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FRAX IS FLAWED.

Data from large populations has shown the relationship between low bone mineral density (BMD), and increased age [1]. This has given rise to the WHO FRAX tool [2] which calculates 10 year fracture risk. We believe that FRAX is unreliable when used for individual subjects because BMD measured by dual energy X-ray absorptiometry (DXA) is inaccurate. 
 
When a beef bone was surrounded by a 3.5 cm thickness of lard, we found the measured BMD was 21% greater than when the bone was not surrounded by lard [3]. Bolotin found that when the BMD of a bone phantom was measured by DXA, the results were altered by the amount and configuration of surrounding fat, so that BMD was over or under-estimated by as much as 20 – 50% [4]. When compared with qCT BMD measured by DXA can overestimate BMD by 1 or T score units in obese patients [5]. 
 
According to FRAX [2], the 10 year risk of hip fracture in a 67 year old 63″ British woman (ethnicity not specified) weighing 120 lb, with a femoral neck BMD of 0.6 g/cm 2 reported by a GE- Lunar densitometer, is 6.6%. If her BMD were 20% less than that reported by DXA, ie 0.48 g/cm 2 her 10 year risk of hip fracture would be 15%. If her BMD were 20% greater than that reported by DXA, ie 0.72 g/cm 2 her 10 year risk of hip fracture would be 2.6%. If the inaccuracy of BMD is ± 50%, the range of risk calculated by FRAX is 0.7 – 45%. 
 
There is a clear relationship between future fracture, low BMD and increasing age in large populations, but FRAX is based on the false assumption that the true BMD of an individual subject is known. According to the data of Kanis et al [1] the 10 year risk of hip fracture in a woman of 67 is 6.5 – 7.2%. Without evidence to the contrary there is no reason to believe that FRAX fracture risk prediction for an individual subject is better than using age alone.