AMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY 131:343–351 (2006)
Osteoporosis in a Population From Medieval Norway
S. Mays,1* G. Turner-Walker,2 and U. Syversen3
1
Ancient Monuments Laboratory, English Heritage Centre for Archaeology, Eastney, Portsmouth PO4 9LD, UK
2
School of Cultural Heritage Conservation, National Yunlin University of Science and Technology, Touliou,
640 Yunlin, Taiwan (Republic of China)
3
Department of Intra-abdominal Diseases, Faculty of Medicine, Norwegian University of Science and Technology,
N7489 Trondheim, Norway
KEY WORDS femur; paleopathology; bone mineral density; fractures; dual X-ray absorptiometry
ABSTRACT Modern populations from Norway and
England differ in their experience of osteoporosis, the
former showing lower bone mineral density (BMD) and a
higher fragility fracture rate. The aim of the present
work was to investigate whether this was also the case
during the Middle Ages. Age-dependent loss of BMD in
the proximal femur was assessed using dual X-ray
absorptiometry (DXA) in male and female adult skele-
tons from a cemetery in the medieval town of Trond-
heim, Norway. Fracture prevalence was also investi-
gated. Results were compared with those previously
reported for a skeletal series from Wharram Percy, a
deserted medieval village in England. Results indicate
that peak BMD and patterns of age-related loss of BMD
Osteoporosis in a condition in which there is a reduc-
tion in bone mass and microstructural deterioration of
bone tissue. This results in increased skeletal fragility
and increased risk of fracture (Christodoulou and Cooper,
2003). Osteoporosis is associated with advancing age in
both sexes, but skeletal fragility is greater in elderly
women than in elderly men. In women, a principal cause
of bone loss is the hormonal changes which accompany
menopause. Although the causes of osteoporosis in men
are less well-understood, it appears that, as in women,
an age-related decline in sex hormones plays a major
role (Anderson et al., 1998). In both sexes, various ex-
traneous factors, such as cigarette smoking, calcium de-
ficiency, and sedentary lifestyle, have been held to exac-
erbate the disease (Ross, 1996; Nguyen and Eisman,
1999).
In most modern populations, osteoporosis (or more
exactly, its attendant fractures) is a major cause of mor-
bidity and mortality (Randell et al., 1995), but there is
marked interpopulation variation in the severity of the
condition. Populations of European origin are among
those most at risk for osteoporosis (Villa, 1994). How-
ever, there is also considerable variation between differ-
ent European groups. Populations from Scandinavia
appear to be more at risk than those from other regions
(Meyer and Johnell, 1997). Norwegian populations in
particular show high frequencies of osteoporotic fracture
(Falch et al., 1985; O’Neill et al., 1996; Lofthus et al.,
2001; Kanis et al., 2002) and low levels of bone mass
(Lunt et al., 1997; Falch and Meyer, 1998; Gjesdal et al.,
2004). For example, osteoporotic fractures are between
approximately one-and-a-half and twice as frequent
among Norwegians than in the UK (O’Neill et al., 1996;
Lofthus et al., 2001; Kanis et al., 2002), and bone min-
C 2006
V WILEY-LISS, INC.
in the Norwegian and the English group were similar.
Among females, the prevalence of osteoporotic fractures
was greater in the Norwegian than in the English popu-
lation. The BMD results suggest that differences in
BMD between English and Norwegians are of recent ori-
gin, although given the fairly modest sample sizes, fur-
ther work is needed to confirm this. Reasons for the
greater prevalence of osteoporotic fractures in women in
the Norwegian skeletal series are unclear, but the colder
climate and greater frequency of hard surfaces may have
meant that falls were more frequent, and when they
occurred, were more likely to result in fractures than in
the rural English group. Am J Phys Anthropol 131:343–
351, 2006. V 2006 Wiley-Liss, Inc.
C
eral density is about 91% of that in the UK (Lunt et al.,
1997). The reasons for these patterns are incompletely
understood, but both genetic and environmental factors
are likely to play a part (Meyer and Johnell, 1997; Nel-
son and Villa, 2003).
The importance of osteoporosis today has stimulated
interest in its occurrence in earlier populations, and
studies have been conducted on excavated skeletal re-
mains from around the world (Agarwal and Grynpas,
1996; Mays, 1999). No paleopathological work on the dis-
ease in earlier Norwegian populations has yet been car-
ried out, despite the observation that the severity of
osteoporosis in modern Norwegians makes this of com-
pelling interest. The current study is a first investigation
of osteoporosis in ancient skeletal remains from Norway.
It is of interest, from the point of view of understand-
ing present-day differences in osteoporosis in European
populations, to investigate whether such differences
have arisen recently, or whether they have their roots in
more ancient times. In the current context, this means
comparing the Norwegian results to another, coeval skel-
etal series, from a region where today the severity of
*Correspondence to: S. Mays, Ancient Monuments Laboratory,
English Heritage Centre for Archaeology, Fort Cumberland, East-
ney, Portsmouth PO4 9LD, UK.
E-mail: simon.mays@english-heritage.org.uk
Received 25 September 2005; accepted 14 February 2006.
