Bone mineral density testing and osteoporosis education improve lifestyle behaviors in premenopausal women: a prospective study

Educação para a saúde em osteoporose com idosos de um programa universitário: repercussões

O objetivo do estudo foi análise do conhecimento, concepções e mudanças de comportamento alimentar de idosos universitários em relação à temática osteoporose, antes e após a intervenção educativa. Utilizou-se a estratégia da pesquisa-ação, aplicando-se o questionário a 95 idosos, com idade entre 60 e 86 anos, com ou sem osteoporose. O trabalho tornou patente o desconhecimento dos idosos em informações importantes sobre a doença e dos cuidados que se deve ter para melhor controlar a progressão da perda da massa óssea. Após o período de quatro meses de atividades educativas mais da metade do grupo reportou mudanças na dieta. Enfatiza-se a necessidade de adotar estratégias educativas capazes de informar não só sobre as práticas preventivas ideais da osteoporose, mas também que possam construir uma nova mentalidade e um novo comportamento que sejam importantes para o controle da doença.

What do men who are at risk of osteoporosis know about osteoporosis in developing countries? A pilot study in Isparta, Turkey

The aim of this study was to investigate the knowledge, health beliefs and the knowledge sources of osteoporosis in Turkish males who are at risk of secondary causes of osteoporosis. One hundred and sixty men who had one of the systemic diseases or drugs which negatively affects bone metabolism were included in the study. Patients were asked to fill in a self-administered questionnaire which was modified from a validated questionnaire for Turkish female patients with osteoporosis. Twenty-two patients (15.7%) had never heard of a disease named osteoporosis. The mean score for general knowledge was 31.86 +/- 20.56 (over 100 points). Only 20 (16.9%) patients had received information from a doctor. Seventy-three (61.8%) of the patients stated that osteoporosis may be seen in men and only 42 (35.6%) patients were aware that they had a risk factor for osteoporosis. Most of the patients were unable to identify significant risk factors. Statistically significant positive correlation was found between KOS and patients' education levels (r = 0.453, p < 0.01). The findings in our study show that Turkish men who are at risk of osteoporosis do not have sufficient knowledge about osteoporosis and its consequences. We conclude that low education level of our patients accounts for poor osteoporosis knowledge.

Nonpharmacological prevention of osteoporotic fractures

In postmenopausal women, the nonpharmacological prevention of osteoporotic fractures pursues the dual objective of minimizing bone loss and preventing falls. In women with a low fracture risk, optimizing the dietary intake of calcium is the main nutritional goal. Regular sustained physical activity should be encouraged. In older women, the high risk of proximal femoral fractures warrants a number of preventive measures, including calcium and vitamin D supplementation, correction of protein deficiency if needed, and minimization of the risk of falls. Hip protectors may be useful in institutionalized women at high risk for falls. These nonpharmacological measures should be part of a comprehensive customized management program used to complement standard pharmacological therapy.

Lifestyle factors for promoting bone health in older women

BACKGROUND

It is accepted practice to recommend a calcium-rich diet, weight-bearing exercise, cessation of smoking and limited alcohol intake to promote bone health. Although one in three women over 50 years old are at risk of osteoporosis, the lifestyle practices of older women in Scotland are not well documented.

AIM

To investigate the lifestyle practices of a group of older women who had received lifestyle advice a year previously whilst participating in research identifying the individual risk of osteoporosis.

METHODS

A mainly quantitative approach was taken from the perspective of the empirical-analytical paradigm. A descriptive survey research design was used and the primary method of data collection was postal questionnaire. Additional qualitative data obtained from a telephone interview of a small number of respondents were content analysed.

FINDINGS

The questionnaire was sent to 320 women. The response rate was 92.5% (n = 296). The majority of women were non-smokers, had no alcohol problems and were participating in regular weight-bearing exercise. However, most had not been taking a calcium-rich diet in the previous year, and only 21.2% (n = 58) had changed their diet following identification of risk of osteoporosis.

