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PubMed1977

Physical training in man. Skeletal muscle metabolism in relation to muscle morphology and running ability.

The metabolic and morphologic adaptation to physical training in skeletal muscle tissue of eleven middle-aged, physically untrained men was studied. Muscle biopsies were taken from the vastus lateralis before, after 8 weeks and after 6 months of physical training for analysis of metabolic and morphologic variables. Glucose tolerance test indicated increased insulin sensitivity after 6 months of physical training. The activities of glycogen phosphorylase, hexokinase and glucose-6-P-dehydrogenase were increased but other enzymes involved in glycogen turnover and glycolysis were unchanged after 6 months of physical traning. The activities of citrate synthase and cytochrome-c-oxidase, representing the oxidative capacity were significantly increased already after 8 weeks of physical training. The incorporation rate of palmitate-carbon into CO2 and triglycerides increased, and the incorporation rate of leucine-carbon into CO2 decreased with 6 months of physical training. The fiber diameter of both Type 1- and Type 2-fibers increased, while the mitochondrial volume increased predominantly in Type 2-fibers. Significant correlations were found between metabolic, physiologic and morphologic variables before and after physical training. The results indicate an increased oxidative capacity, mainly located to Type 2-fibers, and an increased utilization of fatty acids in response to this type of physical training.

Carnitine↗
PubMed1993

Various intensities of leisure time physical activity in patients with coronary artery disease: effects on cardiorespiratory fitness and progression of coronary atherosclerotic lesions.

OBJECTIVES: This study was designed to define the effect of different levels of leisure time physical activity on cardiorespiratory fitness and progression of coronary atherosclerotic lesions in unselected patients with coronary artery disease. BACKGROUND: It has been shown in various studies that regression of coronary atherosclerotic lesions can be achieved by means of lipid-lowering drugs, reduction of fat consumption and physical exercise. METHODS: Patients were prospectively randomized either to an intervention group (n = 29) participating in regular physical exercise or to a control group (n = 33) receiving usual care. Energy expenditure in leisure time physical activity was estimated from standardized questionnaires and from participation in group exercise sessions. After 12 months of participation, repeat coronary angiography was performed; coronary lesions were measured by digital image processing. RESULTS: After 1 year, patients in the intervention group achieved an increase in oxygen uptake at a ventilatory threshold of 7% (p < 0.001) and peak exercise of 14% (p < 0.05), whereas a significant decrease was observed in patients in the control group. To achieve significant improvement in cardiorespiratory fitness, approximately 1,400 kcal/week had to be expended in the form of leisure time physical activity (p < 0.001). The mean energy expended in such activity was 1,876 +/- 163 kcal/week in the intervention group and 1,187 +/- 97 kcal/week in the control group (p < 0.001). In the intervention group, regression of coronary artery disease was noted in 8 patients (28%), progression of disease in 3 (10%) and no change in coronary morphology in 18 (62%). In contrast, coronary artery disease progressed at a significantly faster rate in patients in the control group (progression in 45%, no change in 49% and regression in 6%) (p < 0.001 vs. intervention). When the two groups were combined, the lowest level of leisure time physical activity was noted in patients with progression of disease (1,022 +/- 142 kcal/week) as opposed to patients with no change (1,533 +/- 122 kcal/week) or regression of disease (2,204 +/- 237 kcal/week) (p < 0.005). CONCLUSIONS: Measurable improvement in cardiorespiratory fitness requires approximately 1,400 kcal/week of leisure time physical activity; higher work loads are necessary to halt progression of coronary atherosclerotic lesions (1,533 +/- 122 kcal/week), whereas regression of coronary lesions is observed only in patients expending an average of 2,200 kcal/week in leisure time physical activity, amounting to approximately 5 to 6 h/week of regular physical exercise.

Coronary Angiography↗
PubMed2006

Association between back pain and physical fitness in adolescents.

