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Osteoporosis: Awareness & modification of risk factors in adolescents

Catherine J Coates, Clare A Myers, Jane H Phillips, Kathy Pope

Internet publication: 7  July, 1998

Abstract

The project’s purpose was to reduce the incidence of osteoporosis in the adult population by conducting a primary prevention campaign aimed at adolescents. This involved educating adolescents about osteoporosis, addressing popular misconceptions and imparting practical skills about prevention of the disease.

Year Seven students were involved in an educational seminar and activities (Appendix 1,2). Pre- and post-intervention surveys were used to assess knowledge acquisition (Appendix 3,4). A third was given two weeks later to determine long term memory and behaviour modification (Appendix 5).

The results concluded that our project was successful as 73% were able to correctly identify calcium-rich foods from at least two different food groups following the seminar. In addition, 93% were able to identify multiple risk factors, compared to 31% before the seminar. There was also a marked improvement in the awareness of exercise, with 68% being able to identify multiple weight-bearing exercises.

Key Words:

Osteoporosis, Osteoporosis - Adolescents, Osteoporosis -Prevention and Control, Risk Factors, Osteoporosis - Diet therapy, Osteoporosis - Epidemiology

Health Issue

The project was designed to reduce osteoporosis in adults. Adolescents were targeted, educating them about osteoporosis and its multiple risk factors and demonstrating simple intervention techniques to prevent the disease.

Osteoporosis is a decrease in bone mass, leading to greater bone fragility (1). It is an important public health problem (2) because it is a major cause of fractures often leading to considerable morbidity, mortality and financial burden (3). A hip fracture requires major surgery, hospitalisation and can dramatically affect the person’s lifestyle by impairing their ability to walk unassisted and decreasing their independence. It may even result in death (4). The current cost to the community of osteoporotic fractures among Australians over 60 years old is $800 million annually (3). The problem will escalate in the future due to the ageing population, therefore it is essential to devise and immediately implement successful prevention programs (3).

There are many risk factors for the development of osteoporosis. These can be divided into modifiable and non-modifiable groups.

Non-modifiable risk factors:

• Being female
• Thin and/or small frame
• Advanced age
• A family history of osteoporosis
• Early menopause
• Amenorrhoea
• Testicular failure
• Caucasian or Asian descent
• Some drugs e.g. corticosteroids, anticonvulsants
• Being post-menopausal (2, 4, 5, 6, 7, 8, 9,10)

Emphasis was not placed on these as it may have caused anxiety or reduced compliance with individuals’ drug regimes. It may also have led to the false view that osteoporosis was not relevant to some of the students.

Modifiable Risk Factors:

• Excessive Alcohol
• Smoking
• High salt intake
• High caffeine intake
• High protein diets
• Sedentary lifestyles
• Excessive exercise
• Anorexia nervosa or Bulimia nervosa (2, 10, 11, 12, 13)

Unfortunately, most of the current osteoporosis campaigns are funded by the Dairy Food Corporation and tend to focus on the consumption of dairy foods, whereas prevention of osteoporosis requires:

• A calcium rich diet (dairy and/or non-dairy sources).
• Weight bearing exercises.
• Avoidance of risk factors (smoking, excessive alcohol or diets rich in salt, protein or caffeine). (4, 9, 10, 14, 15)

The program incorporated all of the above to make it more comprehensive and effective.

[not available online]
Figure 1 - Bone Mass Across The Lifespan (10).

The graph reveals many important points about bone physiology:

• Bone is not a static structure but is constantly being remodelled (10).
• Peak bone mass is attained at 18 to 20 years of age (10).
• Peak bone mass is not as high in females (4).
• The rapid withdrawal of oestrogen during menopause leads to the rapid bone loss seen in females (9, 10) .

Females are therefore at a higher risk (14). However, both men and women can be affected (10, 14). Approximately 71% of women and 19% of men over the age of 80 years have this disease (3). One third of all osteoporotic fractures occur in men (9). The current community programs are aimed primarily at women and thus are inadequate, especially considering that the number of men above the age of 70 will double between 1993 and 2050 (9).

