CAUSAL ANALYSIS OF EXERCISE AND CALCIUM INTAKE BEHAVIORS FOR OSTEOPOROSIS PREVENTION AMONG YOUNG WOMEN IN THAILAND Structural Model for Osteoporosis Preventing Behavior in Postmenopausal Women Tailored Interventions to Enhance Osteoporosis Prevention in Women Osteoporosis prevention in young women. What is the impact of osteoporosis education and bone mineral density testing for postmenopausal women in a managed care setting? Impact of the Fracture Risk Assessment on Patient and Physician Behavior in Osteoporosis Prevention [Optimization of calcium intake for the prevention of osteoporosis and osteoporotic fractures: a review of the evidence]. Impact of preventive osteoporosis education on patient behavior: immediate and 3-month follow-up A randomized controlled trial of mailed osteoporosis education to older adults Social support, knowledge, and self-efficacy as correlates of osteoporosis preventive behaviors among preadolescent females. The effect on behavior and bone mineral density of individualized bone mineral density feedback and educational interventions in premenopausal women: a randomized controlled trial [NCT00273260] The Women's Health Initiative calcium-vitamin D trial: overview and baseline characteristics of participants. Effects of Educational Materials concerning Osteoporosis on Women's Knowledge, Beliefs, and Behavior Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: A Clinical Practice Guideline from the American College of Physicians A randomized controlled trial for the primary prevention of osteoporosis among preadolescent girl scouts: 1-year outcomes of a behavioral program. Prevention of osteoporosis as a consequence of aromatase inhibitor therapy in postmenopausal women with early breast cancer: rationale and design of a randomized controlled trial. How do women change osteoporosis-preventive behaviours in their children? Hip fracture prevention with a multifactorial educational program in elderly community-dwelling Finnish women Screening for Postmenopausal Osteoporosis: A Review of the Evidence for the U.S. Preventive Services Task Force Increasing calcium intake in young women through gain-framed, targeted messages: A randomised controlled trial Evaluation of an osteoporosis and fall risk intervention program for community-dwelling elderly. A quasi-experimental study of behavioral modifications Evaluation of a Multimodal, Direct-to-Patient Educational Intervention Targeting Barriers to Osteoporosis Care: A Randomized Clinical Trial. The periodontal-systemic connection: implications for treatment of patients with osteoporosis and periodontal disease.
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 Background : Osteoporosis prevention behaviors ( OPBs ) can prevent and delay bone deterioration ; dual-energy X-ray absorptiometry ( DXA ) scan can identify osteoporosis and provide personal osteoporosis risk information that may promote prevention behaviors . Objectives : This study was design ed to estimate relationships between receiving personal knowledge of bone mineral density ( gained through DXA scan ) , general knowledge of osteoporosis , health beliefs , and the two OPBs of calcium intake and weight-bearing exercise in healthy postmenopausal women 50 to 65 years . Methods : In this longitudinal , r and omized clinical trial ( including covariates ) , receipt of personal DXA information was manipulated by r and om assignment to the experimental or control group . The remaining antecedent and outcome variable measures were collected by question naire at three time points ( initial [ T1 ; pre-DXA ] , 6 months [ T2 ] , 12 months [ T3 ] ) and by bone density assessment from 203 women over an 18-month period in 2001 - 2003 . Results : The experimental manipulation ( DXA results ) had a direct positive effect ( & bgr ; = .23 , p < .05 ) on calcium intake at T2 , and indirectly at T3 through T2 . Women in the experimental group who were informed they had osteopenia or osteoporosis had a greater T1-T2 change in daily calcium intake than those with normal bone density ( & bgr ; = .23 , p < .05 ) . However , providing DXA results did not relate to change in exercise . Health beliefs and general osteoporosis knowledge predicted initial calcium and exercise levels ; there was tentative evidence that susceptibility beliefs partially mediate between DXA results and change in calcium intake . Discussion : Personal knowledge of DXA results was related significantly to increases in calcium intake in postmenopausal women , but not to exercise . Directions for further study are discussed PURPOSE The purpose of this pilot study was to determine if tailored nursing interventions based on personal knowledge of bone mineral density from a dual-energy x-ray absorptiometry cause increases in knowledge of osteoporosis , health beliefs , or osteoporosis-prevention behaviors in postmenopausal women 50–65 years of age , 6 months after the intervention . METHOD The design for this pilot study was a two group quasi-experimental design . The treatment group received a tailored intervention ; the control group did not . Outcome data were gathered at 6 months after dual-energy x-ray absorptiometry . The tailored intervention was design ed and given to each woman via telephone using her dual-energy x-ray absorptiometry results and osteoporosis question naire data that addressed her knowledge of osteoporosis and osteoporosis-prevention behaviors of calcium intake , exercise , smoking , and alcohol use . A written mailed copy of the intervention followed the telephone interview . Six months after the intervention , the women were mailed