CONCLUSION

The findings in relation to diet, smoking, exercise and alcohol were supported by previous research. We recommend that further research with larger samples in the United Kingdom explores the reasons why older women do not have adequate calcium intake. A statistically significant finding was that women at high risk of osteoporosis were the least likely to have made changes in lifestyles. Further research is required to address the information needs and lifestyle practices of older women who are at high risk of osteoporosis.

Impact of preventive osteoporosis education on patient behavior: immediate and 3-month follow-up

OBJECTIVE

To evaluate the effectiveness of an educational video on osteoporosis at increasing knowledge and preventive health behaviors.

DESIGN

A total of 195 women between 35 and 80 years of age without documented osteopenia or osteoporosis, who presented for a gynecological examination in an outpatient setting, were enrolled. Of this number, 98 women were randomly assigned to the intervention group that viewed the video before their office visit, and 97 women were assigned to a control group and saw their physician in a routine manner. After their visit, all participants answered a questionnaire that assessed their knowledge of osteoporosis and baseline health-related behaviors. Three months later, a follow-up questionnaire was mailed to participants, eliciting whether preventive behavior had commenced. Frequencies were compared using the Fisher exact test (2-tailed). Continuous variables were analyzed using the Student's t test.

RESULTS

The two groups had no statistically significant differences in demographics. The intervention group scored a mean of 92% compared with a mean of 80% in the control group on the initial osteoporosis assessment questionnaire (P < 0.001). The 3-month follow-up questionnaire demonstrated that significantly more women in the intervention group started taking calcium supplements (26.5% v 4.9%; P < 0.001), started taking vitamin D supplements (20.6% v 6.6%; P = 0.02), started a program of weight-bearing exercise (13.3% v 1.7%; P = 0.03), and started hormone therapy (8% v 1%; P = 0.04).

CONCLUSION

The use of an educational video on osteoporosis seems to improve patient knowledge and may positively impact health-related behaviors.

Evaluation of an osteoporosis self-referral program to enhance management outcomes

Osteoporosis is a common but undertreated condition. While bone density is known to predict fracture risk, there is currently no economical way of measuring general population risk. This study examined whether an economical screening technique could improve diagnosis and lead to appropriate outcomes in the management of osteoporosis. A self-referral program was established to provide women with information about osteoporosis and an individualized risk assignment. A high-risk designation was provided for postmenopausal women below the lower tertile of a calcaneal broadband ultrasound attenuation (BUA) (< or = 58 db/MHz) or those with a SCORE value > or = 6. A telephone survey was conducted 6 mo after program registration to evaluate osteoporosis management outcomes. Of 271 women surveyed, 181 (67%) were postmenopausal and thus potential candidates for estrogen replacement, and 21% and 63% were assigned a high-risk profile by either calcaneal ultrasound or SCORE, respectively. Women at higher risk were significantly more likely to discuss osteoporosis with their family physician (p < 0.001), and to undergo further testing with dual X-ray absorptiometry measurement (p < 0.005). Utilization of estrogen replacement by postmenopausal women at time of survey was significantly increased compared to registration (p = 0.01). The self-referral program positively impacted decisions women made about preventing osteoporosis, particularly if they considered themselves at higher risk.

Genetic predisposition for adult lactose intolerance and relation to diet, bone density, and bone fractures

Evidence that genetic disposition for adult lactose intolerance significantly affects calcium intake, bone density, and fractures in postmenopausal women is presented. PCR-based genotyping of lactase gene polymorphisms may complement diagnostic procedures to identify persons at risk for both lactose malabsorption and osteoporosis.

INTRODUCTION

Lactase deficiency is a common autosomal recessive condition resulting in decreased intestinal lactose degradation. A -13910 T/C dimorphism (LCT) near the lactase phlorizin hydrolase gene, reported to be strongly associated with adult lactase nonpersistence, may have an impact on calcium supply, bone density, and osteoporotic fractures in the elderly.

MATERIALS AND METHODS

We determined LCT genotypes TT, TC, and CC in 258 postmenopausal women using a polymerase chain reaction-based assay. Genotypes were related to milk intolerance, nutritional calcium intake, intestinal calcium absorption, bone mineral density (BMD), and nonvertebral fractures.