DOI 10.1002/ajpa.20445
Published online 21 April 2006 in Wiley InterScience
(www.interscience.wiley.com).
344 S. MAYS ET AL.
osteoporosis is lower than in Norway. A number of pub-
lished studies investigated osteoporosis in earlier Euro-
pean populations (reviewed in Mays, 1999). However,
differences between studies in methodologies, both for
measuring bone mineral status and for estimating age at
death (Mays, 1999; Brickley and Agarwal, 2003), gener-
ally make direct comparisons problematic. The current
study aims to circumvent this problem by adopting me-
thods which resemble, as closely as practicable, those
used in earlier work on another European paleopopula-
tion, from medieval England.
The overall aims of the current work are to character-
ize age-related bone loss and fracture patterns in a medi-
eval population from Norway, and to compare the find-
ings with a population from medieval England. The aim
of the comparison is to address the question of whether,
as is the case today, the medieval Norwegian people
show a lower bone mass and higher frequency of osteo-
porotic fracture than do their coeval English counter-
parts. This may shed light upon whether current differ-
ences have arisen recently, perhaps due to modern life-
style factors, or whether they also existed for ancient
groups whose lifeways were very different from those of
today, which might imply some inherent difference be-
tween British and Norwegian populations. Reference will
be made to biocultural context, to help interpret any pat-
terns which may emerge.
MATERIALS
The skeletal material for the present study comes from
a series of excavations carried out in central Trondheim
during the 1970s and 1980s, principally on the church-
yard of St. Olav’s church (Anderson and Göthberg,
1986). The collection comprises 928 skeletons dating to
the period 1100–1600 AD. Trondheim is situated on the
Norwegian coast. The mean annual temperature is ap-
proximately 58C, and there are an average of 122 days per
year with a minimum temperature below 08C (Norwegian
Meteorological Institute, 2005). During the medieval pe-
riod, the population of Trondheim was in the low thou-
sands. It was an important town in medieval Norway,
and had many characteristics of an urban settlement: it
had major ecclesiastical and secular administrative func-
tions within the Kingdom of Norway, and was a center
for trade and for the manufacture of goods (Danielsen
et al., 1995).
The comparative group, from the medieval village of
Wharram Percy, England, dates primarily from the
10th–16th centuries AD. Wharram Percy is situated in
northeast England, about 20 miles northeast of York. It
is located, at about 150 m above sea level, in the York-
shire Wolds, an area of chalk upland. The climate is
milder than in Trondheim, with an annual mean temper-
ature of approximately 88C, and an average of 59 days
per year with a minimum temperature below 08C (UK
Meteorological Office, 2005). In the medieval period, the
great majority of inhabitants of the village, and of the
sparsely populated rural parish in which it lay, were or-
dinary peasants engaged primarily in agricultural pro-
duction. Osteoporosis is particularly well-characterized
in that group; various aspects were investigated, includ-
ing bone mineral density (Mays et al., 1998; McEwan
et al., 2004), cortical thickness (Mays, 1996; Mays et al.,
1998), bone microarchitectural features (Agarwal et al.,
2004; Rossi, 2004), fracture patterns (Mays, 1996, in
press), and hip geometry (Chumley et al., 2004). Because
American Journal of Physical Anthropology—DOI 10.1002/ajpa
analyses of fracture patterns and bone mineral density
at Wharram Percy were carried out by teams headed by
one of us (S.M.), the same methods and protocols can
readily be applied to the current material.
METHODS
In the paleopathological study of age-progressive con-
ditions such as osteoporosis, the choice of skeletal aging
technique is critical. In the current work, the Trondheim
adults were aged using dental wear. For populations
showing significant wear on the dentition, assessment of
degree of wear on the molar teeth has been shown to be
a reliable technique for adult age estimation (Tomenchuk
and Mayhall, 1979; Richards and Brown, 1981; Kieser
et al., 1983; Zhang and Ji, 1988; Song and Jia, 1989;
Richards and Miller, 1991; Song et al., 1991; Li and Ji,
1995; Kim et al., 2000; Mays, 2002), and has been shown
to outperform other skeletal age indicators (Johnson,
1976; Lovejoy, 1985; Constandse-Westermann, 1997).
Rate of molar wear varies between different populations,
chiefly as a result of differences in diet and food-prepara-
tion techniques. However, examination of the permanent
molars of juvenile individuals whose ages can be accu-
rately estimated using dental development enables esti-
mation of the rate of wear in the specific population
under study, using the methodology of Miles (1963).
