Archives of Osteoporosis

, 13:132 | Cite as

Revised reference curves of bone mineral density according to age and sex for Iranian children and adolescents

  • Marjan Jeddi
  • Zahra Bagheri
  • Mohammad Hossein DabbaghmaneshEmail author
  • Gholamhossein Ranjbar Omrani
  • Marzie Bakhshayeshkaram
Original Article



Bone health evaluation in children requires an appropriate reference database. We have shown higher curves for spine aBMD in Iranian subjects than Americans, but lower curves for femoral neck and total body. These results can be used as reference values to assist Iranian clinicians in interpreting and monitoring bone densitometry results.


Bone health evaluation requires an appropriate reference database that can identify the bone deficit according to age, sex, puberty, and race. The aim of this study was to determine bone mineral density Z-scores in Iranian children and adolescents and their comparability with other reference data.


A sample of 476 healthy children and adolescents, aged 9–18 years, from Kawar (an urban community, 50 km east of Shiraz, Iran) was selected and bone mineral measurements of the lumbar spine, femoral neck, and total body (less head) were done. Sex-specific height-for-age, weight-for-age, and BMI-for-age Z-scores, as well as bone mineral density Z-scores, were calculated.


Extended reference curves for bone mineral content (BMC) and areal bone mineral density (aBMD) of the total body less head, lumbar spine, and femoral neck, for ages 9–18 years were constructed relative to sex and age. We found that median, − 2SD, and + 2SD curves for the lumbar spine aBMD were higher in Iranian subjects than in the American participants, but the curves of the femoral neck and total body were lower. Also, we showed that subjects with a lower height-for-age Z-score had a lower BMC and aBMD Z-score in the lumbar spine, femoral neck, and total body (p < 0.001).


Relevant differences in bone mineral density and its curves exist between Iranian children and adolescents and other databases, revealing a significant potential for misdiagnosis. However, our results can be used to provide reference databases to assist clinicians in interpreting, assessing, and monitoring bone densitometry.


Bone mass Z-score aBMD 



The authors thank Shiraz University of Medical Sciences, Shiraz, Iran, and the Center for Development of Clinical Research of Nemazee Hospital and thank Dr. Nasrin Shokrpour for editorial assistance.