RESULTS

Twenty-four percent of all women were found to have CC genotypes and genetic lactase deficiency. Age-adjusted BMD at the hip in CC genotypes and at the spine in CC and TC genotypes was reduced by -7% to -11% depending on the site measured (p = 0.04). LCT(T/C-13910) polymorphisms alone accounted for 2-4% of BMD in a multiple regression model. Bone fracture incidence was significantly associated with CC genotypes (p = 0.001). Milk calcium intake was significantly lower (-55%, p = 0.004) and aversion to milk consumption was significantly higher (+166%, p = 0.01) in women with the CC genotype, but there were no differences in overall dietary calcium intake or in intestinal calcium absorption test values.

CONCLUSION

The LCT(T/C-13910) polymorphism is associated with subjective milk intolerance, reduced milk calcium intake, and reduced BMD at the hip and the lumbar spine and may predispose to bone fractures. Genetic testing for lactase deficiency may complement indirect methods in the detection of individuals at risk for both lactose malabsorption and osteoporosis.

Knowledge and Correlates of Osteoporosis: A Comparison of Israeli-Jewish and Israeli-Arab Women

The present study examined levels and correlates of knowledge about osteoporosis among 176 Israeli-Jewish (mean age = 55) and 80 Israeli-Arab (mean age = 51) women. Levels of knowledge about the disease were low among all women, especially regarding some of the risk factors. Knowledge and awareness about the disease were especially deficient among Arab women. Younger age and lower education were the main vulnerability factors among Jewish women, and lower desire to seek information from the medical establishment, higher religiosity, and the lack of extended medical insurance among Arab women. Educational programs, geared to the needs and capabilities of the different ethnic populations, should be encouraged.

Factors related to the use of bone densitometry: survey responses of 494 primary care physicians in New England

Large population-based surveys have shown that approximately 30% of people over age 65 years have osteoporosis and that 17% of the population over 65 years will sustain a fracture during their lifetime. Many people with osteoporosis are never being evaluated even though effective treatments are available. We examined why primary care physicians order few bone mineral density scans. We conducted a cross-sectional survey of primary care physicians practicing in any of the six New England states. Target physician specialties included internal medicine, general practitioners/family physicians, and obstetrician-gynecologists who had a facsimile number listed with the American Medical Association. Demographics, practice characteristics, use of bone densitometry, and attitudes regarding osteoporosis, bone densitometry and health maintenance were assessed by questionnaire. Twelve percent (n=494) of the physicians responded to the questionnaire. Respondents were similar to non-respondents with respect to years of practice, training and geographical state, though they were more likely to be female (p < or =0.05). Respondents had a mean age of 51 years, and 51% were trained in internal medicine, 25% in general practice/family practice and 24% in obstetrics-gynecology. The mean number of self-reported bone densitometry referrals per month was 10+/-11, and 25% of respondents reported that they referred fewer than 4 patients per month. In adjusted logistic models, factors significantly associated with referring fewer than 4 patients per month were: training in internal medicine (odds ratio (OR) 2.0, 95% confidence interval (CI) 1.0-3.9) or general practice/family practice (OR 2.6, 95% CI 1.3-5.2) versus obstetrics-gynecology; practicing in an urban setting (OR 2.5, 95% CI 1.3-4.9) or rural/small town setting (OR 2.2, 95% CI 1.2-4.1) versus a suburban setting; spending less than 50% of professional time in patient care (OR 4.0, 95% CI 1.7-9.5); seeing the lowest proportion of postmenopausal women (OR 2.5., 95% CI 1.2-5.3); the belief that calcium and vitamin D are adequate to treat osteoporosis (OR 2.1, 95% CI 1.0-4.5); and the belief that osteoporosis treatment should not be based on bone density results (OR 3.2, 95% CI 1.7-6.1). Potentially modifiable physician beliefs and a number of practice characteristics are associated with low referral rates for bone densitometry. Educational strategies aimed at improving the use of bone density testing should consider these factors.

