{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,22]],"date-time":"2026-10-22T14:31:27Z","timestamp":1792679487750,"version":"4.5.0"},"reference-count":39,"publisher":"Public Library of Science (PLoS)","issue":"2","license":[{"start":{"date-parts":[[2026,2,23]],"date-time":"2026-02-23T00:00:00Z","timestamp":1771804800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Osteoporosis is a systemic skeletal disease characterised by reduced bone mass and a distortion of bone microarchitecture. It is clinically problematic as it leads to fragility fractures which confers excess morbidity and mortality on patients. Up to 32% of individuals will experience recurrent fragility fractures within two years of an initial fracture, yet existing risk models focus on the risk of having a single fragility fracture at a time. We aim to identify predictors of multiple fragility fractures to help improve risk stratification.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>43,801 patients referred for their first DXA scan in the northwest of England between June 2004 and February 2024 were analysed. Participants underwent lumbar spine and femoral scans to assess bone density and regional body composition. A generalized additive model reporting odds ratios was used to compare risk factors for a single versus multiple fragility fractures.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of the referred population, 14,212 (32.4%) had a single fragility fracture and 3,731 (8.5%) had multiple. Female gender was associated with lower odds of multiple fractures (OR 0.88, 95% CI: 0.79\u20130.99), while increased odds were linked to family history of fractures (OR 1.22, 95% CI: 1.11, 1.35), secondary osteoporosis (OR 1.15, 95% CI: 1.05, 1.26), rheumatoid arthritis (OR = 1.29, 95% CI: 1.08, 1.53), glucocorticoid therapy (OR = 1.18, 95% CI: 1.00, 1.39), smoking (OR 1.27, 95% CI: 1.12, 1.45) and falls risk (OR 2.02, 95% CI: 1.54, 2.63). The combination of falls risk and alcohol consumption increased multiple fracture odds (OR 7.62, 95% CI: 2.77, 20.94). Left femoral T-score and body fat percentage showed significant non-linear effects (both p\u2009&lt;\u20090.001).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Multiple fragility fractures were associated with many traditional risk factors. We also identified a novel link between falls risk and alcohol consumption, as well as the significant associations with body composition.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0343413","type":"journal-article","created":{"date-parts":[[2026,2,23]],"date-time":"2026-02-23T18:33:36Z","timestamp":1771871616000},"page":"e0343413","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Investigating traditional and novel predictors of a single versus multiple fragility fractures in a large observational cohort"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2287-381X","authenticated-orcid":true,"given":"Hamzah","family":"Amin","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhammed Aqib","family":"Khan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4311-5222","authenticated-orcid":true,"given":"Marwan","family":"Bukhari","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,2,23]]},"reference":[{"issue":"6","key":"pone.0343413.ref001","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1007\/BF01622200","article-title":"Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. WHO Study Group","volume":"4","author":"JA Kanis","year":"1994","journal-title":"Osteoporos Int"},{"issue":"10169","key":"pone.0343413.ref002","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1016\/S0140-6736(18)32112-3","article-title":"Osteoporosis","volume":"393","author":"JE Compston","year":"2019","journal-title":"Lancet"},{"key":"pone.0343413.ref003","author":"Densitometry ISfC"},{"issue":"3","key":"pone.0343413.ref004","doi-asserted-by":"crossref","first-page":"237","DOI":"10.4103\/ijem.IJEM_147_20","article-title":"Trabecular Bone Score-An Emerging Tool in the Management of Osteoporosis","volume":"24","author":"R Rajan","year":"2020","journal-title":"Indian J Endocrinol Metab"},{"issue":"2","key":"pone.0343413.ref005","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1055\/s-0038-1660790","article-title":"Osteoporosis: Current Concepts","volume":"6","author":"I Akkawi","year":"2018","journal-title":"Joints"},{"issue":"3","key":"pone.0343413.ref006","doi-asserted-by":"crossref","first-page":"166","DOI":"10.5312\/wjo.v10.i3.166","article-title":"Changing trends in the mortality rate at 1-year post hip fracture - a systematic review","volume":"10","author":"C Downey","year":"2019","journal-title":"World J Orthop"},{"key":"pone.0343413.ref007","volume-title":"ICS0035: Written evidence submitted Royal Osteoporosis Society","author":"Society RO","year":"2022"},{"key":"pone.0343413.ref008","doi-asserted-by":"crossref","first-page":"115286","DOI":"10.1016\/j.bone.2020.115286","article-title":"Risk of major osteoporotic fracture after first, second and third fracture in Swedish women aged 50\u00a0years and older","volume":"134","author":"E