The above graph demonstrates that preventative campaigns could be aimed at either:

1. Increasing the peak bone mass formed during adolescence.
2. Decreasing the subsequent loss of bone in later life.

Most current campaigns are of the latter type. However, our project targets adolescents, providing them with knowledge and motivation to increase their peak bone mass and equipping them with practical skills to maintain a high bone mass throughout life.

Priority Population Group

The project targeted Year Seven students (n=81). Four high schools in our local area were invited to participate (Appendix 6,7,8). The first two to respond were selected. These were the Glamorgan Campus of Geelong Grammar School (n=25) and Hawthorn Secondary College (n=56) (Appendix 9).

Co-educational schools were targeted because, as stated above, both men and women are affected by this disease. There is a public misconception that men are not affected by osteoporosis and it was imperative that this be addressed. Both private and public schools were asked to participate, therefore eliminating any possible bias. As discussed above, for our project to be maximally effective either children or adolescents must be targeted as they have not yet reached their peak bone mass (18 to 20 years) (10).

Year Seven students were the most appropriate targets because they are at an age when:

1. Their parents may be allowing them more freedom in their choice of foods (lunches etc.), and their recreational activity (i.e. they are autonomous).
2. They are forming the health practices and behaviours which they will carry into adulthood.
3. They are first exposed to many of the modifiable risk factors e.g. smoking, alcohol, anorexia and bulimia.
4. They have the ability to understand the concepts presented in our seminar e.g. bone physiology, sex hormones.
5. There is sufficient time before their peak bone mass is attained for behaviour modification to take effect.

It was not appropriate to restrict our focus to specific ‘at risk’ groups, such as adolescents with anorexia nervosa or elite athletes, because osteoporosis has numerous risk factors and it would have been impossible to access all of those at high risk. This disease affects a large proportion of society so it was important that all students were educated on the subject.

Goals and Targets

The project’s goal was to reduce the incidence of osteoporosis in adults. This was achieved by reaching the following targets:

• Assessing current level of knowledge of osteoporosis among adolescents.
• Increasing the level of public awareness of osteoporosis among adolescents.
• Providing information about the disease and its multiple risk factors.
• Demonstrating simple intervention techniques which may aid in the prevention of osteoporosis, for example:
  • How to obtain the recommended daily intake of calcium from a wide variety of food sources.
  • How to perform weight-bearing exercise.
• Dispelling common misconceptions about osteoporosis and improving past preventative campaigns. The main points to be stressed:
• Osteoporosis is preventable.
• Osteoporosis affects both men and women.
• Prevention of osteoporosis requires more than just eating dairy foods.
• Prevention of osteoporosis should be aimed at children and adolescents.
  • Encouraging schools to adopt the ‘National Healthy Bones Week’ into their curriculum to educate future generations of students (Appendix 10).
  • Encouraging schools to adopt the ‘Milk for Schools’ campaign to ensure that all students are receiving at least one third of their daily calcium requirements (Appendix 11).
  • Initiating long term behaviour modification and adoption of a healthy lifestyle.

Strategies and Methods

• Two schools were selected using the method identified in ‘Priority Population’
• Pre-intervention survey (Appendix 3)
• 40 minute seminar involving
  • 20 minute interactive talk (Appendix 1)
  • Games (Appendix 2)
  • Questions
• Post-intervention survey (Appendix 4)
• Two weeks later, a final survey (Appendix 5) (See ‘Evaluation Plan’)

Teaching students between the ages of 12 and 13 requires specific planning. A number of important points were considered:

