(cid:2)ORIGINAL RESEARCH ARTICLE Clinical risk factors for osteoporosis are common among elderly people in Nuuk, Greenland Anna Jakobsen1,2*, Peter Laurberg3, Peter Vestergaard3,4 and Stig Andersen1,2,5 1ArcticHealth ResearchCentre,Aalborg University Hospital, Aalborg,Denmark; 2Department ofInternal Medicine, Queen Ingrids Hospital, Nuuk,Greenland;3Department ofEndocrinology, Aalborg University Hospital, Aalborg,Denmark; 4Department ofHealth Science andTechnology,Aalborg University Hospital, Aalborg,Denmark; 5Department ofGeriatric Medicine, Aalborg University Hospital, Aalborg, Denmark Background. Osteoporosis is a debilitating condition characterized by fractures, pain and premature death. Riskfactors forosteoporosis predictthe riskoffragility fractures. Aim. To describe the occurrence of risk factors for osteoporosis among populations in Nuuk, the capital of Greenland. Methods.Arandomsampleofwomenbornin1934(cid:2)42,1945(cid:2)47,1956,andmenbornin1956wereselected fromthenationalcivilregistry.AquestionnairewassentoutinGreenlandicandDanishonriskfactorsfor osteoporosis:familyhistory,smokinghabits,alcoholintake,presenceofdisease,sunexposure,intakeofdairy products, age at menopause (women) and number of falls. Additional questions included the frequency of backpain,previousfractures,intakeofvitaminDandcalciumsupplements,useofanti-osteoporoticdrugs, steroidsandotherdrugs. Results. The questionnaire was sent to 317 subjects confirmed to be living at an address in Nuuk and 181 (57.1%)responded.Moreyoungwomenthanolderwomenweresmokers(60.6%vs.35.0%;p(cid:3)0.022)while limitedsunexposurewasreportedbymoreoftheoldwomen(37.2%vs.5.6%;p(cid:3)0.003).Familyhistoryof osteoporosis was reported by 15.0%, without difference between groups. Alcohol and milk intake did not differbetweengroups.Prematuremenopausewasreportedby17.9%ofthewomen.Fallswithinthelastyear were reported by42.4% with fewer falls in the oldest age group (21.9% vs. 50.0%; p(cid:3)0.005). Frequencyof fragilityfracturesincreasedwithage(5.7%vs.24.3%vs.30.4%;p(cid:3)0.02)andtheriskofafragilityfracture increased with age (p(cid:3)0.004; OR, 95% CI: 4.5, 1.6(cid:2)12.2, reference: below 70 years), when adjusted for smoking,genderandfalls.Theuseofanti-osteoporoticdrugswaslow(3.4%)while28.8%tookcalciumand vitaminD supplements. Conclusions.AgeisadominatingriskfactorforfragilityfracturesinGreenland.Theuseofanti-osteoporotic drugsis low in Greenland, evenifosteoporoticfracturesarecommon in oldage. Keywords: riskfactors;osteoporosis;fragilityfractures;GreenlandInuit;oldpeople Received:22August2012;Revised:6October2012;Accepted:1November2012;Published:11January2013 Osteoporosis is a condition characterised by the riskofosteoporotic fractures through the use of risk low bone density and micro-architectural dete- factor analysis and bone mineral density (BMD) testing. rioration of bone tissue, which raises the risk LowBMDisassociatedwithincreasedfracturerisk(9,10) of fracture (1). Fractures are associated with pain, that may be reduced by treatment (7), and a number of decreased quality of life, disability and premature death otherfactorsmaybeusedtoevaluatefracturerisk(7). and impose considerable costs on society (2(cid:2)5). The risk of an osteoporotic fracture differs between Osteoporosis may be diagnosed when a fragility frac- regions and may thus be influenced by ethnic origin tureoccurs.Thesearetypicallyseenatthehip,forearmor (11(cid:2)13). Inuit are a distinct ethnic group (14) and lower thoracic and lumbar spine, though fracturerisk at their risk of fragility fractures remains to be elucidated. othersitesisalsoincreased(6(cid:2)8).Itispossibletopredict A study of BMD measured by dual energy x-ray IntJCircumpolarHealth2013.#2013AnnaJakobsenetal.