S\u00f6reskog","year":"2020","journal-title":"Bone"},{"issue":"3","key":"pone.0343413.ref009","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1007\/s00198-022-06663-w","article-title":"Are there specific clinical risk factors for the occurrence of multiple fractures? The FRISBEE study","volume":"34","author":"A Charles","year":"2023","journal-title":"Osteoporos Int"},{"key":"pone.0343413.ref010","doi-asserted-by":"crossref","first-page":"17455057241231387","DOI":"10.1177\/17455057241231387","article-title":"Use of Fracture Risk Assessment Tool in clinical practice and Fracture Risk Assessment Tool future directions","volume":"20","author":"R Zerikly","year":"2024","journal-title":"Womens Health (Lond)"},{"issue":"12","key":"pone.0343413.ref011","doi-asserted-by":"crossref","first-page":"2027","DOI":"10.1007\/s00198-023-06870-z","article-title":"Previous fracture and subsequent fracture risk: a meta-analysis to update FRAX","volume":"34","author":"JA Kanis","year":"2023","journal-title":"Osteoporos Int"},{"issue":"1","key":"pone.0343413.ref012","article-title":"Partial body fat percentage as a predictor of fragility fractures in a large cohort: a cross-sectional study","volume":"8","author":"H Amin","year":"2024","journal-title":"Rheumatol Adv Pract"},{"issue":"3","key":"pone.0343413.ref013","doi-asserted-by":"crossref","DOI":"10.1038\/nutd.2013.5","article-title":"DXA estimates of fat in abdominal, trunk and hip regions varies by ethnicity in men","volume":"3","author":"MA Stults-Kolehmainen","year":"2013","journal-title":"Nutr Diabetes"},{"key":"pone.0343413.ref014","doi-asserted-by":"crossref","first-page":"65","DOI":"10.12688\/wellcomeopenres.16659.3","article-title":"Differences in total and regional body fat and their association with BMI in UK-born White and South Asian children: findings from the Born in Bradford birth cohort","volume":"6","author":"G Santorelli","year":"2022","journal-title":"Wellcome Open Res"},{"issue":"8","key":"pone.0343413.ref015","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1111\/ggi.14219","article-title":"The relationship between alcohol intake and falls hospitalization: Results from the EPIC-Norfolk","volume":"21","author":"GJ Tan","year":"2021","journal-title":"Geriatr Gerontol Int"},{"issue":"1","key":"pone.0343413.ref016","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1007\/s00198-011-1589-y","article-title":"Pattern of use of DXA scans in men: a cross-sectional, population-based study","volume":"23","author":"M Frost","year":"2012","journal-title":"Osteoporos Int"},{"issue":"1","key":"pone.0343413.ref017","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1186\/s41927-023-00347-6","article-title":"Long-term fracture risk in rheumatoid arthritis: impact of early sustained DAS28-remission and restored function, progressive erosive disease, body mass index, autoantibody positivity and glucocorticoids. A cohort study over 10 years","volume":"7","author":"S Ajeganova","year":"2023","journal-title":"BMC Rheumatol"},{"key":"pone.0343413.ref018","doi-asserted-by":"crossref","first-page":"152497","DOI":"10.1016\/j.semarthrit.2024.152497","article-title":"Risk and predictors of fractures in early rheumatoid arthritis - A long term follow up study of an inception cohort","volume":"68","author":"L Theander","year":"2024","journal-title":"Semin Arthritis Rheum"},{"issue":"8","key":"pone.0343413.ref019","doi-asserted-by":"crossref","first-page":"1251","DOI":"10.1002\/acr.21987","article-title":"Risk factors for falls in adults with rheumatoid arthritis: a prospective study","volume":"65","author":"EK Stanmore","year":"2013","journal-title":"Arthritis Care Res (Hoboken)"},{"issue":"4","key":"pone.0343413.ref020","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1517\/14740338.2016.1140743","article-title":"Long-term side effects of glucocorticoids","volume":"15","author":"M Oray","year":"2016","journal-title":"Expert Opin Drug Saf"},{"issue":"3","key":"pone.0343413.ref021","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1016\/j.bbadis.2013.05.029","article-title":"Deconstructing the roles of glucocorticoids in adipose tissue biology and the development of central obesity","volume":"1842","author":"M-J Lee","year":"2014","journal-title":"Biochim Biophys Acta"},{"issue":"1","key":"pone.0343413.ref022","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.afos.2015.07.008","article-title":"THE EFFECT OF GLUCOCORTICOIDS ON BONE AND MUSCLE","volume":"1","author":"GL Klein","year":"2015","journal-title":"Osteoporos Sarcopenia"},{"issue":"6","key":"pone.0343413.ref023","doi-asserted-by":"crossref","first-page":"837","DOI":"10.1007\/s11102-024-01427-7","article-title":"Cushing\u2019s disease and bone","volume":"27","author":"A Zdrojowy-We\u0142na","year":"2024","journal-title":"Pituitary"},{"key":"pone.0343413.ref024","doi-asserted-by":"crossref","first-page":"109240","DOI":"10.1016\/j.steroids.2023.109240","article-title":"Effects of exercise training on glucocorticoid-induced muscle atrophy: Literature review","volume":"195","author":"AG Macedo","year":"2023","journal-title":"Steroids"},{"issue":"6","key":"pone.0343413.ref025","doi-asserted-by":"crossref","first-page":"666","DOI":"10.1016\/j.annemergmed.2023.04.013","article-title":"Emergency