• The information must be readily comprehensible:
  • The depth of information offered in the community health publications was examined (Appendix 12,13,14). This allowed the talk to be aimed at their level of understanding.
• The information must be made relevant:
  • Osteoporosis is often seen as an ‘old persons’ disease which is not preventable in adolescence. This myth needed to be dispelled which was achieved by helping them understand the concept of peak bone mass and fracture threshold (Appendix 15).
• The presentation must be interesting:
  • 38% of students reported excellent and 43% reported good entertainment value.
  • The talk was interactive. During the talk, students were encouraged to ask questions. Initially, it was thought the students would not be attentive during the talk, but they became involved and the questions they asked were intelligent.
  • There were a number of visual displays including overhead projections (Appendix 15 to 21) and a food display (Appendix 22).
  • There were games following the presentation to reinforce the information presented (Appendix 2). The games were crucial to the learning process because when the students were filling out the final osteoporosis survey they used their memories of the games to answer the questions.
  • The talk was under 20 minutes to keep students interested.
• Year Seven students have some autonomy, but they are controlled by the adults in their lives (16, 17):
  • Parents must be involved because they monitor the food their children eat and the activities they participate in. To include families, our pamphlet (Appendix 23) was sent home with the students, with 43% actually showing it to the family.
• The education needs to be ongoing:
  • Reference material was left with the students and school for future education. The teachers were present at the seminar so they could answer any future questions.
  • See ‘Recommendations’ in the ‘Discussion’.

During the talk there were a number of issues that, for ethical reasons, needed to be avoided:

• Some drugs, for example corticosteroids, reduce bone mass (3), however these are used to treat a variety of medical conditions (including asthma) and therefore a number of teenagers need to take them. Discussion of corticosteroids would have caused unnecessary anxiety in these students and potentially decreased compliance with their drug regime.
• Those risk factors which were not modifiable (2,4,5,6,7,8,9,10) were not emphasised (See ‘Health Issue’).
• When discussing the devastating effects of osteoporosis on a persons life, care was taken not to distress the students as there is the possibility that some of their grandparents have the disease.

Evaluation Plan

To evaluate the impact of the presentation three surveys were used (one pre- and two post- intervention). All three surveys were different to avoid students recognizing and repeating answers. The surveys were kept short so the students would stay attentive.

Pre-Intervention (Appendix 3):

• To assess baseline knowledge.
• ‘Tick-the-box’ and short answer questions were used. The short answer questions eliminated the problem of prompting/guessing answers but raised new problems as some students answered them poorly.

Post-Intervention 1 (Appendix 4):

• This survey was done immediately after our presentation.
• To assess whether the students understood the presentation.
• All questions were ‘tick-the-box’ on the basis of time and convenience. Although the information gathered was based only upon their ability to recognise, this was unimportant as it was simply used to see if they understood the information.

Post-Intervention 2 (Appendix 5):

• This was completed two weeks after the presentation.
• It was designed to determine whether the students had:
  • Retained any of the information.
  • Given the brochure to their family.
  • Made an attempt at behavioural change.
• Questions were short answer and ‘tick-the-box’ because, as discussed earlier, it was considered a better method of assessing their knowledge. Unfortunately these answers were extremely difficult to statistically analyse.

Comparison of the pre- and post-intervention surveys was used to assess an increase in knowledge and behaviour change, and therefore the success of the program.

Results

Pre-Intervention:

The pre-intervention survey revealed that knowledge about osteoporosis was very limited, with 56% of students having either no or only slight knowledge about the disease (Appendix 24). However, most students were aware of the role of age (Appendix 25) and gender in the aetiology of osteoporosis (Figure 2), although they were uncertain as to the reason. Most students only listed dairy foods as being rich in calcium (Figure 4), indicating that they were unaware of the calcium content of other foods.

The vast majority of students (60%) were able to identify exercise as being important in the prevention of osteoporosis, but few were aware of other risk factors, such as caffeine and alcohol, in the development of the disease (Figure 6). The high awareness of the role of calcium and exercise in the prevention of osteoporosis is possibly due to advertising campaigns which focus on these factors.