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons 1 Attribution-Noncommercial3.0UnportedLicense(http://creativecommons.org/licenses/by-nc/3.0/),permittingallnon-commercialuse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycited. Citation:IntJCircumpolarHealth2013,72:19596-http://dx.doi.org/10.3402/ijch.v72i0.19596 (pagenumbernotforcitationpurpose) AnnaJakobsenetal. absorptiometry (DXA) reported no differences in BMD of the registry and 169 persons had moved away, died between Inuit and non-Inuit in Greenland when ad- or were unavailable at the address. justed for differences in body size (15). However, a key AcoverletterandaquestionnaireinbothGreenlandic clinicalpointistoidentifyindividualsatrisk,andfurther and Danish were sent out in early April 2011 and a evaluation is recommended for those who have a risk stamped addressed envelope was enclosed. factor forosteoporosis (16). A number of factors are associated with an increased Questionnaire riskofosteoporosis.Surveysofcardiovascularriskfactors The questionnaire included questions related to osteo- among Inuit in Greenland have documented frequent porosis in other groups. The questions examined family smokingandincreasingsedentarylifestyle(17,18).These historyofosteoporosiswithafractureofforearm,spineor are known risk factors in other populations and are hip,smokinghabits(present,pastornever),alcoholintake likely to also increase the risk of osteoporosis among (below or above 14 units/week), sun exposure (limited, averageoraboveaverage),intakeofmilkorcheese(daily, Greenlandic Inuit but a survey of risk factors for this weeklyor rarely), age at menopause, use of steroids and specificpopulationisyettobeconducted. otherdrugsorthepresenceofdiseasesthatmayinfluence This led us to conduct a survey on risk factors bonestrength,numberoffallswithinthelastweek,month for osteoporotic fractures among populations in Nuuk, andyear,frequencyofbackpain(never,rarely,weekly,and Greenland.Inaddition,weassessedtheintakeofcalcium daily), if an x-ray that documented a fracture had been and vitamin D supplements, and of anti-osteoporotic done(spine,hip,forearmandother)withadescriptionof drugs. what caused the fracture, a history of hip surgery, daily Methods intakeofvitaminDandcalciumsupplements,anduseof anti-osteoporotic drugs. Assessment of osteoporosis by Participants the measurement of BMD was not possible as there is Participants were identified through the National Civil no such scanner in Greenland. Information on age and sex was obtained from the national civil registration Registration system in which all persons living in system. Beverages fortified with calcium and vitamin D Greenland, Denmark and the Faeroe Islands are re- werenotavailableinGreenland. corded. We aimed to include women aged 75, 65 and 55 years at the time of investigation and selected all Statistical analysis women living in Nuuk who were born in 1934(cid:2)42 and Frequencies were compared using chi-squared test. compared them with 2 groups of younger post- and Kendall’staucorrelationwasusedtotestforassociations perimenopausal women born in 1945(cid:2)47 and in 1956. between groups. Dependent variables entered into logis- Also,agroupofmenbornin1956wasincluded(TableI). tic regression was an osteoporotic fracture while expla- We included all 317 subjects in the selected age groups, natory variables were age (oldest age group, yes/no), confirmed to be living on the address in the capital city, gender, presently a smoker and falls within the last year Nuuk.Thecityhasapproximately16,000inhabitantsand (yes/no). Also, age, gender and number of risk factors thenumberofelderlypeopleislimitedduetoanaverage (reference: 2 or less) were entered as explanatory vari- life span in Greenland of 66.6 years for men and 71.6 ables.DatawereenteredintothedatabaseusingEpiData yearsforwomen(19). Theoldestage group counted163 Software (The EpiData Association, Odense, Denmark, subjects and only 7 (4.3%) of these were not born in www.epidata.dk). Calculationswere performed using the Greenland. Somedelaywasencounteredintheupdating Statistical Package for the Social Sciences (version 13.0; TableI. NumberofparticipantsandquestionnaireresponserateintheosteoporosisriskfactorsurveyinGreenland Groupsselected Responders Registereda Selectedb Yearborn Age Gender n n n % 1934(cid:2)42 69(cid:2)77years Women 163 102 60 58.8 1945(cid:2)47 63(cid:2)65years Women 117 75 40 53.3 1956 54(cid:2)55years Women 105 68 36 52.9 1956 54(cid:2)55years Men 101 72 45 62.5 All 486 317 181 57.1 aNumberofparticipantsrecordedinthenationalcivilregistrationsystem. bNumberofsubjectsavailableattheaddress. 