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Comparison of whole body bone mineral density
measurement between dual-energy X-ray
absorptiometry and novel foot-to-foot bioelectrical
impedance analyzer
Chih-Lin Chuang
Jen-Ai Hospital
Chung-Liang Lai
Ministry of Health and Welfare
Ai-Chun Huang
National Kaohsiung University of Hospitality and Tourism
Bai-Hua Su
Jen-Ai Hospital
Lee-Ping Chu
China Medical University Hospital
Kuen-Chang Hsieh
Starbia Meditek Co., Ltd
Hsueh-Kuan Lu
National Taiwan University of Sport
Article
Keywords: bone mineral density, muscle strength, body composition
Posted Date: March 5th, 2024
DOI: https://doi.org/10.21203/rs.3.rs-4007759/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License
Additional Declarations: No competing interests reported.
Page 2/13
Abstract
Bone mineral density (BMD) is a crucial indicator of osteoporosis. Bioelectrical impedance analysis (BIA)
introduces a new capability for assessing body composition, specically BMD measurement. This study
aimed to evaluate the accuracy of the novel BIA in conducting whole-body BMD tests in the general
population of Taiwan. Altogether, 318 healthy adults in Taiwan (age, 37.67 ± 19.44 years; 145 male and
173 female patients) were included. Whole-body BMD was measured using foot-to-foot BIA-StarBIA201
(StarBIA Meditek Co. LTD, Taichung, Taiwan) and dual-energy X-ray absorptiometry (DXA) Lunar Prodigy
(GE Medical Systems, Madison, WI, USA). Linear regression analysis, Pearson's correlation coecient,
Bland–Altman Plot, and paired t-test were used. Whole body BMD measured by BIA and DXA was 1.139 ±
0.124 g/cm2 and 1.202 ± 0.168 g/cm2, respectively. The regression equation was y = 1.057x + 0.063. The
Pearson correlation coecient, mean difference, and limits of agreement were
r
= 0.737, − 0.053 g/cm2,
and − 0.290–0.165 g/cm2, respectively. Standing BIA was correlated with the DXA gold standard for
estimating whole-body BMD in adults; however, their interchangeability remains limited. The convenient
BIA method for measuring whole body BMD may be useful in the application of primary screening and
future development of BMD assessment methods.
Introduction
Osteoporosis is a bone disease characterized by reduced bone mineral density (BMD) and fragile bone
structure1. It primarily affects the elderly, especially women. Aging is one of the major factors involved in
the development of osteoporosis2. With an increase in life expectancy, the proportion of the elderly
population has increased, and the prevalence of osteoporosis has increased accordingly. Women are
more likely to develop osteoporosis after menopause owing to hormonal changes3. Osteoporosis renders
bones fragile. This particularly affects the spine, hips, and arms, thereby increasing the risk of fractures.
This may lead to a decline in the quality of life and increase the possibility of damage to physical
functions4. Moreover, this limits movement, which in turn affects the overall function of the body,
including balance and coordination. Osteoporosis imposes a burden on the medical system and
economy of patients' families owing to more time and money needed for medical needs. Osteoporosis is
generally not easily detected before BMD decreases signicantly; therefore, prevention and early
treatment are crucial5. The impact of osteoporosis on people is not only reected at the physiological
level, but also in psychological and social aspects. Prevention, early detection, and proper treatment are
key to managing this disease and helping reduce its negative impact on patients’ lives6.
Dual-energy X-ray absorptiometry (DXA) is commonly used for medical-grade BMD detection. The
advantage of DXA is that BMD measurements are highly accurate and can be used to evaluate the risk of
fractures. However, it needs to be tested in medical institutions, and its cost is relatively high7. In addition,
DXA is mainly used to measure BMD in local areas, such as the spine and thigh bones, which is limited
by the failure to standardize bone size and the load of the corresponding parts8. Quantitative Magnetic
Resonance Imaging (QMRI), which does not involve radiation exposure, is especially suitable for children
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and pregnant women, and can provide more comprehensive BMD data, including systemic and local
areas. Its disadvantages include the high cost of equipment and relatively complicated operation.