STUDY DESIGN: A cross-sectional study of 9413 adolescents. OBJECTIVES: To study the associations between back pain, physical activity, and physical fitness. SUMMARY OF BACKGROUND DATA: A high physical fitness level, and especially muscle endurance in the back muscles, is associated with lower risk of back pain, but little is known about other types of physical fitness and back pain in adolescents. METHODS: A cross-sectional study of 3956 boys and 5457 girls 17 years of age. The associations between self-reported back pain and different types of physical fitness and self-reported physical activity were analyzed in high schoolchildren in Denmark. RESULTS: Back pain was reported by 43% of the girls and 37% of the boys. Back pain was associated with low isometric muscle endurance in the back extensors, and the highest quartile had a lower risk of back pain (odds ratio = 0.71; 95% confidence interval, 0.62-0.82) within the last month. No associations were found to aerobic fitness, functional strength, flexibility, or physical activity level after adjustment for muscle endurance. More girls than boys experienced back pain, and it was more common in taller adolescents. CONCLUSION: Children with high isometric muscle endurance were less likely to report back pain. No other measures of physical fitness or level of self-reported physical activity were linked to back pain reporting.

Adolescent↗
PubMed1977

A 4-year prospective study of the relationship of different habitual vocational physical activity to risk and incidence of ischemic heart disease in volunteer male federal employees.

A prospective study of coronary heart disease (CHD) was done in 2,635 volunteer male federal employees of postal, health, aerospace, and other agencies, aged 35--59 years at intake. The present analysis is concerned with 2,065 initially well whites, of whom 65 suffered clinical CHD during a 4 years of annual follow-up. The subjects differed markedly in their levels of habitual vocational physical activity, which is classified (1) by division into sedentary, moderate, and heavy activity groups, (2) by blue collar or white collar type of occupation, and (3) by calculated annual caloric expenditure for both vocational and non-vocational physical activities. Intake variables that were studied in relation to physical activity and the CHD incidence include age, serum cholesterol, systolic blood pressure, relative body weight, ECG abnormality, and cigarette smoking. Socioeconomic status (SES) is assessed by levels of education and income and by a combined SES categorization based upon both. Estimated composite CHD risk scores are based upon Framingham equations. The CHD risk factors, singly, as well as in a derived composite risk score, are higher for men with heavy compared to sedentary or moderate habitual physical activity. However, this is a spurious association found to be induced by differences of SES. Thus, when physical activity and SES are studied in a concurrent analysis, a higher CHD risk is significantly associated with lower SES status but not with differences of vocational physical activity. The CHD incidence in this population is studied in relationship both to the risk factors and physical activity by multivariate analysis, using the multiple logistic risk model. The incidence of CHD is significantly associated with age, serum cholesterol, systolic blood pressure, and cigarette smoking. It is not found to be associated with the type of occupation (i.e., blue or white collar), the level of reported habitual vocational physical activity, or the calculated total vocational plus nonvocational caloric expenditure in physical activity.

Adult↗
PubMed2004

Features of the metabolic syndrome are associated with objectively measured physical activity and fitness in Danish children: the European Youth Heart Study (EYHS).

OBJECTIVE: Features of the metabolic syndrome are becoming increasingly evident in children. Decreased physical activity is likely to be an important etiological factor, as shown previously for subjective measures of physical activity in selected groups. The purpose of this study was to examine the relationship between the metabolic syndrome and objectively measured physical activity and whether fitness modified this relationship. RESEARCH DESIGN AND METHODS: A total of 589 Danish children (310 girls, 279 boys, mean [+/-SD] age 9.6 +/- 0.44 years, mean weight 33.6 +/- 6.4 kg, mean height 1.39 +/- 0.06 m) were randomly selected. Physical activity was measured with the uni-axial Computer Science & Applications accelerometer (MTI actigraph) worn at the hip for at least 3 days (>/=10 h/day) and fitness with a maximal bike test. As outcomes, we measured sitting systolic and diastolic blood pressure, degree of adiposity (sum of four skinfolds), and, finally, insulin, glucose, triglicerides, and HDL cholesterol in fasting blood samples. The outcome variables were statistically normalized and expressed as the number of SDs from the mean. (i.e., Z scores). A metabolic syndrome risk score was computed as the mean of these Z scores. Multiple linear regression was used to test the association between physical activity and metabolic risk, adjusted primarily for age, sex, sexual maturation, ethnicity, parental smoking, socioeconomic factors, and the Computer Science & Applications unit, as well as for fitness. Robust SEs were computed by clustering on school. RESULTS: All children were in the nondiabetic range of fasting glucose. Metabolic risk was inversely related to physical activity (P = 0.008). The relationship was weakened after adjustment for fitness, but there was a significantly positive interaction between physical activity and fitness. CONCLUSIONS: Physical activity is inversely associated with metabolic risk, independently of potential confounders. The interaction between physical activity and fitness suggests that the potential beneficial effect of activity may be greatest in children with lower cardiorespiratory fitness.

