Osteoporosis Int (1992) 2:252-256 © 1992 European Foundation for Osteoporosis

Osteoporosis International

Original Article A Screening and Counseling Program for Prevention of Osteoporosis B. G u t i n , M. P e t e r s o n , T. G a l s w o r t h y , M. K a s p e r , R. S c h n e i d e r a n d J. L a n e Osteoporosis Center, Hospital for Special Surgery, New York, USA

Abstract. Prevention of osteoporosis is an increasingly salient public health concern as our society ages. This report describes the procedures used at an osteoporosis center to which people come for screening and counseling. The patients on whom this report is based were 53 non-smoking women, 1-10 years postmenopausal at the time of their first visit to the center, who chose not to undertake estrogen therapy, and who returned for a second visit in 12-18 months. They were classified as to adequacy of calcium intake (at least 750 mg/day) and exercise (at least 3 h/week of weight-bearing exercise) at both visits; complete data on calcium intake and exercise were available on 46 of the women. Bone densities were measured at the femoral neck and lumbar spine with dual energy X-ray absorptiometry, and at the distal radius with single photon absorptiometry. At the first visit, 67% of the women reported adequate exercise and 43% reported adequate calcium intake. At the second visit, the percentages in the adequate categories had increased to 74% for exercise (p = 0.06) and 70% for calcium intake (p = 0.02). Age at the first visit was inversely correlated with femoral (r = -0.40, p = 0.003) and spinal (r = -0.36, p = 0.009) bone densities; the correlation with radial bone density did not achieve significance (r = -0.27, p = 0.55). Rather than declining, as would be expected in early postmenopausal women, bone density rose slightly, but not significantly, between visits for all three sites. Neither the first visit values nor the changes between visits were significantly different between groups divided on the basis of adequacy of calcium intake or exercise. These data suggest that bone density is related to age, that a visit to an osteoporosis center may help early postmenopausal Correspondence and offprint requests to: Bernard Gutin, PhD, Professor of Exercise Sciencein Pediatrics, GeorgiaPreventionInstitute, Medical College of Georgia, Augusta, GA 30912-3710, USA. Fax: (404) 721-7150.

women to maintain and improve healthy exercise and eating behaviors, and that bone density does not necessarily decline over a 12-18 month period in women who maintain such behaviors.

Keywords: Bone density; Calcium intake; Osteoporosis prevention; Physical activity; Postmenopausal women

Introduction Osteoporosis is an age-related health problem which promises to become a more serious public health concern as more of our population survives to older age. It affects approximately 24 million Americans and is responsible for 1.3 million bone fractures per year [1]. These fractures result in disability, loss of independent living, and depression [1]. Following hip fractures, permanent disability can result and mortality can exceed 20% within the first year [1]. Osteoporosis is approximately eight times more likely to affect women than men [1]. Since the hypoestrogenism which occurs at menopause in women seems to be responsible for an especially rapid loss of bone density [2,3], many perimenopausal women seek guidance about prophylactic measures they should undertake. The goals of our center are to help clients understand what is currently known about the causes of osteoporosis, and to help them decide on appropriate preventive measures. Estrogen therapy can be effective in preventing postmenopausal bone loss [4]. However, many women decline this therapy for a variety of reasons [5]. Thus, it is important to determine the degree to which bone loss can be ameliorated through an educational approach

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which emphasizes such factors as adequate physical activity and calcium ingestion. This report is based on data collected at our osteoporosis center on women who chose not to embark on estrogen therapy, who returned for a second session in 12-18 months, and who met the other criteria specified in the Methods Section below. We describe the screening and counseling procedures employed, the changes in exercise and eating behaviors which resulted, and the changes in bone densities as measured at femoral, lumbar and radial sites. This information may be of interest to hospitals and health providers involved in osteoporosis prevention activities.

Methods In May 1990 we examined our files to identify retrospectively all women who met the following criteria: 1-10 years postmenopausal; never on estrogen therapy, other steroid medication, or chemotherapy; nonsmoker; no illness known to affect bone density; and two measurements of bone density within 12-18 months using our new system of dual energy X-ray absorptiometry. By assuring at the second visit that the woman had not started menstruating again, we eliminated the possibility that any woman who was not truly postmenopausal would be included in the study group. We found 53 women who met these criteria. Their characteristics are given in Table 1. Table 1. Characteristics of the women for whom bone density values were available (n = 53) and for whom clear data on diet and exercise were available (n = 46)