2 Citation:IntJCircumpolarHealth2013,72:19596-http://dx.doi.org/10.3402/ijch.v72i0.19596 (pagenumbernotforcitationpurpose) RiskfactorsforosteoporosisinGreenland SPSS Inc., Chicago) software. A p-value of less than porosis and there was a trend towards more frequent 0.05 was considered significant. family history of osteoporosis with advancing age (p(cid:3)0.060). The number of present smokers decreased Results with age (trend, p(cid:3)0.002) from half of the younger to The questionnaire was sent to 317 inhabitants in Nuuk 1 in 3 of the oldest age group (Table II) and fewer of in the specific age and sex groups confirmed as living theyoungerwomenwereneversmokers.Oneintenofthe at the address (Table I). The overall response rate was oldest and 1 in 5 of the youngest had a high alcohol 57.1%. intake. None of the oldest women took glucocorticoids TableIIshowstheriskfactorsforosteoporosisinthe4 but1in7reported diseasesthatmayincreasethe riskof groups. One in six reported a family history of osteo- osteoporosis. Limited sun exposurewas reported by1 in TableII. TheoccurrenceofriskfactorsforosteoporosisinthestudypopulationinNuuk Men Women Aged Aged Aged Aged 54(cid:2)55years 54(cid:2)55years 63(cid:2)65years 69(cid:2)77years n % n % n % n % Pa Pb Familyhistory Yes 4 8.9 4 11.4 6 16.2 11 22.0 ns ns No 41 91.1 31 88.6 31 83.8 39 78.0 Smoker Present 19 42.2 20 60.6 16 41.0 21 35.0 ns 0.022 Past 17 37.8 12 36.4 16 41.0 21 35.0 Never 9 20.0 1 3.0 7 18.0 18 30.0 Alcoholunits/week B15 37 82.2 28 77.8 30 76.9 52 89.7 ns ns 15(cid:4) 8 17.8 8 22.0 9 23.1 6 10.3 Otherdiseases Yes 5 11.1 4 11.1 3 7.5 9 15.0 ns ns No 40 88.9 32 88.9 37 92.5 51 85.0 Steroiddaily Yes 1 2.2 1 2.8 0 0.0 0 0.0 na na No 44 97.8 35 97.2 38 100 52 100 Otherboneaffectingdrugs Yes 1 2.2 0 0.0 0 0.0 1 1.8 na na No 44 97.8 35 100 38 100 54 98.2 Sunexposure Often 3 6.7 3 8.3 2 5.3 6 11.8 ns 0.003 Some 34 75.5 31 86.1 30 78.9 26 51.0 Limited 8 17.8 2 5.6 6 15.8 19 37.2 Dairyproducts Daily 29 64.4 26 72.2 24 63.2 41 73.2 ns ns Weekly 7 15.6 6 16.7 5 13.2 9 16.1 Rarely 9 20.0 4 11.1 9 23.6 6 10.7 Ageatmenopause B45 na 6 18.8 7 25.0 4 11.4 na ns 45(cid:4) na 26 81.2 21 75.0 31 88.6 aChi-squaredtestfordifferencesbetweengenders. bChi-squaredtestfordifferenceswithagebetweenwomen. Missing:Familyhistory,14;smoker,4;alcoholintake,3;steroiduse,10;useofdrugaffectingbone,8;sunexposure,11;intakeofdairy products,6;ageatmenopause,41. 3 Citation:IntJCircumpolarHealth2013,72:19596-http://dx.doi.org/10.3402/ijch.v72i0.19596 (pagenumbernotforcitationpurpose) AnnaJakobsenetal. 7 of the younger respondents and by 1 in 3 of the Women aged 63(cid:2)65 years reported back pain more oldest women, and sun exposure declined with age frequently than the other groups, as 40.6% had listed (trend,p(cid:3)0.009).Oneinfivewomenreportedpremature this ‘‘daily’’ or ‘‘weekly’’. In comparison 31.0% of menopause. Family history of osteoporosis, smoking women aged 69(cid:2)77 years, 18.8% of women aged 54(cid:2)55 habits, alcohol intake, frequency of disease, use of ster- and 22.5% of men reported back pain. Back pain was oids orotherdrugs that can affect thebones, and intake associatedwiththenumberofriskfactors(pB0.001)and of dairy products did not differ with gender. with the occurrence offragility fractures (p(cid:3)0.013). Fewer women in the oldest age group compared to Fragility fractures were reported more frequently youngerwomenreportedfalls(p(cid:3)0.005).Amongwomen with increasing age (p(cid:3)0.009) as depicted in Fig. 2. aged 63(cid:2)65 years, 61.3% reported 1 or more fallswithin Hip fractures were reported by 3 women aged 70 years thelastyear,comparedto46.4%amongtheyoungestand or above. Also, 1 man reported a hip fracturebeforethe 21.9%amongtheoldestwomen(TableIII). age of 30 years. Age remained a main risk factor for an