Logics and logistics of community intervention against osteoporosis: an evidence basis

Long-term effects of a ten-year osteoporosis intervention program in a Swedish population—A cross-sectional study

The aim of the study was to explore long-term effects seven years after the completion of a ten-year community-based osteoporosis intervention program in Vadstena, Sweden. The association between calcaneal bone mineral density and several life style factors, and the impact of risk factors for sustaining a fracture after the age of 50 were also studied. Previous participants in the intervention group, and matched subjects were invited to calcaneal bone mass measurement by a portable device including the dual X-ray and laser (DXL) technology by Calscan, and to complete a questionnaire in 2006. A total of 417 persons (63% of those invited) in the intervention (I) group, and 120 persons (47% of those invited) in the control (C) group participated. Mean age was 63 years (37–94 years). There was somewhat more knowledge of osteoporosis in the I-group (M = 18) than in the C-group (M = 17) (p < 0.05), and more use of shoe/cane spikes in elderly women in the I-group (67%) than in the C-group (40.5%). The fully adjusted model of logistic regression showed that participants with an osteoporotic DXL T-score (≤− 2.5) had a 3-fold increased risk (95%CI 1.48–6.89) of having a history of a self-reported fracture after the age of fifty compared to women with a calcaneal T-score >− 2.5. The long-term effects of a ten-year, community-based, osteoporosis intervention program on knowledge and behavior were modest seven years after its completion.

•

The effect of community-based osteoporosis intervention seems modest in the long run.

•

Elderly women were compliant with fall prevention advice using spikes in winter.

•

An osteoporotic calcaneal T-score may imply increased risk for fracture.

•

Moderate/high physical activity was positively associated with calcaneal BMD in men.

•

Brisk walks in the summer were positively associated with calcaneal BMD in women.

Is calcaneal stiffness more sensitive to physical activity than forearm bone mineral density? A population-based study of persons aged 20 - 79 years

Aims: The aim of this study was to investigate the associations between forearm bone mineral density (BMD), calcaneal stiffness, and physical activity levels in a normal population using different non-invasive methods. Methods: The participants were invited to undergo bone measurements using single photon absorptiometry of the forearm and quantitative ultrasound (QUS) of the calcaneal bone, and also to complete a questionnaire. Physical activity levels were designated low, moderate, and high in the question on leisure-time activity. Results: There were 956 participants included in the present study. Forearm BMD in the eighth age decade was 0.40 g/cm2 (95% CI 0.33 - 0.46 g/cm2) lower than in the third decade among women and 0.28 g/cm2 (95% CI 0.18 - 0.37 g/cm2) lower among men. The differences in calcaneal stiffness between the same age decades were 22.4 (95% CI 17.5 - 27.4) among women and 15.8 (95% CI 8.0 - 23.5) among men. The correlation between forearm BMD and calcaneal stiffness was 0.58 (95% CI 0.52 - 0.64) in women and 0.34 (95% CI 0.25 - 0.42) in men. Reported moderate and high leisure-time activity levels in both genders were associated with higher calcaneal stiffness but not with forearm BMD. Conclusions: The QUS may be used to measure the effect of present physical activity levels on calcaneal bone at the population level. Further longitudinal studies are warranted in order to determine the most appropriate non-invasive method in population-based studies.

Prevalence and correlates of insufficient calcium intake in a Swedish population

OBJECTIVE

To examine associations between calcium intake in the diet, lifestyle factors, and forearm bone mineral density (BMD) in order to identify population subgroups for targeting by screening programs.

METHODS

A questionnaire was sent to a random sample of 15% of the inhabitants aged 20-79 years from 2 Swedish municipalities, and the subsample from one of the municipalities was invited to measurement of BMD. The survey response rate was 74% (n = 1,112/1,510) and participation in BMD measurements was 68% (n = 448/659).

RESULTS

Only a tendency ( p = .085) toward direct association between calcium intake and forearm BMD was found, and the best multiple regression model was retained to explain BMD excluded calcium intake. Low calcium intake was, instead, in complementary analyses, found to be correlated with the factors old age, female sex, and urban residence in the best multiple regression model.

CONCLUSIONS

Population subgroups whose calcium intake is in a range that justifies preventive action could be identified. Screening programs staffed by public health nurses can thereby be informed regarding the subgroups of the population that are at the highest risk of insufficient calcium intake.

Evaluation of an osteoporosis and fall risk intervention program for community-dwelling elderly. A quasi-experimental study of behavioral modifications

BACKGROUND AND AIMS

Osteoporosis and fall fractures are increasing problems amongst the elderly. The aim of this study was to explore whether combined population-based and individual interventions directed at risk factors for osteoporosis and falls result in behavioral changes in an elderly population.

METHODS

A quasi-experimental design was used for the study. Persons aged >or=65 years were randomly selected in the intervention and control community. An intervention program was managed from the primary health care center and delivered to the community. Health education was designed to increase awareness of risk factors for the development of osteoporosis and falling. Questionnaires about lifestyle, health, previous fractures, safety behavior and physical activity level were distributed at baseline in 1989 and at the follow-ups in 1992 and 1994 in both communities.