Compared to DXA, the wide application of QMRI is relatively limited9. Another simple bone density
measurement method is ultrasonic BMD measurement, which is more portable and simpler than DXA and
QMRI, does not involve radiation exposure, and is suitable for specic individuals. Its disadvantages are
that its accuracy is relatively low, it is affected by soft tissue, and it can generally only evaluate the BMD
of the ankle bone10.
Recent studies have indicated that bioelectrical impedance vector analysis (BIVA), its phase angle (PhA),
the whole body, spine, and pr of middle-aged and elderly people. The BMD of the proximal femur has a
certain correlation, especially in the lower PhA, which is related to osteoporosis11–13. Bioelectrical
impedance analysis (BIA) is a noninvasive method for estimating the composition of the body according
to the degree of resistance of the body tissue by passing a low-intensity current through the body. The
measurement process is relatively simple, fast, and inexpensive and does not require signicant technical
support. However, the current applied by BIA or BIVA cannot ow directly through the bones; therefore, its
application in the evaluation of bone diseases, such as osteoporosis, requires further in-depth study.
Although relevant research on BIA and BIVA for BMD measurement has been published, their actual
application to BMD is limited. This study aimed to apply new BIA devices to determine the accuracy of
whole-body BMD measurements in the general population. This study was conducted on adults in
Taiwan. The new BIA measurement of the overall BMD and the DXA measurement results were consistent
when participants had different levels of obesity.
Results
This study included 318 participants (145 men and 173 women). Their characteristics are summarized in
Table1. The average age of the participants was 37.88 ± 19.41 years (19.4–84.0 years). The BMI of the
participants ranged from 13.1 to 39.0 kg/m2, and the body fat percentage of the male and female
participants was 18.75% ± 9.05% and 33.01% ± 8.16%, respectively. The one mineral content (BMC) of the
sexes was 3.18 ± 0.57 and 2.38 ± 0.61 kg, respectively.
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Table 1
Physical characteristics of the subject1
Item Male (
n
= 145) Female (
n
= 173) Total (
n
= 318)
Age(year) 36.58 ± 15.16
(18.00,82.0)**
37.76 ± 21.09(19.0,84.0) 37.66 ± 19.41((19.4,84.0)
Height(cm) 170.7 ±
6.28(152.0,196.0)**
160.19 ±
6.12(143.0,175.0) 165.02 ±
8.13(143.0,196.0)
Weight(kg) 67.99 ±
3.86(47.17,118.37)**
57.53 ±
10.34(32.81,108.88) 62.3 ± 12.76(32.81,118.3)
BMI(kg/m2)23.25 ± 3.86(17.21,38.69) 22.43 ± 3.90(13.14,39.04) 22.8 ± 3.89(13.1, 39.0)
BPFDXA(%) 18.75 ± 9.05(5.80,37.10)** 33.01 ± 8.16(15.90,52.40) 26.5 ± 11.1(5.80,52.4)
BMCDXA(kg) 3.18 ± 0.57(1.69,4.78)*2.38 ± 0.61(1.26,4.05) 2.73 ± 0.73(1.26,4.78)
BFMDXA(kg) 13.53 ± 8.74(5.08,37.10)** 19.52 ± 7.77(6.44,56.66) 16.79 ± 8.74(2.92,56.6)
**, P < 0.01, *, P < 0.05, 1All value are minimum and maximum in parentheses; subscript
DXA, indicates the application of DXA measurement; BMI, body mass index; BFP, body fat percent;
BMC, bone mineral content; BFM, body fat mass.
Whole-body BMD results measured using BIA and DXA are presented in Table2. Whole-body BMD
measured in men, women, and the total using BIA was signicantly lower than that measured using DXA.
Table 2
Bone mineral density by dual-energy X-ray absorptiometry (DXA) and by bioelectrical
impedance analysis (BIA).