Department Visits for Alcohol-Associated Falls Among Older Adults in the United States, 2011 to 2020","volume":"82","author":"K Yuan","year":"2023","journal-title":"Ann Emerg Med"},{"issue":"5","key":"pone.0343413.ref026","doi-asserted-by":"crossref","first-page":"976","DOI":"10.1111\/acer.13365","article-title":"Trends in alcohol consumption among older Americans: National health interview surveys, 1997 to 2014","volume":"41","author":"RA Breslow","year":"2017","journal-title":"Alcohol Clin Exp Res"},{"issue":"4","key":"pone.0343413.ref027","doi-asserted-by":"crossref","first-page":"200","DOI":"10.22540\/JFSF-08-200","article-title":"The measurement and reporting of falls: Recommendations for research and practice on defining faller types","volume":"8","author":"DA Jehu","year":"2023","journal-title":"J Frailty Sarcopenia Falls"},{"issue":"7","key":"pone.0343413.ref028","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2021-060282","article-title":"Comparison of fracture risk calculators in elderly fallers: a hospital-based cross-sectional study","volume":"12","author":"G Todorov","year":"2022","journal-title":"BMJ Open"},{"issue":"12","key":"pone.0343413.ref029","doi-asserted-by":"crossref","first-page":"1093","DOI":"10.1037\/ccp0000447","article-title":"A meta-analysis of cognitive-behavioral therapy for alcohol or other drug use disorders: Treatment efficacy by contrast condition","volume":"87","author":"M Magill","year":"2019","journal-title":"J Consult Clin Psychol"},{"issue":"2","key":"pone.0343413.ref030","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2021-057729","article-title":"Primary care-based interventions addressing social isolation and loneliness in older people: a scoping review","volume":"12","author":"P Galvez-Hernandez","year":"2022","journal-title":"BMJ Open"},{"key":"pone.0343413.ref031","doi-asserted-by":"crossref","first-page":"101105","DOI":"10.1016\/j.bonr.2021.101105","article-title":"Which treatment to prevent an imminent fracture?","volume":"15","author":"I Laura","year":"2021","journal-title":"Bone Rep"},{"issue":"2","key":"pone.0343413.ref032","doi-asserted-by":"crossref","DOI":"10.1210\/clinem\/dgad415","article-title":"Obesity and Skeletal Fragility","volume":"109","author":"R Chen","year":"2024","journal-title":"J Clin Endocrinol Metab"},{"issue":"15","key":"pone.0343413.ref033","doi-asserted-by":"crossref","DOI":"10.3390\/ijms23158303","article-title":"Obesity and Bone Health: A Complex Relationship","volume":"23","author":"A Pi\u00f1ar-Gutierrez","year":"2022","journal-title":"Int J Mol Sci"},{"key":"pone.0343413.ref034","doi-asserted-by":"crossref","first-page":"861","DOI":"10.3389\/fendo.2019.00861","article-title":"Aging and Imaging Assessment of Body Composition: From Fat to Facts","volume":"10","author":"F Ponti","year":"2020","journal-title":"Front Endocrinol (Lausanne)"},{"issue":"1","key":"pone.0343413.ref035","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1111\/1753-6405.12152","article-title":"Associations between obesity and overweight and fall risk, health status and quality of life in older people","volume":"38","author":"RJ Mitchell","year":"2014","journal-title":"Aust N Z J Public Health"},{"issue":"2","key":"pone.0343413.ref036","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1002\/jcsm.13418","article-title":"Muscle parameters in fragility fracture risk prediction in older adults: A scoping review","volume":"15","author":"C Vendrami","year":"2024","journal-title":"J Cachexia Sarcopenia Muscle"},{"key":"pone.0343413.ref037","doi-asserted-by":"crossref","first-page":"1209319","DOI":"10.3389\/fpubh.2023.1209319","article-title":"Effectiveness of exercise interventions on fall prevention in ambulatory community-dwelling older adults: a systematic review with narrative synthesis","volume":"11","author":"M Sadaqa","year":"2023","journal-title":"Front Public Health"},{"issue":"4","key":"pone.0343413.ref038","doi-asserted-by":"crossref","first-page":"599","DOI":"10.1016\/j.advnut.2023.03.008","article-title":"Alcohol Consumption and Risk of Fractures: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies","volume":"14","author":"Y Ke","year":"2023","journal-title":"Adv Nutr"},{"issue":"10","key":"pone.0343413.ref039","doi-asserted-by":"crossref","first-page":"1881","DOI":"10.1002\/jbmr.3523","article-title":"Glucocorticoid Exposure and Fracture Risk in a Cohort of US Patients With Selected Conditions","volume":"33","author":"A Balasubramanian","year":"2018","journal-title":"J Bone Miner Res"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0343413","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,23]],"date-time":"2026-02-23T18:33:43Z","timestamp":1771871623000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0343413"}},"subtitle":[],"editor":[{"given":"Gaetano Paride","family":"Arcidiacono","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,2,23]]},"references-count":39,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,2,23]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0343413","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,23]]}}}