Blood Pressure↗
PubMed1995

Characteristics of elementary school principals and their support for the physical education program.

The purpose was to describe the characteristics of elementary school principals who support elementary physical education programs. A statewide random sample of 500 elementary school principals and their respective elementary physical education teachers (n = 500) were mailed questionnaires. A total of 321 principals responded (64%) to a 20-item questionnaire which assessed their physical fitness and their perceptions of elementary physical education. A total of 340 physical education teacher (68%) responded to a 23-item survey assessing their perceptions of their elementary principals' support for the physical education program. The majority of teachers perceived their principals to be supportive of them and the physical education program. A series of t tests showed no significant differences in principals' age, gender, years of experience as a principal, or how important they thought health and physical education was compared to other subjects taught in the elementary school and how supportive of physical education the principals were perceived to be. Finally, a stepwise backward multiple regression analysis indicated that seven variables, including fitness of the principal and body mass index, did not explain more than 13% of the variance in teachers' perceived support by principals.

Adult↗
PubMed2003

Worksite intervention model for facilitating changes in physical activity, fitness, and psychological parameters.

The purpose was to examine the effectiveness of a physical activity intervention which combined behavior-change strategies with a variety of physical activities for 30 sedentary adults in a 12-wk. intervention that included behavior-change strategy sessions and supervised physical activity. Before and after the intervention, psychological and physiological variables were measured. Statistically significant changes right after the intervention included (1) an increase in physical activity participation, (2) an increase in muscular endurance, flexibility, and predicted VO2 max, and (3) a decrease in the number of barriers to physical activity. Changes in physical self-perception, a psychological variable often linked to increased physical activity, were not statistically significant, but effect sizes were large. The use of behavior-change strategies in conjunction with a variety of physical activities may be useful in improving physical and psychological well-being in previously sedentary adults. Stability of change requires study.

Adaptation, Psychological↗
PubMed1983

The effect of physical conditioning on serum lipids and lipoproteins in white male adolescents.

This study was designed to measure the effect of physical conditioning on the serum lipid and lipoprotein levels of white male adolescents. Fifty white males, ages 11-17 yr, underwent pre-test evaluations including physical measurements, physical activity levels, nutritional intake, physical working capacity, and fasting serum lipid and lipoprotein levels. Each subject was randomly assigned to a physical conditioning group or to a control group. There were no statistically significant differences in pre-test measurements. The physical conditioning group participated in an 8-wk progressive aerobic exercise program 30 min/d for 4 d each wk. The pre-test measurements were then repeated for both groups. Based on Student's t-test, the physical conditioning group had a significantly higher physical working capacity on the post-test than the control group. An analysis of covariance test showed no differences between the groups in the post-test serum lipid and lipoprotein levels. The results suggested that although the exercise program was strenuous enough to increase significantly the physical working capacity of the exercise group, it did not alter their serum lipid and lipoprotein levels during the 8-wk period.

Adolescent↗
PubMed2003

Relationship of changes in physical activity and mortality among older women.

CONTEXT: Physical activity has been related to reduced mortality, but it is not clear whether changes in physical activity affect mortality among older women. OBJECTIVE: To examine the relationship of changes in physical activity and mortality among older women. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study conducted at 4 US research centers (Baltimore, Md; Portland, Ore; Minneapolis, Minn; and Monongahela Valley, Pa) among 9518 community-dwelling white women aged 65 years or older who were assessed at baseline (1986-1988), 7553 of whom were reassessed at a follow-up visit (1992-1994; median, 5.7 years later). MAIN OUTCOME MEASURES: Walking and other physical activities at baseline and follow-up; vital status, with cause of death confirmed by death certificates/discharge summaries, tracked for up to 12.5 years after baseline (up to 6.7 years after the follow-up visit). RESULTS: Compared with continually sedentary women, those who increased physical activity levels between baseline and follow-up had lower mortality from all causes (hazard rate ratio [HRR], 0.52; 95% confidence interval [CI], 0.40-0.69), cardiovascular disease (HRR, 0.64; 95% CI, 0.42-0.97), and cancer (HRR, 0.49; 95% CI, 0.29-0.84), independent of age, smoking, body mass index, comorbid conditions, and baseline physical activity level. Associations between changes in physical activity and reduced mortality were similar in women with and without chronic diseases but tended to be weaker among women aged at least 75 years and among those with poor health status. Women who were physically active at both visits also had lower all-cause mortality (HRR, 0.68; 95% CI, 0.56-0.82) and cardiovascular mortality (HRR, 0.62; 95% CI, 0.44-0.88) than sedentary women. CONCLUSION: Increasing and maintaining physical activity levels could lengthen life for older women but appears to provide less benefit for women aged at least 75 years and those with poor health status.

