Use of toenail fluoride levels as an indicator for the risk of hip and forearm fractures in women

The relation between fluoride intake and risk of osteoporotic fractures remains unclear. The lack of individual measures of long-term fluoride intake has limited epidemiologic studies. We used toenail fluoride in this study as a measure of long-term intake to evaluate the relation between fluoride intake and subsequent risk of hip and distal forearm fractures. Between 1982 and 1984, we collected toenail clippings from 62,641 women in the Nurses' Health Study who were free from cancer, heart disease, stroke, and previous hip or forearm fracture. We identified fracture cases (53 proximal femur and 188 distal forearm) through subsequent biennial mailed questionnaires and matched controls to cases on year of birth. The odds ratio of hip fracture among women in the highest quartile of toenail fluoride [>5.50 parts per million (ppm)], compared with those in the lowest quartile (<2.00 ppm), was 0.8 (95% confidence interval = 0.2-4.0), with adjustment for menopausal status, postmenopausal hormone use, caffeine intake, and alcohol consumption. The corresponding adjusted odds ratio for forearm fracture was 1.6 (95% confidence interval = 0.8-3.1). Further adjustment for body mass index, smoking status, and calcium and vitamin D intake did not alter these results.