Variable

Age at menopause Age at first visit Weight (kg) Height (cm)

n = 53

n = 46

Mean

SD

Mean

SD

48.9 55.2 58.2 162.3

4.75 5.14 9.1 8.6

48.7 55.0 57.5 160.0

4.98 5.45 8.3 8.8

Before the visit to our center, patients completed a questionnaire which provided information to the nurse about lifestyle, nutrition, and medical/genetic history. The questionnaire was formulated by an epidemiologist. Upon arriving at the hospital, they had their bone density measured as described below. Then they met with the nurse to discuss and clarify the information on the questionnaire. Thus the information on diet and exercise was of a clinical rather than a research nature and should be interpreted cautiously. For example, no information was available concerning calcium absorption by these women, making any statements about 'adequacy' of calcium intake very tentative. However, calcium absorption studies on all women visiting an osteoporosis center are not commonplace at

this time. The adequacy of exercise and calcium ingestion were estimated from the questionnaire and by personal interview by the nurse. Clear dietary and exercise information could be gleaned from the charts in 46 of the women. Their characteristics are also shown in Table 1. The one-to-one counseling session lasted approximately 1 h and was provided by two nurses experienced in osteoporosis counseling. The patient's risk factors for osteoporosis and issues relating to menopause, such as the pros and cons of estrogen therapy, were discussed. The patient's nutritional and exercise habits were evaluated and counseling provided to help her achieve and maintain optimal bone health. The criterion of adequate excercise was at least 3 h of weight-bearing exercise (e.g. walking, jogging, tennis, aerobics) per week and the criterion of adequate calcium was at least 750 mg/day in food and supplements. The calcium criterion was set at approximately 50% of the 1500 rag/day recommendation for postmenopausal women adopted by a National Institute of Health consensus conference on osteoporosis in 1984 [6]. There is controversy over whether the RDA should be changed from the 800 rag/day of the National Research Council [6]. The women were encouraged to return for another session in approximately a year's time. The screening and counseling visit should not be considered an intervention, as might occur in a controlled research study. Rather, it was part of the selfcare undertaken by the women. Thus, we do not ascribe any changes observed in activity or diet exclusively to the visit to the center. Bone density was measured with dual energy X-ray absorptiometry (Lunar DPX) at the lumbar ( L 2 ~ ) and femoral sites. These measurements have a precision of approximately 1% and 2%, respectively. Distal radius bone density was measured with a Norland single photon densitometer; this measurement has a precision of approximately 3 %. Quality control studies were done by scanning aluminium phantoms of the spine and femoral necks in water baths daily to assure reproducibility over time. Radiation exposure was tess than 5 mR for each visit. The data were analyzed on a PC using SAS. Statistical procedures included chi-squared tests, correlations, t tests, and analyses of variance. Repeated measures analyses of variance were used to examine changes between visits. The alpha level was set at 0.05.

Results As mentioned above, complete data on physical activity and nutrition at both visits were available for 46 women. At the first visit 31 women (67%) reported adequat e physical activity and only 15 reported inadequate physical activity. As regards calcium, 20 (43%) had adequate intake and 26 inadequate intake. At the second visit, 5 women dropped from adequate to inadequate in physical activity while 8 who had been in the inadequate category moved up to the adequate category, with the

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result that 74% were now in the adequate category. This positive trend did not achieve significance (p = 0.06) For calcium intake 2 of the 20 in the adequate category dropped into the inadequate category while 14 of the 26 who had been in the inadequate category moved into the adequate category; thus 70% were then rated adequate. This positive change was significant (p = 0.02), suggesting that the women tended to improve this aspect of nutrition. The age of the 53 women when they visited the center was inversely and significantly related to femoral (r = -0.40, p = 0.003) and spinal (r = -0.36, p = 0.009) bone densities. The correlation for radial bone density (r = -0.27) did not achieve significance (p = 0.055). Table 2 shows the bone density values for the two visits. For all three sites, the expected age-related reduction in bone density was not found. In fact, all three mean values rose slightly and none of the changes was significant. Two-way repeated measures analyses of variance were used to compare groups of women on the basis of their adequacy of physical activity and/or calcium intake. Both first and second visit bone densities and changes between visits were used as dependent variables. None of these analyses revealed significant bone density differences between groups judged adequate or inadequate in calcium intake and/or exercise. Table 2. Bone densityat two visits to the osteoporosiscenter. Values are means (SD) in mg/cm2

Femoral neck (n = 53) Lumbar spine (n = 53) Radius (n - 52)

Visit 1

Visit 2

0.81 (0.10) 0.95 (0.14) 0.64 (0.12)

0.82 (0.10) 0.96 (0.15) 0.65 (0.10)

The correlations between the first and second bone density values are all significant (p

A screening and counseling program for prevention of osteoporosis.

Prevention of osteoporosis is an increasingly salient public health concern as our society ages. This report describes the procedures used at an osteo...
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