Context: One of the important challenges in the management of osteoporosis is to identify women who are at high risk of developing osteoporosis and fragility fractures.

Objective: To evaluate if assessment of bone metabolism at multiple occasions can identify women with the highest risk for bone loss.

Design: The Malmö OPRA study is an ongoing longitudinal study. Participants have been evaluated at baseline and after 1, 3 and 5 years.

Setting: Population-based study.

Participants: 1044 women, all 75 years old at baseline.

Main outcome measures: Seven bone turnover markers were assessed at baseline, 1, 3 and 5 years (n=573). Five year change in areal bone mineral density (aBMD) was also determined.

Results: Baseline markers correlated weakly to change in total body aBMD. The associations were more pronounced when the average of the baseline and 1-year measurements was used (standardized regression coefficients -0.12 to -0.23, p<0.01). Adding the 3-year and 5-year measurement further strengthened the correlation (regression coefficients up to -0.30 (p<0.001)). Women with constantly high turnover lost significantly more bone at total body (-2.6%) than women with intermediate (-1.6%) or low turnover (-0.2%, p for trend <0.001). They also had a greater decrease in hip BMD (-8.3%, -6.0% and -5.1%, respectively, p=0.010). Results were similar also in the subgroup of women with osteopenia.

Conclusions: Our results suggest that serial assessment of bone turnover improves the identification of women with the highest rate of bone loss and osteoporosis risk.