Briefly, this method involves using the age at eruption of
the various molars to relate the degree of wear to the
functional age of the tooth in the juvenile cohort. By a
process of extrapolation from this baseline, the age at
death is estimated for the entire adult cohort, starting
with the youngest and working through to those individ-
uals showing the heaviest wear (discussion in Hillson,
1996, p. 239–242; Mays, 1998, p. 60–62). Juveniles in
the Trondheim assemblage were used to calibrate the
wear rate in that population, using the methodology of
Miles (1963). Dental-wear aging using the technique of
Miles (1963) has been specifically tested on known-age
individuals, and its reliability confirmed (Kieser et al.,
1983). The Wharram Percy adults were aged using
dental wear (Mays, 1996), calibrated using juveniles from
that population according to the technique of Miles
(1963). Many workers using molar wear to age adult skel-
etal remains from archaeological sites use 10-year age
categories. However, for the present purposes, a conserva-
tive strategy was adopted, whereby individuals were sim-
ply classified as young adults (ca. 18–29 years), middle
adults (ca. 30–49 years), or older adults (ca. 50þ years).
This matches the strategy used for Wharram Percy
(Mays, 1996).
Sex was determined in the Trondheim material using
dimorphic aspects of the pelvis and skull (Brothwell,
1981). The same techniques were used at Wharram Percy
(Mays, 1996).
The technique used to evaluate bone mineral status
was dual X-ray absorptiometry (DXA) of the proximal fe-
mur. The criteria for acceptance of a bone for study were
as follows: femurs should be complete and undamaged,
and show no external signs of soil erosion in the area to
be scanned; there should be no sign of soil infiltration
into the bone interior on X-ray; all femoral epiphyses
should be fused; and skeletal survival should permit age
at death to be estimated in the categories described
above, and permit unambiguous sex determination. Us-
ing these criteria, femurs from 128 adults (63 males and
65 females) were suitable for inclusion in the study.
 OSTEOPOROSIS IN MEDIEVAL NORWEGIAN POPULATION
TABLE 1. Summary statistics for BMDN and BMDW
at Trondheim1
BMDN BMDW
Age-group N Mean SD Mean SD
Females
18–29 10 0.953 0.105 0.883 0.118
30–49 44 0.783 0.097 0.636 0.115
50þ 11 0.702 0.097 0.532 0.114
Males
18–29 25 0.981 0.148 0.923 0.166
30–49 29 0.886 0.117 0.713 0.143
50þ 9 0.828 0.101 0.603 0.146
1
BMDN, bone mineral density at femur neck; BMDW, bone
mineral density at Ward’s triangle; N, number of individuals.
Age in years. BMDN and BMDW in g cm
2.
One femur from each individual was scanned using a
Hologic QDR-4500A bone densitometer (Hologic, Inc.,
Bedford, MA). Each femur was placed in a plastic box
containing dry rice as a soft-tissue substitute. The bone
was placed anterior-surface uppermost, so that the femo-
ral neck lay flat, and the diaphysis was oriented parallel
to the axis of the scanner. Measurements were made of
bone mineral density (BMD) at the femur neck (BMDN)
and Ward’s triangle (BMDW). This protocol matches that
used for the Wharram Percy femurs (Mays et al., 1998),
but those were scanned using a Lunar DPX densitome-
ter (Lunar Corp., Madison, WI). Technical differences in
hardware and software mean that absolute values ob-
tained on equipment from different manufacturers can-
not be directly compared (Genant et al., 1994; Hui et al.,
1997; Boonen et al., 2003). For this reason, it is usual,
when conducting multicenter studies, to undertake
cross-calibration of equipment. To this end, nine femurs
were scanned in both machines. Scatterplots suggested a
linear relationship between results from the two ma-
chines. Relationships were expressed as linear regres-
sion equations, which were used to convert the Lunar
values into their Hologic equivalents. Hui et al. (1997)
described a similar standardization procedure for bone
mineral density measurements using patients.
A skeletal inventory was compiled for 91 (44 males
and 47 females) of 128 individuals whose femurs were
scanned, and the presence of fractured elements was
noted using careful gross inspection. Factors beyond our
control precluded recording these aspects on the remain-
ing 37 skeletons. For the females, those not examined
for fractures resembled those that were, in terms of both
age at death and BMD, so this was unlikely to bias the
results. However, by chance, few of the males examined
for fractures were aged over 50 at death; this inhibited
the investigation of fractures in elderly men.
RESULTS
Bone mineral density
The results for BMDN and BMDW are shown in Table 1.
Many aspects of the results are broadly consistent with
patterns that might be expected on physiological grounds
on the basis of comparison with modern European refer-
ence data (Looker et al., 1995, 1998). Analysis of variance
(Table 2) indicates that both sexes show a significant age-
related decline in both BMDN and BMDW. In the study
group as a whole, BMD is greater in males than in
females (BMDN: t ¼ 5.21, P < 0.001; BMDW: t ¼ 4.01,
American Journal of Physical Anthropology—DOI 10.1002/ajpa
345
TABLE 2. Results of analysis of variance for BMDN and
BMDW vs. age at Trondheim1
Analysis of variance
Significance Multiple
F-value of F comparison tests
Females
BMDN 18.3 <0.001 All
BMDW 26.4 <0.001 All
Males
BMDN 6.1 0.004 18–29 vs. 30–49
18–29 vs. 50þ
BMDW 19.7 <0.001 18–29 vs. 30–49
18–29 vs. 50þ
1
Multiple comparison tests, indication of between which age
groups significant differences (P < 0.05) in bone mineral density
lie by least significant difference statistic.