Overall,having3ormoreriskfactorsforosteoporosis osteoporotic fracture in the adjusted analysis (p(cid:3)0.005; doubledtheriskofapreviousfragilityfracture(Figure1, OR, 95% CI: 3.2, 1.4(cid:2)7.2 (age B69 years reference)). p(cid:3)0.031). This was also found after adjusting for age Fourwomenaged69(cid:2)77yearsand2aged63(cid:2)65years andgender(p(cid:3)0.045;OR,95%CI:2.3,1.0(cid:2)5.3(1orno took an anti-osteoporotic drug (Table III). None of the risk factor reference)). women aged 54(cid:2)55 or the menused such drugs. Fourof Table III. The frequency of events associated with osteoporosis and the use of antiosteoporotic drug and calcium and vitamin D supplements Men Women 54(cid:2)55yearsa 54(cid:2)55yearsa 63(cid:2)65yearsa 69(cid:2)77yearsa n % n % n % n % Pb Backpain Never 3 7.5 4 12.5 2 6.3 10 23.9 ns Rarely 28 70.0 22 68.7 17 53.1 19 45.2 Weekly 6 15.0 3 9.4 3 9.4 5 11.9 Daily 3 7.5 3 9.4 10 31.2 8 19.0 Falls(n) Lastyear 11 40.7 13 46.4 19 61.3 7 21.9 0.005 Lastmonth 6 24.0 5 19.2 10 34.5 0 0.0 0.011 Lastweek 1 3.2 2 6.7 3 10.7 0 0.0 na Fracture None 26 60.4 26 74.3 15 40.5 32 57.1 0.018 Osteoporotic 3 7.0 2 5.7 9 24.3 17 30.4 0.020 Other 14 32.6 7 20.0 13 35.2 7 12.5 Hipsurgery Yes 0 0.0 1 2.8 2 5.3 4 7.1 na No 45 100.0 35 97.2 36 94.7 52 92.9 Osteoporoticdrug Yes 0 0.0 0 0.0 2 5.3 4 7.1 na No 45 100.0 36 100.0 36 94.7 52 92.9 VitaminD Yes 15 34.1 15 42.9 18 47.4 22 37.9 ns No 29 65.9 20 57.1 20 52.6 36 62.1 Calcium Yes 12 27.3 11 30.6 13 35.1 21 36.8 ns No 32 72.7 25 69.4 24 64.9 36 63.2 aDecadesborn:1930s,1940s,and1950s. bDifferencebetweenwomen. Missing:Backpain,35;falls,52;fracture,10;hipsurgery,6;drugforosteoporosis,6;intakeofvitaminD,9;andcalcium,7. 4 Citation:IntJCircumpolarHealth2013,72:19596-http://dx.doi.org/10.3402/ijch.v72i0.19596 (pagenumbernotforcitationpurpose) RiskfactorsforosteoporosisinGreenland 40 survey, took an antiosteoporotic drug and focus on osteoporosis is encouraged. y gilit 30 Fracturerateshavebeenreportedtodifferwithethnic a origin (12,13). The number of hip fractures was lower s with frure (%) 20 i(n20A(cid:2)2fr2i)c.aBno-Awmeetraicl.an(2s3)cofomupnadretdhawtiAthsiaAnmseargiceadn65Wyheiaterss ntct aa or above suffered only half the number of hip fractures pfr Partici 10 cfroamctpuarreesd,wthoicChaiuscianskiaenesp,inbgutwaitthlefiansdtinasgsmbaynoythveerrste(b2r4a)l. Thus, studiescomparing Caucasians, African-Americans 0 <3 3+ and Asians suggest that ethnicity influences the risk of Number of risk factors osteoporotic fractures. A few studies of osteoporotic fractures have been Fig. 1. Percentage of participants with a previous fragility made among Inuit. A study from Alaska reported fracture depending on numberof risk factors forosteoporosis. twice the number of hip fractures in Inuit compared The riskof a fragility fracture was higher with 3 or more risk to subjects from the lower states in the United States factors(p(cid:3)0.031). (25). However, this study did not take into account environmental differences such as the number of days the participants who took an antiresorptive drug re- with icy pavements, the number of hours with sunlight ported no fragility fractureswhile only 1 with a forearm and the presence of a polar night, which may influence fracture and 1 with avertebral fracture reported the use the risk of falls. These are considered risk factors for ofanti-osteoporoticdrugs.Two(6.5%)ofthosewhohad osteoporosis, as up to 98% of hip fractures are related previously experienced an osteoporotic fracture were to falls (26). Leslie et al. (27) found aboriginals in currently taking medication forosteoporosis. Canada to suffer twice as many osteoporotic fractures Finally,‘‘anyfracture’’wasassociatedwithhighalcohol compared to non-aboriginals after adjusting for gender, intake (p(cid:3)0.043) and back pain (p(cid:3)0.037) aswell as a age and area of residence. They used administra- ‘‘numberofriskfactors’’(p(cid:3)0.003). tive health data and explained their finding of a higher Discussion fractureriskbyco-morbidityandsubstanceabuserather Risk factors for osteoporosis