RESULTS

There was a difference of 17.7% between the dual intervention (receiving both population-based and individual interventions) and the control samples regarding the self-reported use of shoe/cane spikes, and a difference of 20.5% regarding the reported "moderate level" of physical activity in 1994. There was an increase in the number of participants in the dual intervention sample who, at baseline, had not reported equipping their homes with non-slip mats and removing loose rugs but who did report these changes in 1994. The increase in the reported use of shoe/cane spikes in the dual intervention sample was observed mainly for the period 1992-1994.

CONCLUSIONS

A public health intervention model, including both population-based and individual interventions, can contribute to behavioral changes in the prevention of falls and changed physical activity patterns amongst elderly people.

Impact of a community-based osteoporosis and fall prevention program on fracture incidence

Associations between a 10-year community-based osteoporosis and fall prevention program and fracture incidence amongst middle-aged and elderly residents in an intervention community are studied, and comparisons are made with a control community. A health-education program was provided to all residents in the intervention community, which addressed dietary intake, physical activity, smoking habits and environmental risk factors for osteoporosis and falls. Both communities are small, semi-rural and situated in Ostergotland County in southern Sweden. The analysis is based on incidences of forearm fractures in the population 40 years of age or older, and hip fractures in the population 50 years of age or older. Data for three 5-year periods (pre-, early and late intervention) are accumulated and compared. In the intervention community, forearm fracture incidence decreased in women. There are also tendencies towards decreasing forearm fracture incidence in men, and towards decreasing trochanteric hip fracture incidences in women and in men in the late intervention period. No such changes in fracture incidences are found in the control community. Cervical hip fracture incidence did not change in the intervention and the control communities. Although the reported numbers of fractures are small (a total of 451 forearm and 357 hip fractures), the numbers are based on total community populations and thus represent a true difference. The decrease in forearm fracture incidence among women, and the tendency towards decreasing trochanteric hip fractures, in contrast to the absence of change in cervical hip fractures, might be mainly due to a more rapid effect of fall preventive measures than an increase in bone strength in the population. For the younger age groups an expected time lag between intervention and effect might invalidate the short follow-up period for outcome measurements. Thus, the effect of the 10-year intervention program on fracture incidence should be followed during an extended post-intervention period.

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.

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.

Introducing the theme in a qualitative interview using a visual starter

Community involvement implies conscientious citizen engagement, not as passive recipients but active contributors. Insufficient understanding of concepts of health outcome in a socioeconomic deprived context with unemployment'as a major feature was identified as a hindrance to intervention. This communication gives a report of a "visual starter" used as a cognitive instrument for qualitative research on concepts of joblessness and health. Health education and behavioral change efforts are often insufficient in reaching empowerment on individual or community levels. It is suggested that understanding different categories of thinking using a phenomenographic method could contribute to strategies for community involvement. The "visual starter" uses pictures to introduce the theme as well as for associative purposes in the interview.

Effects of physical exercise on bone mass, balance skill and aerobic capacity in women and men with low bone mineral density, after one year of training--a prospective study

Vadstena is a small community in the county of Ostergötland, Sweden, where a project began in 1989 to prevent osteoporosis and to lower the expected incidence of osteoporotic fractures. Persons aged 40-70 years who had a low bone mineral density (BMD) value at screening of the distal radius by single-photon absorptiometry (SPA) were invited to participate in a training study during one year. The definition of low BMD was a densitometry value below -1 SD (standard deviation) from a sex- and age-specific reference value (z-score). Fifteen persons wanted to exercise in a group and 15 persons wanted to become a control group. All participants answered a questionnaire about lifestyle, occupation, diseases, medication and heredity. Clinical tests were made regarding mobility of the joints and muscles, balance and physical fitness. BMD for the hip and the lumbar spine were assessed by dual-energy X-ray absorptiometry (DXA) before and after the investigation period. The training programme was carried out for 60 min twice a week during one year and had the intention to improve bone mass, muscle strength and flexibility, balance skill and aerobic capacity. After the training period there was a significant increase in BMD at the greater trochanter (P < 0.01), in balance skill (standing on one leg with closed eyes and "ski step"-test) (P < 0.05) and in oxygen uptake capacity (P < 0.05) in the exercise group. In the control group, there was a significant increase in BMD at the lumbar spine (P < 0.05). However, these results should be judged with caution because several participants were over the age of 60, and at that age degenerative changes in the lumbar spine may increase to a greater or lesser extent. Regular weight-bearing exercises during one year seem to influence BMD at the greater trochanter in a training group comprising both women and men. However, our study was small in number and further training studies are needed to assess the effect of weight-bearing training on bone mass in different sex- and age-specific groups.

"Healthometer"--an instrument for self-distributed health screening and prevention in the population

In the ongoing expansion of medical systems toward prevention and health promotion, primary care is increasingly recognized as a key vehicle and agent. In order to establish a comprehensive health dialogue in the population, there is a need for innovative instruments corresponding to the information and linked media revolution that this shift is a part of. Based upon the experiences of the Department of Preventive Medicine in Malmö, Sweden, a self-mediated, interactive health testing and promotion instrument called "healthometer" has been developed and tested for feasibility. The instrument uses a special variety of a quintile-distributed visual analog scale with the thermometer as reference and allows: (a) easy summation and averaging of single or different aggregates of the test items as a "wellness" profile and score with emphasis upon the positive aspects of health, and (b) recognition against this on the whole favorable background of the weak points motivating further action. The instrument, which can be distributed on paper or electronic medium, supports participation and insight in the initial stages of a directed individual health program for the continuation of which the utilization of professional counsel is stimulated.