P < 0.001). In both sexes, age-related loss of BMD, mea-
sured by comparison of levels in those aged 50þ years
with those aged 18–29 years, is greater at Ward’s triangle
than at the femur neck (females: t ¼ 2.7, P < 0.02; males:
t ¼ 2.86, P < 0.02). Loss of BMD at the femur neck is
greater in females than in males (t ¼ 2.34, P ¼ 0.032).
The same pattern would be expected at Ward’s triangle,
but in the current data, the difference fails to reach sta-
tistical significance (t ¼ 0.77, P ¼ 0.45).
There are, however, some differences between patterns
seen in the Trondheim group and those in the modern
reference data. In the modern reference data (Looker
et al., 1995), adult males show sequentially lower BMD
in successive age groups. In the current male data, sig-
nificant differences could only be demonstrated between
the 18–29-year group and the other two age groups.
That no significant difference was found between the
50þ and 30–49-year age groups may reflect the small
sample size (N ¼ 9) for the male 50þ group and the ob-
servation that, because less age-related loss of BMD is
expected in males than in females, larger sample sizes
would be needed in males in order for patterns to reach
statistical significance. Interestingly, a significant differ-
ence was found in female BMD between the 18–29 and
30–49 age groups. However, in the modern reference
data (Looker et al., 1995), femur BMD differences be-
tween females in these two categories were minor. This
phenomenon, which implies pre- or perimenopausal bone
loss in the medieval women, was noted previously for
Wharram Percy females (Mays et al., 1998). Turner-
Walker et al. (2000, 2001) suggested that this may reflect
the effects of high parity and relatively late weaning of
offspring, which may have been customary in medieval
times (Shahar, 1990; Benedictow, 1992; Richards et al.,
2002). In modern populations, minor reductions in BMD
may occur during pregnancy and lactation, but are
quickly recovered (Kohlmeier and Marcus, 1995; Kalk-
warf and Specker, 1995; Laskey and Prentice, 1999).
Turner-Walker et al. (2001) suggested that, in medieval
times, recovery of bone mass following pregnancy and
lactation may have been slowed by poor maternal nutri-
tion. This may explain the apparent greater loss of bone
during the reproductive years in the medieval women,
although other as yet unidentified factors may also be
involved.
Comparison of the Trondheim BMD results with those
from Wharram Percy is shown in Table 3. Intergroup
comparisons using t-tests reveal no evidence for differ-
346 S. MAYS ET AL.
TABLE 3. Mean values for BMDN and BMDW for three age classes at Trondheim and Wharram Percy1
BMDN BMDW
Trondheim Wharram Percy Trondheim Wharram Percy
Females
18–29 0.953 (100%) 0.951 (100%) 0.883 (100%) 0.877 (100%)
30–49 0.783 (82.2%) 0.808 (85.0%) 0.636 (72.0%) 0.642 (73.2%)
50þ 0.702 (73.7%) 0.724 (76.1%) 0.532 (60.2%) 0.535 (61.0%)
Males
18–29 0.981 (100%) 0.988 (100%) 0.923 (100%) 0.910 (100%)
30–49 0.886 (90.3%) 0.934 (94.5%) 0.713 (77.2%) 0.811 (89.1%)
50þ 0.828 (84.4%) 0.826 (83.6%) 0.603 (65.3%) 0.625 (68.7%)
1
Figures in parentheses are values expressed as percentage of those in young adult (18–29-year) age groups. Wharram Percy data
(N ¼ 54 females, 75 males) are values from Mays et al. (1998) transformed to Hologic values, using following equations: Hologic
BMDN ¼ 0.789126 3 Lunar BMDN þ 0.081403; Hologic BMDW ¼ 0.934769 3 Lunar BMDW
0.140822. For methods used to gen-
erate these conversion algorithms, see text. Age in years. BMDN and BMDW in g cm
2.

ences between the two populations in peak bone density
(taken to be that in the 18–29-year age groups). They
also provide no great evidence for differences in patterns
of age-related decline in BMD. The only suggestion of a
difference is the slightly earlier loss of BMD at Ward’s
triangle in the Trondheim males: BMDW in the 30–49-
year group is lower in the Trondheim than in the Whar-
ram Percy males (t ¼ 2.5, v ¼ 57, P < 0.05).
When interpreting BMD results from buried bone, the
possibility that diagenetic change (particularly, physical
contamination of bone by soil infiltration and microstruc-
tural alteration of bone) might influence results should
be considered. In the current context, one might reason-
ably suggest that, since the broad age- and sex-related
patterning in BMD both at Wharram Percy (Mays et al.,
1998) and at Trondheim resembles in general terms that
in modern reference data, this implies that postdeposi-
tional changes in BMD values are slight. It seems highly
improbable that some complex pattern of differential dia-
genesis between different sex and age groups could have
fortuitously reproduced these patterns. Nevertheless, it
was thought prudent to consider further the possibility
of diagenetic change, as any differential alterations
between the two sets of material could potentially preju-
dice the comparisons which are a major focus of this
paper. Physical contamination of bone with soil, and
microstructural diagenesis, are each considered, both for
Wharram Percy (Mays et al., 1998) and for Trondheim.