Method All subjects (n=318) Female (n =173) Male (n=145)
BMDBIA 1.15±0.12(0.81,1.51)** 1.07±0.09(0.81,1.28)** 1.25±0.08(0.92,1.51)**
BMDDXA 1.20±0.17 (0.74,1.59) 1.13±0.16(0.74,1.44) 1.29±0.13(0.94,1.59)
1 All value are x ±
SD
minimum and maximum in parentheses; ** Signicant different from DXA,
P
< 0.001
(paired t test)
The analysis of all participants revealed that the measurement correlation coecient (r) of the whole-
body BMD using BIA and DXA was 0.736. The regression line equation was y = 1.03x + 0.05, which
indicated no proportional or xed error of BIA measurement of systemic BMD (Fig.1A). The Bland–
Altman diagram of BMD measured by BIA and DXA is provided in Fig.1B. The average difference
between the two methods was − 0.054 g/cm2, and the LOA was − 0.281 to 0.174 g/cm2. The trend
−
x
±
SD
;
Page 5/13
equation (trend line) was y = − 0.348x + 0.366, r = 0.417. The trend equation revealed that with an increase
in BMD, the BMD difference measured by the two methods indicated an evident trend from positive to
negative. When the participants were divided into underweight (BMI < 18.5 kg/m2), normal (18.5 kg/m2 <
BMI < 25 kg/m2), overweight (25 kg/m2 < BMI < 30 kg/m2), and obesity (30 kg/m2 < BMI) groups, the
correlation values between BIA and DXA were 0.710 (n = 31), 0.709 (n = 218), 0.807 (n = 53), and 0.841 (n
= 17), respectively. The difference between BIA's measurement of whole-body BMD compared with DXA in
the four groups was − 0.031 ± 0.100, − 0.059 ± 0.113, − 0.050 ± 0.128, and − 0.040 ± 0.112 g/cm2,
respectively. The results are demonstrated in Fig.2.
Discussion
To the best of our knowledge, this study was the rst to verify the systemic BMD measurement applied to
the bioelectrical impedance method in the general public. At present, although relevant theories and
studies on the application of bioelectrical impedance to BMD have been proposed, actual research
applied to BMD measurements remains scarce. Currently, the published verication research literature on
relevant technologies and equipment is also lacking. The experimental results of this study revealed that
BIA with the standing foot-to-foot model had a moderate positive correlation with total body BMD and
DXA measured by the participants in this study. The Bland–Altman plots demonstrate that BIA measures
total-body BMD relative to DXA and underestimates whole-body BMD. The measurement difference
between the two devices decreased with an increase in whole-body BMD. The accuracy of BIA
measurement of BMD still demonstrated improvement to a certain extent compared with that of DXA.
Quantitative ultrasonography (QUS) measured the correlation between BMD and DXA throughout the
body, and its r value was between 0.35 and 0.8014, 15. Therefore, the World Health Organization has not
recognized QUS for clinical applications. Although QUS is more convenient than DXA, DXA is more
convenient, safe, low-cost, and fast. Moreover, it has unique characteristics from QUS, which may make
DXA more suitable for screening for BMD or osteoporosis.
Several studies have reported age as one of the main risk factors for fractures16. In addition to aging,
changes in postmenopausal women are particularly evident owing to small bone loss due to changes in
body composition and hormonal changes17. In addition, family history18, lifestyle19, weight20,
hormones21, chronic diseases, and long-term use of certain drugs22 would affect bone density. The
existing standard method for evaluating BMD is DXA. However, DXA has some shortcomings, including
limited availability and high costs10. Thus, DXA is unsuitable for use in screening.
Currently, DXA is used to measure BMD to assess osteoporosis in the lumbar spine, proximal femur, and
forearm. Although the measurement results of systemic BMC were used as a clinical diagnostic
reference, most of them were in pediatric patients because the measurement results of systemic BMD
were highly reproducible for the examination of systemic bone condition. Systemic BMD can provide a
comprehensive and integrated evaluation basis, and systemic BMD testing can provide personalized
treatment policies for patients. BMD in different parts of the body may differ; therefore, systemic testing
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can help doctors formulate targeted treatment plans more accurately to minimize the risk of fractures.
Although systemic BMD is less commonly used to assess osteoporosis than the lumbar spine, proximal
femur, or forearm femur, the judgment of systemic BMD for osteoporosis is heterogeneous. Peak bone
mass and standard deviation calculated from the population were not suitable for all individuals. At
present, no evidence that BMD is the best reference location has been reported23. The whole-body BMD of
the participants in this study was still highly positively correlated with the BMD of the lumbar spine,
proximal femur, and forearm bone (r = 0.81–0.90, data not shown). The BMD in specic parts can provide
independent information on fracture risk. Systemic BMD is typically considered a more comprehensive
indicator.