Asian and Asian-American college students' awareness of osteoporosis

STUDY OBJECTIVE

To quantify Asian and Asian-American college students' knowledge of osteoporosis and preventive health behaviors.

DESIGN

Sixty-four-question survey

SETTING

University of Minnesota.

SUBJECTS

One hundred sixty-eight male and female Asian and Asian-American students, mean age 21 +/- 3.4 years.

MAIN RESULTS

About half of the students consumed 0-1 servings/day of dietary calcium, 42% consumed 2 cups/day or more of caffeinated beverages, 8% smoked cigarettes, and 61% exercised 2.5 hours/week or less. At least 1 serving/day of phytoestrogen was consumed by 80% of the students. Only 11% of students answered at least 75% of osteoporosis fact questions correctly. Women (p = 0.011) and the United States-born participants (p = 0.006) were more apt to change their health behaviors to prevent or treat osteoporosis than men and Asia-born participants. Thirty-eight percent of Hmong participants attributed osteoporosis to fate, chance, or luck whereas Vietnamese participants were more likely to attribute osteoporosis to diet. Most participants (63%) did not know whether their culture objected to estrogen replacement therapy, and 42% said menopause was a natural occurrence for which pharmacologic treatment should not be administered.

CONCLUSIONS

Many Asian and Asian-American college students did not practice health behaviors to prevent osteoporosis, and most lacked sufficient knowledge about the condition.

Causal analysis of exercise and calcium intake behaviors for osteoporosis prevention among young women in Thailand

The goal of health education is to provide information to affect attitudes, beliefs, and intentions for behavior change. However, little is known about the effects of changes in knowledge on behaviors for osteoporosis prevention. Our objective is to develop and test theoretical models of the effects of knowledge, attitude, and self-efficacy on exercise and calcium intake among young women before and after an intervention program. First, we hypothesized that knowledge would positively predict attitude, self-efficacy, calcium intake, and exercise. Second, attitude would positively predict self-efficacy, calcium intake, and exercise. Third, self-efficacy would positively predict calcium intake and exercise. Fourth, attitude and self-efficacy would mediate the effect of knowledge on calcium intake and exercise. At the beginning and end of the study, participants in the control group and intervention group completed the osteoporosis knowledge test, the osteoporosis health belief scale, the osteoporosis self-efficacy scale, a self-report for food records, and exercise. The causal model was examined as a result of our study. After the intervention program, calcium intake and exercise were predicted by knowledge when mediated by attitudes and self-efficacy. The final model accounted for 30% and 45% of the variance in calcium intake and exercise, respectively. We conclude that interventions to enhance young women's knowledge and self-efficacy may result in increased calcium intake and exercise.

Bone density and heel ultrasound testing do not identify patients with dialysis-dependent renal failure who have had fractures

Patients with dialysis-dependent renal failure are at increased risk for low-trauma fractures. However, the optimal means of identifying patients at high risk for fracture is not known. We assessed the association between fracture history and two tests of bone mineral density (dual x-ray absorptiometry [DEXA] and calcaneal ultrasound) among patients with hemodialysis-dependent renal failure. We evaluated 71 men and 33 women aged 55 years or older who had been receiving hemodialysis for at least 1 year. All patients underwent spinal radiography, DEXA of the hip and lumbar spine, and calcaneal ultrasonography. We assessed risk factors for low-trauma fractures by questionnaire and medical chart review. Of patients, 52% had a fracture on spinal radiographs or a history of a low-trauma fracture, 69% had osteopenia by DEXA, and 26% had a low heel ultrasound measurement. Neither DEXA nor calcaneal ultrasound was associated with fracture history, however. Our findings indicate that fractures among patients with dialysis-dependent renal failure are common. Tests of bone strength do not adequately identify patients with a history of fractures. Prospective studies to determine the optimal method of identifying patients with dialysis-dependent renal failure at high risk for fracture are needed.

Knowledge of osteoporosis in a Swedish municipality--a prospective study

BACKGROUND

As a part of the Vadstena Osteoporosis Prevention Project, the knowledge of osteoporosis was examined before the intervention program started, after 5 and 10 years.