At both Wharram Percy and Trondheim, all femurs
were radiographed, and specimens showing evidence of
soil infiltration were excluded from analysis. Nonethe-
less, one might still suggest that minor contamination
with soil particles, too subtle to be visible on plain film
radiographs, may be present and may potentially affect
BMD values. Investigation of bone microstructure was
carried out using scanning electron microscopy on bone
from both sites (Mays et al., 2001; Turner-Walker and
Syversen, 2002; Turner-Walker et al., 2002). At Whar-
ram Percy, there was little evidence of physical contami-
nation in microstructural features such as Haversian
canals. The soils at this burial site are calcareous (Abra-
hams, 1977). If significant physical contamination from
the soil was a problem at Wharram Percy, then we
would expect to find elevated bulk calcium levels in the
bones. This is not the case: calcium levels, measured
using inductively coupled plasma atomic emission spec-
trometry (ICP-AES), resemble those in modern bone
(Mays, 2003). Consistent with this, X-ray diffraction
(Mays, in press) and analysis of carbonate:phosphate
ratios (Nielsen-Marsh and Hedges, 2000) provide no evi-
dence of intrusive calcite. Turning to the Trondheim ma-
terial, as with Wharram Percy, few mineral inclusions
are visible in the microstructure under scanning electron
microscopy. Unlike Wharram Percy, no bulk chemical
analyses or X-ray diffraction spectra are available for
the skeletal remains. This makes it difficult to exclude
the possibility of minor soil infiltration. However, the fol-
lowing observations suggest that, even if present, this is
unlikely to affect BMD significantly. The Wharram Percy
specimens showing gross soil infiltration were measured
for BMD, even though they were subsequently excluded
from analysis. BMD values were found to be little differ-
ent from radiographically uncontaminated specimens
(Mays et al., 1998). This indicates that even a degree of
physical contamination sufficient to be visible in plain
film radiographs had no great effect on BMD. Slight,
radiographically invisible soil infiltration is therefore
unlikely to greatly affect BMD values.
Microscopic study (Mays et al., 2001; Turner-Walker
and Syversen, 2002; Turner-Walker et al., 2002) indicated
that the Wharram Percy bones show advanced microstruc-
tural diagenesis (of the type described by Hackett, 1981;
Hedges et al., 1995), whereas those from Trondheim are
minimally altered. The question is therefore whether the
diagenetic alterations in the Wharram Percy material
have affected BMD. Several observations are pertinent
here. Both the absolute BMD values and age-related
trends are similar to those at Trondheim (Table 3), despite
the fact that the latter are well-preserved microstructur-
ally; were diagenetic effects a great influence on BMD, we
would have expected differences in BMD between two col-
lections with such different microstructural preservation.
Examination of histological sections of the Wharram
Percy bones (Turner-Walker and Syversen, 2002) showed
that microstructural diagenesis resulted in discrete areas
of hyper- and hypomineralization, visible as areas of dif-
ferent tonal values under scanning electron microscopy.
Elemental analysis by energy-dispersive X-ray spectrome-
try on areas of the bone section exhibiting different tonal
values suggests that, although diagenesis has caused dis-
solution and reprecipitation of bone mineral, movement of
bone mineral in this process appears to have been a highly
localized phenomenon, and bulk calcium content is little
changed (Turner-Walker and Syversen, 2002). That bulk
calcium levels in the Wharram Percy bones resemble mod-
ern values was confirmed by ICP-AES (Mays, 2003). This
implies that bulk bone density should be little affected by
the microstructural diagenesis seen in that material.
The above considerations suggest that the BMD values
in both sets of archaeological material considered in this

American Journal of Physical Anthropology—DOI 10.1002/ajpa

 OSTEOPOROSIS IN MEDIEVAL NORWEGIAN POPULATION 347
TABLE 4. Frequency of fracture types at Trondheim
by age and sex1
Age group
18–29 30–49 50þ
Females
‘‘Osteoporotic fracture’’ 0 2 3
Other fracture 0 5 0
No fracture 8 24 5
Males
‘‘Osteoporotic fracture’’ 0 1 1
Other fracture 3 3 0
No fracture 21 13 2
1
Age in years. ‘‘Osteoporotic fracture’’, Colles’ fracture or verte-
bral compression fracture. Other fracture, individuals lacking
‘‘osteoporotic’’ fractures but showing fractures in other skeletal
elements.