Preventive measures and raising public awareness on bone health are important to reduce the prevalence
of osteoporosis24. Specically, proper calcium and vitamin D intake is required. Appropriate physical
activity is essential to ensure good bone health. Quitting smoking and limiting alcohol intake are
important factors in maintaining healthy bones. Regular physical examinations and medical guidance
can help individuals understand their bone health. Regular bone density testing is performed, especially
for high-risk groups such as postmenopausal women, patients who use glucocorticoids for a long time,
and individuals with osteoporosis in the family. The measurement results of whole-body BMD of the
equipment discussed in this study are better than those of ultrasonic BMD detection25–27, which is
convenient for application in family health care. BIA can detect osteoporosis at an early stage, and can be
conducive to the early adoption of prevention and treatment measures that are not provided by existing
BMD measurement equipment.
Osteoporosis symptoms were not evident. In the face of possible patients, the best prevention method is
to use bone healthcare and related examinations, including daily medical examinations or general initial
screening28. Otherwise, the importance of diagnostic examination and treatment may still be dicult to
understand when considering only "symptoms of early aging". Thus, an effective, safe, and convenient
method or tool is necessary to measure bone density that is different from the present. For example, the
convenient BIA method, if it has undergone large-scale verication research, can prove that its accuracy is
useful for screening for osteoporosis, thus suggesting its application and promotion value.
This study has some limitations. First, the study participants were adults who could stand and walk
independently in Taiwan. Thus, the results cannot be inferred from other age groups or physiological
conditions. Second, the BIA device discussed in this study is a standing foot-to-foot BIA with a BMD
measurement function. Therefore, it cannot be inferred from other brands, models, or body composition
analyzers. Lastly, the number of participants included in the study was limited. In the future, relevant
research should be conducted on other ethnic groups under different physiological conditions.
Currently, the application of BIA for BMD measurements is relatively limited7. BIA is mainly used to
measure electric current ow through the human body to estimate body composition, rather than directly
measuring bone density. The electrical characteristics of the current owing through the bones, muscles,
and other tissues need to be further studied. However, continuous progress in scientic research and
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technology may lead to new application directions for BIA in this regard. For example, integrating other
biological measurements and combining BIA with other biological measurement methods could improve
the accuracy of BMD estimation to establish a more comprehensive model and further improve the
evaluation of BMD. In the future, new electrodes and measurement technologies may be developed to
improve BIA's sensing and measurement capabilities of bone tissues. This includes improvements in the
frequency, waveform, and electrode design of the current. It is used to increase the estimation of BMD in
various parts of the body. In addition, more in-depth research should be conducted on specic groups of
people such as children, elderly, and patients with osteoporosis. Alternatively, deep learning and articial
intelligence technology can be used to extract complex patterns from vast data to further optimize BIA's
BMD evaluation model.
Conclusion
The BIA method is simple, convenient, and safe for body composition measurements, and the total BMD
measurement method in ordinary people has the potential to screen for osteoporosis.
Methods
Study Design
Cross-sectional research data were collected between September 2022 and September 2023. All
participants were informed of the objectives and risks of this study and provided informed consent before
the experiment. This study was approved by the Human Medical Ethics Committee of the Caotun
Sanatorium of the Ministry of Health and Welfare (no. I RB-111047). Participants were recruited through
oral introductions and posters. This study was conducted at Chiayi Puzi Hospital of the Ministry of
Health and Welfare. Adults between 18 and 85 years of age who could stand and walk independently
were included in the standard age group. The exclusion criteria included surgery that changed the body
composition (such as obesity surgery). The sample size was calculated after considering type I (α = 0.05)
and type II errors (β = 0.95). For linear regression analysis, post-effect analysis revealed that in the case of
α = 0.05 and β = 0.95, 262 participants were needed to achieve an average effect size of 0.20. The sample
size was calculated using the G* Power software version 3.1.9.4 (Universitat Dusselfodorf, Germany).