METHODS

At baseline (in 1989) 15% of the population in two Swedish municipalities was randomly invited to the study. The participants in the study group were invited for examination by forearm bone densitometry and a questionnaire concerning lifestyle and risk factors for osteoporosis and also knowledge of osteoporosis, while the subjects in the control group were examined only by questionnaire. Follow-ups were made in 1994 and in 1999. Meanwhile education about osteoporosis was given to the study group, to the public, and to various professionals in the study community.

RESULTS

There was a difference in the level of knowledge between the groups prior to the intervention. The rate of increment did not differ significantly between the groups for the study period. Previous participants had 0.58 higher score than new participants in the study group in 1994 (P = 0.031) and 0.76 higher score in 1999 (P < 0.001) regarding the total number of correct answers. The women in the study group had 0.63 higher score than the men in 1994 (P = 0.016) and 1.03 higher score in 1999 (P < 0.001) regarding the total number of correct answers.

CONCLUSION

There was no significant effect of a general intervention program concerning the knowledge of osteoporosis in participants in the intervention area compared to the control area.

Effects of an osteoporosis prevention program incorporating tailored educational materials

PURPOSE

To evaluate the effects of two interventions on calcium intake and exercise and assess whether intervention effects varied as a function of participants' stage of change.

DESIGN

The study used a 2 by 2 factorial research design. Baseline, 3-, 6-, and 12-month follow-up data were collected.

SETTING

Twelve counties in western North Carolina.

SUBJECTS

Of 714 women recruited, 547 (76.6%) completed all data collection procedures.

INTERVENTION

One intervention, conducted at the individual level, compared the effects of tailored vs. nontailored educational materials. The tailored educational intervention was delivered via two packets of written materials and one telephone counseling session. The written materials and counseling session were tailored according to participants' current calcium intake and exercise level, perceived adequacy of these behaviors, stage of change, behavioral goals, and perceived barriers to change. A community-based intervention was also evaluated. This intervention, implemented in 6 of the 12 counties, included establishing an Osteoporosis Resource Center, conducting a workshop on osteoporosis prevention, and offering free bone density screening.

MEASURES

Outcome measures were calcium intake and exercise level. Stage of change was assessed as a moderating variable.

RESULTS

Irrespective of intervention group, among women not consuming adequate calcium at baseline, intake increased an average of about 500 mg/d over the course of the study. Changes involving exercise were more modest. Repeated measures regression analyses were used to evaluate intervention effects. The effect of the tailored educational intervention varied, in appropriate ways, among women in different stages of change at baseline (F2,527 = 6.37, p < .002). Among women in the Engaged stage, the tailored intervention was associated with a greater increase in calcium intake. In contrast, among women who were obtaining adequate calcium at baseline (i.e., Action stage), the tailored intervention appeared to forestall inappropriate increases in calcium intake. The community-based intervention had no consistent effects on calcium intake, either alone, or in combination with the tailored intervention. Finally, neither intervention had an effect on exercise, either alone or in combination.

CONCLUSIONS

Limited support for the superiority of tailored vs. nontailored educational interventions was found. The differential effects observed could be due to the telephone counseling received by women in the Tailored Education Group, however.

Enhancing recall of information from a patient education booklet: a trial using cardiomyopathy patients

A quasi-experimental trial was conducted to compare the effect on information recall of: (a) the use of adjunct questions (AQ) in printed materials; and (b) a procedure (the 5Rs) for integrating printed patient education materials into face-to-face teaching. A total of 51 patients with severe left ventricular failure (cardiomyopathy) was assigned to one of three groups (n=17). Each group worked with a purpose-prepared booklet, the first in association with the 5Rs procedure; the second group with a version of the booklet containing adjunct questions; and the third with a text only version of the booklet. Recall of information from the booklet was measured using a checklist scored on the basis of responses secured in a standardised interview. Improved recall was associated with both the adjunct questions and the 5Rs procedure, with the latter achieving a substantially superior outcome. The practical implications of these findings are presented and directions for further research indicated.