Compliance with ethical standards

Conflict of interest



  1. 1.
    Bachrach LK, Gordon CM (2016) Bone densitometry in children and adolescents. Pediatrics 138(4):e20162398CrossRefGoogle Scholar
  2. 2.
    Crabtree NJ, Arabi A, Bachrach LK, Fewtrell M, El-Hajj Fuleihan G, Kecskemethy HH et al (2014) Dual-energy X-ray absorptiometry interpretation and reporting in children and adolescents: the revised 2013 ISCD Pediatric Official Positions. J Clin Densitom 17(2):225–242CrossRefGoogle Scholar
  3. 3.
    Jeddi M, Roosta MJ, Dabbaghmanesh MH, Omrani GR, Ayatollahi SM, Bagheri Z et al (2013) Normative data and percentile curves of bone mineral density in healthy Iranian children aged 9-18 years. Arch Osteoporos 8:114CrossRefGoogle Scholar
  4. 4.
    Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R et al (2000) CDC growth charts: United States. Adv Data 8(314):1–27Google Scholar
  5. 5.
    Bishop N, Arundel P, Clark E, Dimitri P, Farr J, Jones G, Makitie O, Munns CF, Shaw N, International Society of Clinical Densitometry (2014) Fracture prediction and the definition of osteoporosis in children and adolescents: the ISCD 2013 Pediatric Official Positions. J Clin Densitom 17(2):275–280CrossRefGoogle Scholar
  6. 6.
    Kelly T, Specker B, Binkley T, Zemel B, Leonard M, Kalkwarf H et al (2005) Pediatric BMD reference database for US white children. Children’s Bone health Abstract, Sorrento, Italy. Bone 36(suppl 1):S5–S110Google Scholar
  7. 7.
    Ward KA, Ashby RL, Roberts SA, Adams JE, Zulf Mughal M (2007) UK reference data for the Hologic QDR Discovery dual-energy x ray absorptiometry scanner in healthy children and young adults aged 6-17 years. Arch Dis Child 92(1):53–59CrossRefGoogle Scholar
  8. 8.
    Kocks J, Ward K, Mughal Z, Moncayo R, Adams J, Hogler W (2010) Z-score comparability of bone mineral density reference databases for children. J Clin Endocrinol Metab 95(10):4652–4659CrossRefGoogle Scholar
  9. 9.
    Ma J, Siminoski K, Alos N, Halton J, Ho J, Lentle B, Matzinger M, Shenouda N, Atkinson S, Barr R, Cabral DA, Couch R, Cummings EA, Fernandez CV, Grant RM, Rodd C, Sbrocchi AM, Scharke M, Rauch F, Ward LM, Canadian STOPP Consortium (2015) The choice of normative pediatric reference database changes spine bone mineral density Z-scores but not the relationship between bone mineral density and prevalent vertebral fractures. J Clin Endocrinol Metab 100(3):1018–1027CrossRefGoogle Scholar
  10. 10.
    Bachrach LK (2007) Osteoporosis in children: still a diagnostic challenge. J Clin Endocrinol Metab 92(6):2030–2032CrossRefGoogle Scholar
  11. 11.
    Cole TJ (1998) Fitting smoothed centile curves to reference data. J R Stat Soc Series A (Statistics in Society) 151(3):385–418Google Scholar
  12. 12.
    Cole TJ, Green PJ (1992) Smoothing reference centile curves: the LMS method and penalized likelihood. Stat Med 11(10):1305–1319CrossRefGoogle Scholar
  13. 13.
    Zemel BS, Kalkwarf HJ, Gilsanz V, Lappe JM, Oberfield S, Shepherd JA, Frederick MM, Huang X, Lu M, Mahboubi S, Hangartner T, Winer KK (2011) Revised reference curves for bone mineral content and areal bone mineral density according to age and sex for black and non-black children: results of the bone mineral density in childhood study. J Clin Endocrinol Metab 96(10):3160–3169CrossRefGoogle Scholar
  14. 14.
    Leonard MB, Shults J, Elliott DM, Stallings VA, Zemel BS (2004) Interpretation of whole body dual energy X-ray absorptiometry measures in children: comparison with peripheral quantitative computed tomography. Bone 34(6):1044–1052CrossRefGoogle Scholar
  15. 15.
    Saki F, Omrani GR, Jeddi M, Bakhshaieshkaram M, Dabbaghmanesh MH (2017) Investigating the prevalence of low bone mass in children of southern Iran and its associated factors. Int J Endocrinol Metab 15(4):e14099PubMedPubMedCentralGoogle Scholar
  16. 16.
    Kalkwarf HJ, Zemel BS, Gilsanz V, Lappe JM, Horlick M, Oberfield S, Mahboubi S, Fan B, Frederick MM, Winer K, Shepherd JA (2007) The bone mineral density in childhood study: bone mineral content and density according to age, sex, and race. J Clin Endocrinol Metab 92(6):2087–2099CrossRefGoogle Scholar
  17. 17.
    Bachrach LK, Hastie T, Wang MC, Narasimhan B, Marcus R (1999) Bone mineral acquisition in healthy Asian, Hispanic, black, and Caucasian youth: a longitudinal study. J Clin Endocrinol Metab 84(12):4702–4712PubMedGoogle Scholar
  18. 18.
    Faulkner RA, Bailey DA, Drinkwater DT, McKay HA, Arnold C, Wilkinson AA (1996) Bone densitometry in Canadian children 8-17 years of age. Calcif Tissue Int 59(5):344–351CrossRefGoogle Scholar
  19. 19.
    Ellis KJ, Shypailo RJ, Hardin DS, Perez MD, Motil KJ, Wong WW et al (2001) Z score prediction model for assessment of bone mineral content in pediatric diseases. J Bone Miner Res 16(9):1658–1664CrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2018

Authors and Affiliations

  • Marjan Jeddi
    • 1
  • Zahra Bagheri
    • 2
  • Mohammad Hossein Dabbaghmanesh
    • 1
    • 3
    Email author
  • Gholamhossein Ranjbar Omrani
    • 1
  • Marzie Bakhshayeshkaram
    • 4
  1. 1.Endocrine and Metabolism Research CenterShiraz University of Medical SciencesShirazIran
  2. 2.Department of BiostatisticsShiraz University of Medical SciencesShirazIran
  3. 3.Endocrine and Metabolism Research Center, Nemazee HospitalShiraz University of Medical SciencesShirazIran
  4. 4.Health Policy Research CenterShiraz University of Medical SciencesShirazIran

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