another osteoporosis question naire to determine if the tailored intervention made a difference in the outcome variables . SAMPLE A total 124 women between the ages of 50 and 65 ( 101 control , 23 treatment ) comprised the sample . RESULTS There was no difference in knowledge between groups . On the average , there were significantly more perceived barriers to calcium in the tailored group ( mean = 13.48 ) than in the nontailored group ( mean = 11.55 ) ( t = 2.147 ; df = 122 ; p = .034 ) . There were significantly more perceived barriers to exercise in the tailored group ( mean = 14.39 ) than in the nontailored group ( mean = 12.21 ) ( t = .144 ; df = 122 ; p = .034 ) . Daily calcium intake increased in both the tailored and the nontailored groups . The tailored intervention increased women 's daily calcium intake from 614.28 to 1039.10 mg ( t = −2.896 ; df = 22 ; p = .008 ) . The nontailored group daily calcium intake increased from 587.91 to 916.30 mg ( t = −3.541 ; df = 100 ; p = .001 ) ; there was no significant difference between the groups . Weight-bearing exercise behaviors decreased from 96.04 minutes to 59.2 minutes in the tailored group but increased slightly in the nontailored group from 81.47 to 87.26 minutes of exercise . CONCLUSION Tailored interventions  increased women 's perceived barriers to calcium and exercise . Both groups increased calcium intake . The mixed findings of increased perception of barriers to calcium and exercise and decreased exercise behaviors indicate the need for further study . This important intervention has implication s for orthopaedic nurses and healthcare professionals involved in health promotion and prevention of osteoporosis PURPOSE To assess whether young women who participate in an osteoporosis prevention program based on the Health Belief ( Rosenstock , 1966 ) and Self-Efficacy Models ( B and ura , 1977 ) demonstrate higher levels of knowledge regarding osteoporosis prevention than young women who do not participate in such a program . DESIGN A classic experimental design with one treatment group and one control group was used to test the efficacy of the osteoporosis prevention program . Pretest data on knowledge , health belief attitudes ( 7 subscales ) , and self-efficacy ( 2 subscales ) were collected in the treatment and control groups . SAMPLE A convenience sample of 31 young college women were r and omly assigned to an experimental group or to a control group to receive an osteoporosis prevention program . METHOD Subjects in the experimental and control groups completed the  Osteoporosis Knowledge Test , the Osteoporosis Health Belief Scale  , and the Osteoporosis Self-Efficacy Scale  ( Kim et al. , 1991 ) at two times . The experimental group received an osteoporosis prevention program . MAIN RESEARCH CLASSIFICATIONS Osteoporosis , Health Belief , Self-Efficacy , Women 's Health . FINDINGS Subjects in the experimental group had significantly higher knowledge and health belief scores after receiving the intervention than their pretest scores while subjects in the control group had no change in scores . CONCLUSION The osteoporosis program was effective in increasing awareness of osteoporosis prevention in this group of young women . IMPLICATION S FOR NURSING RESEARCH The results may be useful for developing young women 's awareness and knowledge of osteoporosis prevention . Future research could include developing osteoporosis prevention programs at an earlier age when girls are in grade school and junior high school . Teaching health promotion strategies for bone health is essential to all women across the life span Objective To assess whether osteoporosis education , with and without bone mineral density ( BMD ) testing , increases the initiation of lifestyle changes and pharmaceutical treatment to prevent osteoporosis . Design A total of 508 women , aged 54–65 , from a large managed care organization who were not on osteoporosis prevention therapy participated in an intervention study . Participants were r and omly assigned to either an education class on osteoporosis ( n = 301 ) or education plus BMD ( n = 207 ) . A control group of 187 women receiving no intervention were also surveyed to serve as comparison . Group differences and differences based on BMD test result were compared 6 months after education regarding self-reported changes in health behaviors using & khgr;2 tests and logistic regression analyses . Results Of the 508 intervention participants , 455 ( 90 % ) responded to the follow-up survey . Initiation of hormone replacement therapy was reported by 9 % , with 5 % reporting starting alendronate . More than half reported changes in diet , exercise , or calcium intake . Forty-three percent increased their vitamin D intake . There were no significant group differences in behavior except with regard to pharmaceutical therapy ; subjects with education plus BMD were three times more likely than those receiving education only to report starting hormone replacement therapy ( p = 0.004 ) . Low BMD scores were associated with increasing vitamin D intake ( p = 0.03 ) and starting medication ( p = 0.001 ) . Women in the intervention groups were significantly more likely to report modifying their diet ( p < 0.001 ) , calcium ( p < 0.01 ) , and vitamin D intake ( p < 0.0001 ) than women in the control group , not exposed to education . Conclusion Education regarding osteoporosis prevention seems to encourage women to make lifestyle changes . The inclusion of BMD testing enhances the likelihood that women will consider pharmaceutical therapy Objective : To evaluate the impact of