Aged↗
PubMed1998

Risk for endometrial cancer in relation to occupational physical activity: a nationwide cohort study in Sweden.

Notwithstanding its biologic plausibility, the association between physical activity and endometrial cancer has been analyzed in only a few epidemiological studies. Retrospective assessment of exposure and small sample size often hampers interpretation of published data. We studied risk for endometrial cancer in relation to physical activity at work in a large cohort of Swedish women identified in the nationwide censuses in 1960 and 1970, with jobs that could be consistently classified into one of 4 levels of physical demands. Follow-up from 1971 through 1989 was accomplished through record linkages. Multivariate Poisson regression models were used to estimate relative risk. The risk for endometrial cancer increased regularly with decreasing level of occupational physical activity (p for trend < 0.001), and was associated more strongly with activity in 1970 than in 1960. In multivariate analyses, adjusted for age at follow-up, place of residence, calendar year of follow-up, and social class, the relative risk among women with the same physical activity level in 1960 and in 1970 was 30% higher for sedentary as compared with high/very high activity level; (p for trend=0.04). The protective effect of physical activity appeared to be confined to women aged 50 to 69, among whom sedentary work was associated with a 60% higher risk than that observed among women estimated to be physically most active. The excess seemed to disappear within 10 years after a change in physical activity level. Although confounding cannot be ruled out in our data, occupational physical activity appears to reduce the risk for endometrial cancer.

Adult↗
PubMedDate not supplied

Physical activity and fitness: pathways from childhood to adulthood.

Contemporary thinking in public health posits that childhood and adolescent physical activity and physical fitness may influence health status during childhood and adolescence, as well as throughout adulthood. This paper addresses the evidence dealing with potential associations of physical activity and physical fitness in childhood and adolescence to health status during childhood, adolescence, and adulthood. There are generally low to moderate relationships between childhood and adolescent physical activity and health (operationalized largely in terms of health-related physical fitness) and adult physical activity and health. A large part of the variability in health-related fitness is not accounted for by physical activity as assessed in the available studies. Nevertheless, the trends emphasize the importance of a lifestyle of regular physical activity during childhood and adolescence, which continues into and throughout adulthood, for the health and well-being of the individuals and populations.

Adolescent↗
PubMed2006

Longitudinal follow-up of fitness during childhood: interaction with physical activity.

Health-related fitness values during childhood (from age 11 to 16 years) were analyzed in relation to changes in physical activity level. One hundred fifty-eight children were monitored over a 4-year period. Twice a year, they performed six physical fitness tests: standing broad jump, 10 x 5-meter shuttle run, sit-and-reach, handgrip, number of sit-ups in 30 s, and 20-m shuttle run. Height was measured four times per year to assess age at peak height velocity. Physical activity was assessed with a self-administered questionnaire at baseline and at the end of the follow-up. The physical activity level was defined by the frequency and the time spent in moderate-to-vigorous physical activities. Two groups were constituted: regularly active and sedentary. A multiple linear multilevel regression analysis was used to analyze the longitudinal relationships between changes in physical activity and physical fitness levels. Corrections were made for both time-dependent (time) and time-independent (sex) variables. Except for flexibility, boys' fitness performances increased more than that for the girls. Positive and significant (P < 0.05) regression coefficients were found with the regularly active for standing broad jump, 20-m shuttle run, number of sit-ups, 10 x 5-m shuttle run in both sexes, and for the girls' sit-and-reach performance. Increasing or decreasing physical activity level was not associated with changes in fitness performances over time, except for flexibility for the girls and the 20-m shuttle run for the boys. From childhood to adolescence, increasing physical activity is not sufficient to be more fit. The children who are stayed the most active were the fittest, particularly the girls. Am. J. Hum. Biol. 18:51-58, 2006. (c) 2005 Wiley-Liss, Inc.