Post-Intervention:

To calculate the improvement in knowledge the final survey was compared to the pre-intervention survey. Overall, there was an increase in knowledge, particularly in the areas of risk factors and weight bearing exercises, possibly due to reinforcement via games. Although students failed to remember the actual amount of calcium (in mg) required each day (Appendix 26), they were aware of how to achieve their recommended dietary intake in terms of portions of various calcium rich foods (Figure 5). This is a more useful, practical skill. Their knowledge of calcium sources, other than dairy foods, increased with 73% able to identify calcium rich sources from at least two different food groups following the seminar.

[not available online]
Figure 2 - Knowledge of who is most at risk from osteoporosis?

[not available online]
Figure 3 - Response to question ‘What are 3 good foods for healthy bones?’

It is important to note that in the above graph, the reason why the number of three correct responses decreased in the post-intervention survey was that students were asked to identify three foods that are rich in calcium from three different food groups. Therefore, the question was markedly more difficult than in the initial survey where students were allowed to respond with three different dairy foods. The graph on the following page indicates the calcium-rich foods identified prior to the seminar.

[not available online]
Figure 4 - Pre-seminar survey - ‘What are good foods for healthy bones?’

[not available online]
Figure 5 - Post-seminar survey - ‘What are good foods for healthy bones?’

As this graph, does not adequately reflect the wide number of responses provided, the table on the following page provides additional information about the same question.

[not available online]
Table 1 - Post-seminar Survey - ‘What are good foods for healthy bones?’

[not available online]
Figure 6 - Pre-seminar Survey - ‘What are risk factors for osteoporosis?’

[not available online]
Figure 7 - Post-seminar Survey - ‘Risk factors for osteoporosis'

[not available online]
Figure 8 - Post-seminar Survey - ‘What are good exercises for healthy bones?’

For other graphs showing further results see Appendix 24 to 35.

Discussion

The project was designed to improve upon past osteoporosis prevention campaigns by targeting both males and females; focusing on adolescents; emphasising the less well known risk factors; and discussing preventative measures beyond eating dairy foods. The project targets were met with an increase in knowledge and behaviour modification. 50% of students either exercised more or consumed more calcium following the program. This gives the project a good chance at achieving the ultimate goal of reducing the incidence of osteoporosis in this target group when they reach adulthood.

Limitations :

• More parental involvement is required to make long-term behaviour modification (food and exercise choices).
• An increase in teacher involvement would be beneficial so that they are better equipped to answer future questions or teach future grades of students about bone health.
• A post-intervention period of longer than two weeks would have allowed behaviour modification to be more accurately assessed.
• A follow-up talk would have allowed the students knowledge to be consolidated and reinforced.
• A more comprehensive cross-section of the community would be beneficial. Involving more schools and students from different areas in Melbourne would have allowed more accurate statistical analysis.
• The surveys could have involved more ‘tick-the-box’ questions, or could have included yes/no questions, which would also have assisted statistical analysis.

Recommendations:

• The implementation of permanent changes in the school curriculum:
  • Weight-bearing exercise each day.
  • Joining the ‘Milk for Schools’ Program (Appendix 11). One of the schools is already involved in this and the State Government needs to be lobbied for state schools to become involved.
  • Participating in the ‘National Healthy Bones Week’ (Appendix 10). One of the schools already has a ‘Bone Week’.
  • Changes to the foods offered at tuckshop.

• If more time is available, a longer intervention period with numerous short sessions.
• More involvement of parents/family.

Acknowledgments

The following people should be thanked for their help and guidance:

Dr. Christine Rodda, Paediatric Endocrinologist at Monash Medical Centre, for supervising our project and for her thoughtful advice.

Ms. Julie Woods, Dietitian at Monash Medical Centre, for providing us with expert information.

Dr. Bridget Hsu-Hage, the Convenor of Health Promotions Unit.

Dr. Tony Gray and Monash Medical Centre Radiology Department, for lending us osteoporotic x-rays.

The Arthritis Foundation of Victoria (incorporating Osteoporosis Victoria) and The Australian Dairy Corporation for the posters, brochures and information.

Thanks must also go to the students and staff of Hawthorn Secondary College and Geelong Grammar School (Glamorgan Campus) who participated so readily and enthusiastically in the project.

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