are common among than by ethnicity. The responders in our survey con- populations in the capital city Nuuk in Greenland and firm more frequent fragility fractures among women increasetheriskofhavinghadanosteoporoticfractureas aged 63(cid:2)65 years and 69(cid:2)77 years compared toyounger 1 in 3 women in the oldest age group reported to have women in the capital city of Greenland. This finding sufferedfromatleast1fragilityfractureverifiedbyx-ray is similar to those in other groups and suggests and subjects with multiple risk factors for osteoporosis some similarity between populations in Greenland and had an increased risk of fractures. Only 2 of the elsewhere. participants with a fragility fracture, and 6 in the entire Osteoporotic fractures are more frequent in subjects with low BMD (9,10). Nelson et al. (28) found that 50 differencesinBMDbetweenethnicgroupsin2countries weresmallerthanthedifferencesbetweendifferentethnic 40 groups within the same country. While this supports an %) ethnic difference in BMD, a comparative study of Inuit e ( andnon-InuitinNorthGreenlandfoundsimilarBMDin ur 30 ct the 2 ethnic groups when adjusted for body build (15). a gility fr 20 Hbeetnwceee,nnoIneutihtnaincddiCffaeurecnacsieanins.BMD seems tobepresent a Fr Factors important for the riskof osteoporosis among 10 other ethnic groups (7,16) may also play a role among populations in Greenland. This is suggested by the 0 findings by Cote and colleagues (29,30). They measured 54–55 y 54–55 y 63–65 y 69–77 y bonestiffness byboneultrasound andfoundan associa- men women women women tion with age, smoking, menopause, use of hormone replacement therapy, physical activity, and weight and Fig.2. Percentageofparticipantswhohadfragilityfractureby participant groups. The occurrence increased with age height in addition to an influence of polychlorinated (p(cid:3)0.009). biphenyls. Our finding that fragility fractures are twice 5 Citation:IntJCircumpolarHealth2013,72:19596-http://dx.doi.org/10.3402/ijch.v72i0.19596 (pagenumbernotforcitationpurpose) AnnaJakobsenetal. as common in individuals with more than 2 risk factors in Greenland is important considering the predicted lendsfurthersupporttothisnotion. increase in life expectancy. Smokingisawell-establishedriskfactorforosteoporo- The number of falls was markedly lower in the sisinotherpopulations(30,31)andtheimpactofsmoking oldest compared to the younger age groups. This may may increase with latitude (32). Accordingly, Filner and beexplainedbythefactthattheoldestpeopleareretired colleagues (33) found that current and former smoking and don’t have to go out on icy pavements and roads increased the riskof low BMD in Alaska natives. In our combined with an inability to get outside when condi- survey, 61% of the younger respondents were smokers, tions are inhospitable. This is in keeping with the whichisinkeepingwithpreviousfindings (17).Fewerin notably lower sun exposure reported by the oldest age the old age group were current smokers but the old group. Despite the fewer falls in the old, there was a responders remained at a higher risk of osteoporosis steep rise in the occurrence of fragility fractures with compared with never smokers. Hence, smoking may be age, which emphasises the importance of focus on an important factor in influencing fragility fractures in both the treatment and prevention of osteoporosis in Greenlandbutthesizeofthepopulationstudieddidnot Greenland. allowforanalysisofindividualriskfactors. Treatment of osteoporosis was reported to be very Limited alcohol consumption may have a positive in- scarce. Even subjectswith obvious fragility fractures did fluence on BMD while heavy drinking increases the risk not take medication forosteoporosis. This seems odd as of osteoporotic fractures (34,35). In our survey, alcohol all medication in Greenland is free of charge and anti- consumption was associated only with the risk of any osteoporotic drugs are efficient and readily available. fracture and not with fragility fractures. This may relate