Adolescent↗
PubMed1999

Physician contact with older community patients: is there an association with physical fitness?

BACKGROUND: Contact with family physicians by older adults may be linked to their physical fitness in addition to other health, behavioral, and sociodemographic determinants. We studied a stratified random sample of urban community-dwelling elderly patients in London, Ontario, Canada, to describe the interaction of physical fitness measures and a number of health and lifestyle behaviors and sociodemographic outcomes with family physician contact over 1 year. We hypothesized that physician contact would be associated with lower indices of physical fitness and that association would be similar to other known determinants of physician utilization. METHODS: Three hundred seventy-five noninstitutionalized elderly men (N = 185) and women (N = 190) ages 55 to 84 years were recruited from the municipal tax assessment list for the city of London (population 280,000). Four categories of independent variables were selected to reflect common determinants of health (physical fitness, self-reported and clinically measured health, lifestyle behaviors, and sociodemographics). The association between these categories of variables and self-reported contact with family physicians and a variety of health professionals was determined for the year prior to the study. RESULTS: Forty-six percent of the subjects had at least one physician contact in the month prior to the study and 79% within the previous year. None of the other health professions (including nursing, chiropractic, physiotherapy, homemaking, and dentistry) were contacted more than once in the previous year. Lifestyle and sociodemographic variables including activity habits, smoking, income, marital status, and education were not associated with physician contact, whereas poor self-reported cardiovascular health and use of cardiovascular and pulmonary medications were associated with physician contact. Interestingly, physical fitness variables including maximal aerobic capacity, grip strength, and hip flexibility were not associated with physician contact. CONCLUSIONS: The absence of an association among physical fitness, lifestyle, and sociodemographic variables and physician contact was not anticipated and may be due to the selection of individuals who were independent, active community dwellers. It may be that most of the physician contact in this relatively healthy and physically fit sample was preventive in nature, for example, monitoring common chronic disease states in the elderly including cardiovascular and pulmonary disease. This paper reports baseline data from a longitudinal study of the interaction between physical fitness and health outcomes in groups of older community-dwelling individuals. As this group ages further, it would be interesting to determine the use of the health care system in relation to their changing functional and health status. In particular, do chronic health conditions such as cardiovascular disease, which increase in prevalence with age, become modified through maintenance of physical fitness and does this impact on health service use?

Aged↗
PubMed2000

Social-cognitive and perceived environment influences associated with physical activity in older Australians.

BACKGROUND: Regular physical activity in older adults can facilitate healthy aging, improve functional capacity, and prevent disease. However, factors associated with physical inactivity in older populations are poorly understood. This study attempts to identify social-cognitive and perceived environmental influences associated with physical activity participation in older populations. METHODS: In a randomly selected sample of 449 Australian adults age 60 and older, we assessed self-reported physical activity and a range of social-cognitive and perceived environmental factors. Respondents were classified as sufficiently active and inactive based on energy expenditure estimates (kcal/week) derived from self-reported physical activity. Two logistic regression models, with and without self-efficacy included, were conducted to identify modifiable independent predictors of physical activity. RESULTS: Significantly more males than females were physically active. Physical activity participation was related to age with a greater proportion of those age 65-69 being active than those age 60-64 or 70 or older. High self-efficacy, regular participation of friends and family, finding footpaths safe for walking, and access to local facilities were significantly associated with being active. CONCLUSION: Identifying predictors of physical activity in older populations, particularly social support, facility access, and neighbourhood safety, can inform the development of policy and intervention strategies to promote the health of older people.

Aged↗
PubMed1999

Aerobic fitness and leisure physical activity as moderators of the stress-illness relation.

