in smoking and heavy drinking. Smoking decreased from 38% in the 1970s to 15% in the late 2000s, while heavy drinking decreased from 7.0% to 4.5%. The prevalence of other risk factors for hip fracture, such as underweight (body mass index <18.5), obesity (body mass index >30), and early menopause (age <45 years) were stable over the study period. When persons who never smoked were evaluated, a change in the incidence of -3.2% (95% CI, -6.0% to -0.4%) per year was observed. The difference between the decrease of the entire population and nonsmokers of 1.5% per year was similar to the hazard ratio conferred by smoking (hazard ratio, 1.5; 95% CI, 1.14-1.96). Conclusions and Relevance In this study, individuals born more recently appeared to have a low risk for hip fracture. Reductions in smoking and heavy drinking were the risk factor changes coincident with the observed decrease in hip fracture. Attributing the decrease in hip fracture incidence up to 2010 solely to better treatment is not supported by these data, emphasizing the need to treat patients with osteoporosis while continuing to encourage public health interventions for smoking cessation and heavy drinking. This cohort study examines the decrease in the incidence of hip fractures noted over 40 years in the US. Question Is hip fracture incidence associated with changes in time period, birth cohort, or the known risk factors for hip fracture? Findings This cohort study including 10552 individuals (>105000 person-years) in follow-up over 40 years found that those born more recently experienced a lower incidence of hip fracture for a given age. Decreases in the prevalence of smoking and heavy drinking were associated with the decrease in the incidence of hip fracture. Meaning In this study, the decrease in hip fracture incidence appeared to be associated with birth cohort effects and improvement in lifestyle factors, such as smoking and heavy drinking, in addition to better treatment.