TABLE 5. BMD values at Trondheim for those showing

osteoporotic fractures and those without osteoporotic fractures,
but showing other types of fractures
BMDN BMDW
N Mean SD Mean SD
Females
With osteoporotic 5 0.620 0.146 0.458 0.130
fracture
With other 5 0.804 0.085 0.628 0.083
fracture
t-test t ¼ 2.43, P ¼ 0.04 t ¼ 2.47, P ¼ 0.04
Males
With osteoporotic 2 0.789 0.028 0.537 0.113
fracture
With other 6 0.968 0.147 0.833 0.090
fracture
t-test t ¼ 1.63, P ¼ 0.15 t ¼ 3.84, P ¼ 0.01
Fig. 1. First through fourth lumbar vertebrae, Sk115
(female, aged 50þ years). There is a healed compression frac-
ture of L1. Femur BMDN and BMDW are 0.671 g cm
2 and
0.559 g cm
2, respectively. Each is approximately 2.7 standard the age of individuals when fractures occurred, save that
deviations below young adult female mean. they were not confined to the oldest age groups in either
males or females. In order to determine whether osteo-
work are likely representative of in vivo values, rather porotic-type fractures are collectively associated with low
than being artifacts of diagenesis. We therefore infer bone mass, and hence are distinct from other fractures,
that the Trondheim population resembled the Wharram it needs to be demonstrated that individuals with osteo-
Percy people, in terms of both age-dependent loss of porotic-type fractures show lower BMD than those with
BMD and peak BMD values. other fracture types. Results of this comparison (Table 5)
show that, for females, individuals with osteoporotic-type
fractures do indeed show lower BMD than those with
Fracture patterns other fracture types. This supports the idea that the for-
mer are distinct from other fracture types and are as-
The classic fractures of osteoporosis occur at the hip sociated with osteoporosis, as they are in modern popula-
(neck of the femur), wrist (Colles’ fracture of the distal tions. For males, too few show osteoporotic-type frac-
radial metaphysis), and spine (compression fracture of tures to permit firm conclusions in these respects.
thoracic or lumbar vertebral bodies) (Resnick and A comparison of the frequency of osteoporotic fractures
Niwayama, 1988). In the Trondheim population, 18 of 91 in females over age 50 years at Trondheim and at Whar-
individuals examined showed a combined total of 30 ram Percy is given in Table 6. Sample sizes for males
fractured bones (out of a total of 10,245 bones exam- over age 50 years were too small to permit a worthwhile
ined). Of these, seven individuals showed eight fractures comparison for males. All three cases of osteoporotic
in skeletal locations consistent with osteoporotic frac- fracture in the Wharram Percy women were vertebral
ture. Three females and two males showed a combined compression fractures; there were no hip or wrist frac-
total of six vertebral compression fractures (Fig. 1), and tures. Table 6 indicates a higher prevalence of osteopor-
two females each showed a Colles’ fracture. There were otic fractures among Trondheim females over age 50,
no hip fractures. The distribution of these ‘‘osteoporotic and Fischer’s exact test indicates that the difference is
fractures’’ and fractures of other types with respect to statistically significant (P ¼ 0.04). This is not an artifact
age and sex is shown in Table 4. of differential representation of skeletal elements. Rates
All osteoporotic-type fractures were firmly healed. of recovery of distal parts of the radii, and of thoracic/
Other than that they did not occur immediately prior to lumbar vertebral bodies, are similar in females aged over
death, there is little further that can be said concerning 50 at the two sites (the frequencies of these elements,

American Journal of Physical Anthropology—DOI 10.1002/ajpa

348 S. MAYS ET AL.
TABLE 6. Prevalence of osteoporotic fractures among females
over age 50 years at death at Trondheim and Wharram Percy1
Trondheim Wharram Percy
With osteoporotic fracture 3 3
Without osteoporotic fracture 5 41
Total 8 44
1
Wharram Percy data from Mays (in press).
expressed as percentages of those expected if all skele-
tons were complete, are 63% and 87%, respectively, for
Trondheim; for Wharram Percy, the figures are 75% and
79%, respectively). Nor does the greater prevalence of
osteoporotic fractures in the Trondheim women appear
to reflect a generally higher frequency of trauma in the
Trondheim females, as prevalences of nonosteoporotic
fractures (i.e., fractures of elements other than the verte-
bral bodies and distal radial metaphyses) are similar at
the two sites (frequency for Trondheim females ¼ 5/47
individuals ¼ 10.6%; for Wharram Percy females, 18/140
¼ 12.9%).
DISCUSSION
A problem in comparing age-related bone loss in osteo-
porosis between skeletal populations is that even if simi-
lar aging techniques are used, their imprecision means
that we cannot precisely age-match samples. The prob-
lem is most acute in the 50þ-year age category: if the
mean age of the 50þ cohort was greater at one site than
at the other, this would seriously prejudice comparisons.
Because the question of the age composition of the 50þ-
year cohort is not one which can be resolved osteologi-
cally, previous approaches with other paleopopulations
(Mays, 1996, 2006) involved modeling the likely age
structure of the 50þ group using documentary evidence.
However, there appear to be no documentary demo-
graphic data which would allow this for medieval Trond-
heim. Although there is no a priori reason to suppose
that the age distribution of the over-50 cohort is very dif-
ferent at Trondheim and Wharram Percy, there is no
direct evidence to confirm this.