Testing the effectiveness of an osteoporosis educational program for nursing students in Thailand

OBJECTIVE

Osteoporosis, a health problem that is on the rise, has received considerable attention among the health care community and the public. The majority of primary prevention programs for osteoporosis have been focused on women in mid-life. A concern is that young women may not be aware of osteoporosis risk factors and therefore may not be engaging in preventive behaviors. The purpose of this study was to test the effectiveness of an osteoporosis educational program for young women.

METHODS

A sample of 100 female undergraduate students who were enrolled in the first year of a nursing program in Thailand were randomly assigned to a control group or an experimental group. Participants in the experimental group participated in a 3-hour osteoporosis educational program (OEP). At entry to and exit from the study, all participants completed the Osteoporosis Knowledge Test, the Osteoporosis Health Belief Scale, and the Osteoporosis Self-Efficacy Scale.

RESULTS

The experimental group had higher change scores for knowledge, health belief, and self-efficacy than the control group. The OEP increased knowledge of osteoporosis in these young women.

CONCLUSION

These findings indicate the need for further health education concerning the importance of dietary calcium and exercise on osteoporosis prevention in young women.

The Importance of Meeting Calcium Needs with Foods

Calcium can be obtained from foods naturally rich in calcium such as dairy foods, from calcium-fortified foods and beverages, from supplements or from a combination of these. Recognition of calcium's many health benefits, along with Americans' low calcium intake, has led to interest in how best to meet calcium needs. Foods are the preferred source of calcium. Milk and other dairy foods are the major source of calcium in the U.S. In addition, these foods provide substantial amounts of other essential nutrients. Consequently, intake of dairy foods improves the overall nutritional quality of the diet. Other foods such as some green leafy vegetables, legumes and cereals provide calcium, but generally in lower amounts per serving than do dairy foods. Also, some components such as phytates in cereals and oxalates in spinach reduce the bioavailability of calcium. Calcium-fortified foods and calcium supplements are an option for individuals who cannot meet their calcium needs from foods naturally containing this mineral. However, their intake cannot correct poor dietary patterns of food selection which underlie Americans' low calcium intake. Considering the adverse health and economic effects of low calcium intakes, strategies are needed to optimize calcium intake. A first step is to recognize factors influencing dietary calcium consumption. Substituting soft drinks for milk and eating away from home are among the barriers to adequate calcium intake. The American public needs to understand why consuming foods containing calcium is the best way to meet calcium needs and learn how to accomplish this objective.

The role of physiotherapy in the prevention and treatment of osteoporosis

Osteoporosis is an increasing public health problem that causes loss of life and reduced quality of life in sufferers. Strategies to improve bone density and reduce the likelihood of falls are important in the prevention of osteoporosis. Physiotherapists have a role to play in this condition through exercise prescription, therapeutic modalities, specific techniques and education. Appropriate treatment goals can be established following a thorough assessment of signs and symptoms, risk factors for osteoporosis and functional status. Levels of bone density measured from dual energy X-ray absorptiometry can help guide patient management. Since the aim is to maximize peak bone mass in children and adolescents, participation in a variety of high-impact activities should be encouraged. In the middle adult years, small increases in bone mass may be achieved by structured weight-training and weight-bearing exercise. In the older adult years, particularly if osteopenia or osteoporosis is present, the aim is to conserve bone mass, reduce the risk of falls, promote extended posture, reduce pain, and improve mobility and function.

Bone density issues in the adolescent gynecology patient

Because adolescence is a critical period for acquisition of peak bone mass, adolescent gynecology clinicians can play an important role in promoting and reinforcing skeletal health. Efforts should be focused on maximizing nutrition, exercise, and a normal sex steroid status during these formative years. Close attention should also be given to factors that jeopardize the attainment of peak bone mass: amenorrhea, malnutrition (e.g., anorexia nervosa), use of medications with deleterious effects on bone, and underlying medical conditions that may predispose a young woman to early bone loss. This review places special emphasis on a patient commonly seen in the adolescent and gynecology practice, the female athlete.