Exercise as a moderator of the stress-illness relation was examined by exploring leisure physical activity and aerobic fitness as potential "buffers" of the association between minor stress on physical and psychological symptoms in a sample of 135 college students. The goal was to gather information regarding the mechanisms by which exercise exhibits its buffering effects. Researchers have examined both physical activity and physical fitness in an attempt to demonstrate this effect; however, whether both of these components are necessary to achieve the protective effects against stress is unknown. This study examined engaging in leisure physical activity and having high aerobic fitness to determine if both were necessary for the stress-buffering effects or if one factor was more important than the other. Findings suggested a buffering effect for leisure physical activity against physical symptoms and anxiety associated with minor stress. This effect was not found with depression. Additionally, there was no moderating effect for aerobic fitness on physical or psychological symptoms. Collectively, the data suggested that participation in leisure physical activity as opposed to level of aerobic fitness is important to the stress-buffering effect of exercise. Implications for exercise prescription are discussed.

Exercise↗
PubMed2000

Physical activity, self-esteem, and self-efficacy relationships in older adults: a randomized controlled trial.

A randomized controlled trial examined the growth and form of multidimensional self-esteem over a 12-month period (6-month exercise intervention and 6-month follow-up) in 174 older adults engaged in either a walking or stretching/toning program. The extent to which changes in physical fitness parameters and physical self-efficacy were related to changes in perceptions of attractive body, strength, physical conditioning, and physical self-worth was also determined. Latent growth curve analyses showed a curvilinear pattern of growth in esteem with significant increases at all levels of self-esteem upon completion of the intervention followed by significant declines at 6 months postintervention in both groups. Frequency of activity and changes in physical fitness, body fat, and self-efficacy were related to improvements in esteem perceptions relative to attractive body, strength, and physical condition. Model fitting procedures suggested that the best fit of the data was to a model in which the influence of changes in efficacy and physical parameters on physical self-worth were mediated by perceptions of attractive body and physical condition.

Aged↗
PubMed2003

Effect of previous and present physical activity on bone mass in elderly women.

The importance of a physically active lifestyle as a preventive measure for maintaining bone mass is often stressed. The aim of this study was to evaluate the effect of everyday physical activity on bone mass from young adulthood to old age in 75-year-old women. Bone mineral density (BMD) was assessed by dual-energy X-ray absorptiometry technique in total body, hip (femoral neck and trochanter), and spine (LII-LIV) in a population-based cohort of 995 women, all 75 years old. Each woman responded to a questionnaire giving an estimate of the previous and present physical activity level at work and leisure time from youth and up to the present age of 75 years. No correlations were found between the different estimates of physical activity level and BMD. In a multiple regression analysis the different estimates of physical activity level did not have any combined effect on BMD in any of the skeletal regions measured; neither did the physical activity, previous or present, differ when the subgroup of women with a BMD in the highest quintile at all sites was compared with women with a BMD in the lowest quintile. The activity level in the various areas of life did not correlate to each other indicating that few women had chosen a generally active vs non-active lifestyle. A hypothetical positive effect on bone by one activity could therefore be diminished by another. The answer alternatives were mostly not normally distributed, which could also affect the results, making it difficult to identify women with extremely high or low physical activity level. In conclusion, the results from this study of randomly selected elderly women cannot confirm an effect of previous and present everyday physical activity on bone mass. Neither was it possible to find an effect of physical activity in those women with the highest BMD at all sites, suggesting that other factors are of greater importance for maintaining bone mass in elderly women.

Aged↗
PubMed2000

Calcaneus bone mineral density is lower among men and women with lower physical performance.

Fracture risk is influenced by both bone strength and by falls. Measures of physical function and performance are predictors of falls. However, the interrelationships among bone mineral density (BMD), regular physical activity, and measures of physical performance are not well known. We studied 447 community-dwelling Japanese people aged 40 years and over (96 men and 351 women) to examine the association of calcaneus BMD with measures of physical performance (grip strength, walking speed, chair stand, and functional reach) and regular physical activity. Calcaneus BMD decreased with age by approximately 25% in men and 42% in women. Measures of physical performance decreased with age by approximately 30% in both genders, however, performance on the chair stand test declined by approximately 60%. There were only minimal differences in performance measures and calcaneus BMD between people with and those without regular physical activity in both genders, and most differences were not significant. However, there were significant BMD increases of 3-6% per standard deviation (SD) increase in all performance measures for women and a 7% increase in BMD per SD increase in grip strength for men, after adjusting for age. These associations remained after additional adjustment for body mass index and regular physical activity. These findings suggest that bone density and physical function decline markedly in both men and women with age, and that low BMD and poor function tend to occur together, which would increase fracture risk more than either risk factor alone.

Absorptiometry, Photon↗