Adherencetotreatmentwithanti-osteoporoticdrugsmay either to the drinking pattern in Greenland that is be low due to side effects. Still, the low frequency of characterised by binge drinking or to the lack of statis- treatment is common in many countries and should be tical power due to the limited number of heavy drinkers addressed in Greenland. inoursurvey. Our survey had limitations. First, the study popula- Osteoporosis is a common disease at high latitude tion was of limited size. However, we included all countries such as the Scandinavian countries (11,36). inhabitants in the capital Nuuk in the defined age ThismayrelatetolowvitaminDlevelsduetoinadequate groups and had to extend the age range in the oldest sun exposure. The solar zenith angle is even higher in group to reach an acceptable number of participants. Greenland than in Scandinavia. Still, we included the Despite the limited size, we were able to reach valid question ‘‘limited sun exposure’’ in our questionnaire conclusions regarding the importance offactors that are and we consider it to be a risk factor because the high associatedwithanincreasedriskofosteoporosisinother intensity of the light in Greenland during spring and ethnic groups: Advanced age, smoking, limited sun indication of dermal vitamin D production even in exposure, falls, the occurrence of previous fractures NorthGreenland(37)inadditiontovitaminDprovided and the ‘‘number of risk factors’’. Second, a delay in by the traditional Inuit diet (38). Furthermore, strato- the recording of address changes combined with a spheric ozone depletion increases the UVB radiation in frequent change of address may have influenced risk the circumpolar area in the range required for dermal profiles of the participant groups as those who have a vitamin D production (39). Thus, sun exposure is likely frequent change of address or have no permanent an issue in populations in Greenland too. address differ in income and social group compared to Relativelyfewparticipantsreportedafamilyhistoryof those with a more stable life style, and the formergroup osteoporosiscomparedtootherpopulations(7).Thelow numbermaybeduetoalackofawarenessofosteoporosis carries a higher riskof osteoporosis. They are less likely in Greenland as the disease manifests with fractures at to have a registered address and they may not have oldage.Ashortlifespanwascommonuntilrecentyears. responded. This tends to underestimate the risk of The mean life span has increased by 5.9 and 3.2 years osteoporosis found in our survey. Third, the question- among men and women respectively over the past 18 naire survey carries the risk of reporting bias and yearsandthe fractionofpeople aged65 yearsandolder findings should be confirmed by surveys using other is expected to double in the next 30 years (40). Thiswill methods. increase the occurrence of fragility fractures and hence Confirming the occurrence of risk factors for osteo- the awareness ofosteoporosis. porosis in populations in Greenland helps to prevent Age is a major risk factor for osteoporosis in other futurecasesofosteoporosisandfractures.Indoingso,we populations (30,31,41). A similar association was seen hope to reduce the pain, decreased quality of life, in our study with a rise in fragility fractures with age disability and premature death, and the considerable leading to an increase in fragility fractures that reached coststhatthisdisorderplacesontheGreenlandicsociety 1in3oftheoldestwomen.Hence,focusonosteoporosis (2(cid:2)5). 6 Citation:IntJCircumpolarHealth2013,72:19596-http://dx.doi.org/10.3402/ijch.v72i0.19596 (pagenumbernotforcitationpurpose) RiskfactorsforosteoporosisinGreenland Conflict of interest and funding 17. Bjerregaard P, Jørgensen ME, Borch-Johnsen K. Cardiovas- cularriskamongstmigrantandnon-migrantGreenlandInuit The authors declare no conflict of interest. The study inagenderperspective.ScandJPublicHealth.2007;35:380(cid:2)6. was supported by grants from the Greenland Home 18. Dahl-Petersen IK, Jørgensen ME, Bjerregaard P. 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