One could suggest that the similarity in BMD between
the medieval Wharram Percy and Norwegian popula-
tions examined in this work might, given the substantial
evidence for a genetic influence on BMD (Prentice, 2001;
Rapuri et al., 2004), simply reflect a Norse contribution
to the Wharram Percy gene pool, making the two groups
rather similar genetically. Viking raids on England
started in the late 8th century, and by the 9th century
Norse settlement began, most particularly in northeast
England (Richards, 1991). Craniometric analyses (Mays,
in press) indicate that although crania from medieval
York resemble those from medieval Norway, the crania
from Wharram Percy do not. This suggests that the
Norse contribution to the Wharram Percy population
was probably minor, at least compared with that to me-
dieval York (where there is other archaeological and his-
torical evidence for a strong Norse presence; Hall, 1994).
In this light, it seems unlikely that a Norse contribution
to the Wharram Percy population could explain why
BMD at Wharram Percy is similar to that in medieval
Trondheim.
The observation that no difference in BMD was
detected between the two medieval study samples in the
current work might suggest that the difference in BMD
observed today between Norwegian and UK populations
American Journal of Physical Anthropology—DOI 10.1002/ajpa
is of recent origin. However, given the rather modest
sample size and the limitations of skeletal aging tech-
niques, this interpretation must be made with caution.
Despite the evidence for age-related bone loss in the
femur neck area, there were no hip fractures in the
Trondheim material. In this respect, the study popula-
tion appears to resemble other paleopopulations: frac-
tures of the femur neck generally seem to have been
rare in the past (Agarwal and Grynpas, 1996; Brickley,
2000). Precise reasons for the dearth of hip fractures at
Trondheim are unclear, but some possibilities can be
suggested. In modern populations, the frequency of hip
fracture only begins to rise in women after about age
75–80 years, and is associated with so-called type II or
senile osteoporosis. By contrast, the frequency of wrist
and vertebral compression fractures begins to rise imme-
diately after menopause; they are a feature of postmeno-
pausal or type I osteoporosis. Wrist and vertebral com-
pression fractures outnumber hip fractures in modern
populations until about age 75 years (Buhr and Cooke,
1959; Black and Cooper, 2000). It has been suggested
that, in paleopopulations, too few people generally sur-
vived into advanced old age for hip-fracture prevalence
to be appreciable (Brickley, 2000), and medieval docu-
mentary evidence (discussed in Mays, 1996) supports this
suggestion. Hip geometry influences resistance of the fe-
mur neck to fracture, i.e., a longer femoral neck is associ-
ated with increased risk of fracture (Faulkner et al.,
1993; Cummings et al., 1994). Recent work (Chumley
et al., 2004) suggests that femur necks are shorter at
Wharram Percy than in a modern reference sample, so
perhaps this is a factor in the dearth of hip fractures in
that population. This aspect has yet to be investigated in
the Trondheim group. Other as yet unidentified factors
may also be involved in the lack of hip fractures at Trond-
heim.
Although hip fractures were absent, Colles’ fracture
and compression fractures of the vertebral bodies were
identified in the study material. For females, an associa-
tion was demonstrated between low BMD and fractures
at the wrist and spine, but too few men showed these
fracture types to permit firm conclusions for males. Loss
of BMD in osteoporosis is clinically silent. It only has
health implications when it leads to fractures. Hip
fractures are the principal contributor to the morbidity
and excess mortality associated with osteoporosis (Chri-
schilles et al., 1994). However, wrist and vertebral frac-
tures may also give rise to chronic pain, and are to some
extent associated with long-term residual disability
(Ettinger et al., 1992; O’Neill et al., 2001). The presence
of these fractures, and their association with low BMD,
show that osteoporosis would have had a significant
health impact for women in medieval Trondheim.
Despite the lack of any indication of differences in hip
BMD between Trondheim and Wharram Percy, there
was evidence for a difference in fracture patterns, with
Colles’ fractures and vertebral compression fractures
being collectively more frequent in older females from
Trondheim. It might be suggested that in the Trondheim
population, hip BMD has been not a good indicator of
spine or wrist BMD, and hence the present results do
not exclude the possibility of differences in BMD at the
skeletal sites showing fractures. Although further study
of the Trondheim material would be required to settle
this conclusively, clinical studies suggest that it is
unlikely. Hip BMD has been shown to be correlated with
spine and wrist BMD (Deng et al., 1998; Augat et al.,
 OSTEOPOROSIS IN MEDIEVAL NORWEGIAN POPULATION
1998), and low hip BMD is a predictor of fracture risk at
the wrist and spine (Dey et al., 2000; Kanterewicz et al.,
2002).
Although BMD is probably the most important indica-
tor for risk of osteoporotic fracture (Miller and McClung,
1996; Ammann and Rizzoli, 2003; Moyad, 2003), other
factors also play a part. The role of gross bone geometry
has already been referred to, but various microstructural
features of living bone, sometimes collectively known as
‘‘bone quality,’’ may deteriorate in osteoporosis and influ-
ence bone fragility (Grynpas, 2003). These features com-
prise bone microarchitecture, mineralization, and me-
chanical properties, and these in turn may be influenced
by bone turnover, which is a factor in the efficiency with
which fatigue-damaged bone is renewed (Schnitzler and
Mesquita, 1998). Bone quality has yet to be investigated
in the Trondheim remains. A further factor affecting
fracture prevalence is exposure of older individuals to
risk of skeletal trauma, particularly through falls.
