Investigating the association between urban rural classification with fragility fractures and bone density in the UK: evidence from a large observational clinical cohort

Abstract Objectives Geographic variation in fracture risk exists across the UK, yet rural/urban differences in fracture risk and bone density have yet to be explored. We aimed to investigate associations between rural urban classification (RUC) and bone health outcomes in a UK clinical population. Methods We analysed patients who underwent DXA scanning between June 2004 and May 2025 in northwest England. Geographic status was assessed using the 2011 UK Census RUC. Multiple imputation with parameter pooling was performed with logistic and linear regression models adjusted for Fracture Risk Assessment Tool (FRAX) risk factors to investigate the associations between urban and rural residence and major osteoporotic fractures, hip fractures, bone mineral density and body composition. Results Of 40 951 eligible patients, 32 324 (79%) were women with a mean age of 68.2 years; 11 811 major osteoporotic fractures were reported including 2208 hip fractures. No significant association existed between rural/urban status and odds of having a previous fragility fracture [major osteoporotic fractures: odds ratio (OR) 0.97 (95% CI 0.92, 1.02); hip fractures: OR 0.98 (95% CI 0.90, 1.07)]. Rural residence was associated with lower osteoporosis odds [femoral neck OR 0.86 (95% CI 0.80, 0.92); lumbar spine OR 0.85 (95% CI 0.80, 0.91)]. Rural patients had significantly lower regional body fat [femoral fat percentage: β = −0.45 (95% CI −0.55, −0.34), P < 0.001; abdominal fat percentage: β = −0.43 (95% CI −0.58, −0.29), P < 0.001]. Conclusions Rural residence was associated with improved bone density and body composition but was not associated with fragility fractures in our referred UK clinical cohort.