Each experiment was between 9:00 a.m. and 12:00. The participants were advised to avoid vigorous
exercise 48 h before the formal experiment and maintain normal and regular eating habits during the
experiment. Before the test, the participants were required to adhere to the following: (1) change into
cotton robes and only wear underwear; (2) remove any accessories such as rings, earrings, zippers,
buttons, etc. that may attenuate the X-beam; (3) avoid ingesting or taking radionuclides within 5 days
before the experiment (radionuclides) or radiopaque agents; (4) avoid consuming heavily caffeinated or
alcoholic beverages within 48 h before the experiment; (5) avoid moderate or high-intensity exercise 12 h
before the test; (6) empty the front row of the test bladder urine; (7) not take any diuretics7 days before
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the examination; and (8) rescheduling the test time in case menstruation occurs during the test. (9)
Women who might be pregnant or who were pregnant were excluded from this experiment.
BIA
The analyzer measured resistance at two frequencies (50 and 250 kHz) using a four-electrode dual-
frequency StarBIA-201 foot-to-foot bioimpedance analyzer (StarBIA MediTek Co., Taichung, Taiwan). In
the manual, the manufacturer emphasizes that following the correct measurement process can obtain a
high level of accuracy, including the height required for input in StarBIA-201. This study used a digital
rangender (Jenix DS-102, Dong Sang Jen Ix Co., Ltd., South Korea) accurately measured the height of
the participants to 0.1 cm. Before the measurement, the participants stood on the measuring platform
after emptying the bladder and were instructed to stand quietly for 5 min before the test. Through the
pressure formed by the body weight, the soles of the feet touched the two electrode pairs, and the
measurement was completed in 1 min.
DXA
A GE Lunar Prodigy Advance dual-energy X-light absorber (GE Medical System Lunar, Madison, WI, USA)
was used for bone density measurement, and enCORE 2011 version 13.50.0 (GE Medical System Lunar,
WI, USA) was used for scanning. During the scan, the participant remained in supine, with both arms on
the body and palms on both sides facing down. Because all participants were within the scope of the
scanning platform, skeletal tissue was not evaluated. All scans and adjustments were performed by
trained technicians according to the International Society for Clinical Density Measurement (ISCD)
Standards29. After obtaining data on age, height, weight, sex, and race, the participants’ data were entered
before each measurement. Using the ISCD bone density measurement accuracy calculation tool version
2.1 to calculate the accuracy of the whole body, the root-mean-square standard deviation (RMS-SD) and
percent coecient of variation (%CV) were determined as 0.007 g/cm2 and 0.62%, respectively. The
RMSD-SD and %CV used for least signicant change were 0.021 g/cm2 and 1.74%, respectively.
Statistical analysis
All data are presented as average values, standard deviations, minimum values, and maximum values,
which were used for the descriptive analysis of numbers. Peak and asymmetry were applied to verify the
normality of the data (range between − 2 and + 2), the variables were normally distributed. Paired-
t
test
was used to compare whole-body BMD measured using BIA and DXA. The correlation between BMD
estimated by BIA and BMD measured by DXA was analyzed using Pearson’s correlation, and signicance
was set at
P
= 0.05. A Bland–Altman plot30 was used to analyze the consistency of the two devices
(limits of agreement, LOA), and the deviation was calculated as the average value of 1.96 standard
deviation of the difference between the two variables. A one-factor analysis of variance was performed to
analyze the difference between BIA and DXA methods for different degrees of obesity (normal and
overweight body mass index [BMI]). A simple regression analysis was performed. The xed and
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proportional errors of BIA prediction between BMD and DXA were determined. SPSS Version 20 (IBM
SPSS, Armonk, NY, USA) was used for all statistical analyses.
Declarations
Funding
This research was supported by a grant from China Medical University in Taiwan with the award number
of DMR-109-083. Ministry of Health and Welfare Hospital Research and Development plan the award
number of PG11202-0334.
Author Contribution
All authors made a signicant contribution to the work reported, whether that is in the conception, study
design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in
drafting, revising or critically reviewing the article; gave nal approval of the version to be published; have
agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects
of the work.
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Figures
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Figure 1
BMDBIA and BMDDXA: (A) Regression line and distribution plot, y = 1.00 x + 0.05, r = 0.736, n = 318 (B)
Bland-Altman plot, trend - y = -0.348 x + 0.366, r = 0.417
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Figure 2
Bar chart of differences between BMDBIA and BMDDXA in different BMI groups (*, p<0.05)