Colles’ fracture occurs a result of a fall onto an out-
stretched hand (Vogt et al., 2001). In those with very se-
vere osteoporotic bone loss, most often those in advanced
old age, vertebral compression fractures may occur with
negligible trauma, such as lifting a trivial object or sneez-
ing. However, in most cases, significant trauma is re-
quired to induce a fracture. Causes are generally a fall or
stumble, or heavy lifting (Old and Calvert, 2004). There
is no reason to suspect a greater frequency of heavy lift-
ing among Trondheim women than among those from
Wharram Percy; indeed, given the generally higher activ-
ity levels that were inferred for the Wharram Percy
women compared with coeval urban females (Mays, in
press), one might, if anything, expect that the reverse
should be the case. It may be that frequency and type of
falls differed between the two groups. In the rural envi-
ronment of Wharram Percy, Mays (1996) suggested that
falls, when they occurred, were generally onto grass,
earth, or mud, and that these yielding surfaces tended to
absorb energy on impact, helping to minimize fracture
risk. In a more urban environment, such as at medieval
Trondheim, cobbled or stone surfaces were likely more
frequent, and falls onto such surfaces might more often
be expected to result in fractures for those (most often, el-
derly females) whose skeletal integrity was compromised
by loss of BMD. Climatic differences between Trondheim
and Wharram Percy mean that in Trondheim, slippery
conditions caused by ice or snow would be more frequent,
making falls more likely, and compact ice would form a
surface of similar hardness to stone or cobbles for many
weeks of the year.
CONCLUSIONS
The results of the current study suggest that both
sexes at medieval Trondheim showed age-related loss of
BMD. For females, this appears to have rendered the
skeleton sufficiently fragile to predispose to fractures at
the wrist and spine.
The Trondheim population appeared to resemble the
Wharram Percy people, both in terms of age-dependent
loss of BMD and peak BMD values. This may suggest
that the difference in BMD observed today between Nor-
wegian and UK populations is of recent origin, but in
view of the fairly small sample sizes, this inference must
remain tentative. This highlights a general problem with
paleopathological population-based studies: due to the
nature of archaeological material, sample sizes will
American Journal of Physical Anthropology—DOI 10.1002/ajpa
349
almost invariably be smaller than those typical in epide-
miological studies on living subjects, with a consequent
lack of statistical power in the paleopathological work.
Although differences between archaeological groups which
are confirmed by adequate inferential statistical tests
can be considered robust, the status of negative findings
will tend to be somewhat equivocal. The extent to which
this is a problem for comparative work on paleopopula-
tions will clearly depend on the subtlety of the pattern-
ing we are trying to detect. Interpopulation BMD differ-
ences today can be quite marked: variation in femur-
neck BMD between different European populations is
such that the mean value in the population with the low-
est BMD is only about 86% of that in the group with the
highest (Lunt et al., 1997). Although the UK is not at
the extreme end of the spectrum, the mean femur-neck
BMD for females over age 50 from Oslo is only 91% of
that for women over age 50 from northern England
(Lunt et al., 1997). Differences of this degree are poten-
tially detectable not only with the very large sample
sizes of modern epidemiological studies, but also with
the more modest samples customarily available to paleo-
pathologists. This indicates the value of paleopathologi-
cal work in determining whether some of the interpopu-
lation differences which exist in BMD today also existed
in past European populations.
The greater frequency of osteoporotic fractures at medi-
eval Trondheim than at Wharram Percy echoes the higher
frequency found in Norwegian populations today. The
degree to which this represents some inherent difference
between populations and/or living environments is
unclear. It is suggested here that the pattern may, to some
extent, reflect the fact that the Norwegian medieval group
came from an urban environment where there was a
greater likelihood of fracture when falls occurred because
of the greater frequency of hard surfaces, and from a re-
gion with a colder climate so that falls due to slippery con-
ditions underfoot were probably more frequent. Although
the lower BMD seen in modern Scandinavian populations
compared with other European groups must be implicated
in the higher rates of osteoporotic fractures in Scandina-
via, it was suggested that cold climate might also be a
contributory factor (e.g., Rogmark et al., 1999). Although
this is controversial (Lofthus et al., 2001), there is evi-
dence that osteoporotic fractures of a type which generally
occur in an outdoor setting do show winter peaks in occur-
rence in Norway today (Hove et al., 1995).
Despite the above, reasons for the elevated prevalence
of fractures in modern Norwegian populations remain
incompletely understood. Given the constraints on paleo-
pathological work imposed by the nature of skeletal sam-
ples, understanding differences in earlier populations is
likely to prove even more challenging. However, in the
current case, further work on trabecular bone quality,
cortical bone status, and femur-neck morphology in the
Trondheim material, to match the studies done on the
Wharram Percy population (Mays, 1996; Agarwal et al.,
2004; Chumley et al., 2004; Rossi, 2004), would help shed
further light on any differences in osteoporosis between
the two groups.
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