a pharmacist-directed osteoporosis screening program utilizing the  fracture risk assessment ( FRAX ) tool on patient and physician behavior . Methods : Postmenopausal women 45 to 65 years with Achilles T score < −1.0 not receiving bisphosphonate therapy were r and omly assigned to a control or intervention group . All participants received a heel ultrasound and pharmacist education on risks of low bone mass . The intervention group received the FRAX and shared their results with their physician . Three months after screening , a telephonic question naire was administered to all participants . Results : A total of 749 patients were screened , with 87 meeting the enrollment criteria ( 43 control and 44 intervention )  . Physician behavior was not different between the groups with respect to ordering vitamin D levels , prescription medication , or dual-energy x-ray absorptiometry scan . A significant difference in vitamin D supplementation occurred between the 2 groups ( P = .024 ) . At follow-up , 72.2 % of responding participants increased daily calcium intake and 76.4 % started or increased physical activity . Conclusion : Physician behavior was not influenced by FRAX results in the intervention group ; however , positive patient behavior changes occurred in both groups . Primary prevention efforts conducted through heel ultrasound screening and pharmacist consultation led women to follow-up ; however , awareness still needs to be raised of the value of FRAX in osteoporosis prevention One of the main focuses of lifestyle modification for the prevention of osteoporosis and osteoporotic fractures  in Japan is improvement in dietary calcium intake . However , virtually no r and omized controlled trial to assess the preventive effects of administration of calcium on the risk of fractures has been conducted in Japan . In this study , we review ed all the scientific papers currently available from medical literature data bases to propose evidence -based recommendations on the preventive procedures for osteoporosis . The result of the present systematic review gives the evidence showing that calcium supplementation or optimal dietary calcium intake increases bone density in childhood and adolescence and reduces the risk of fracture due to osteoporosis in the elderly people regardless of the gender . The evidence also supports the current health policy guiding the elderly to increase their dietary calcium intake in daily life 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 r and omly 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 question naire that assessed their knowledge of osteoporosis and baseline health-related behaviors . Three months later , a follow-up question naire 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 question naire ( P < 0.001 ) . The 3-month follow-up question naire 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 Introduction Osteoporosis represents a growing public health concern ; however , current rates of management are sub-optimal . The aim of our study was to assess , in a r and omized controlled trial , the effect of a mailed educational intervention on older adults ’ knowledge , attitudes , and preventive behaviors regarding osteoporosis . The setting was a large publicly funded state pharmacy benefits program . The patients were 31,715 Medicare beneficiaries from Pennsylvania who participated in a drug benefits program for low-to-moderate income elderly people . Methods All women aged over 65 years , and all men and women with a history of fracture or long-term oral use of glucocorticoid , were included . Approximately half of the participants ( intervention group ) were r and omly selected to receive three mailings aim ed at improving knowledge of osteoporosis and enhancing preventive activities , such as using calcium and vitamin D , reducing fall risks in the home , obtaining a bone mineral density ( BMD ) test , and taking medications when necessary . The other participants did not receive the intervention mailings and served as controls . We surveyed a sample of intervention and control subjects to determine the effects of the intervention on knowledge , attitudes , self-efficacy ( confidence in one ’s ability to perform specific activities ) , and behavior regarding osteoporosis prevention and treatment . Six hundred r and omly selected participants in the intervention group and an equal number in the control group were invited to participate . Results Twenty-six had died and 636 of the remaining 1,185 ( 54 % ) completed the survey . Respondents and non-respondents did not differ significantly with respect to measured sociodemographic factors . All scales had good reliability ( all Cronbach ’s alphas > 0.65 ) . Knowledge of osteoporosis was generally very good and did not differ between intervention ( mean = 65 % correct responses ) and control subjects ( mean = 67 % correct ; P=0.4 ) . Perceived susceptibility to osteoporosis was relatively high and similar across groups ( P=0.4 ) . Self-efficacy for participating in osteoporosis prevention and treatment was very strong in both the intervention ( mean = 4.3 on a 0–5 scale ) and control ( mean = 4.2 , P=0.03 ) groups . On average , subjects in the intervention group reported participating in 3.5 of 6 preventive osteoporosis activities compared with 3.4 in the control group ( P=0.5 ) . Conclusions Compared with the controls , a mailed educational intervention for osteoporosis was not associated with better knowledge , higher perceived susceptibility , or performance of preventive measures among the at-risk older adults that we studied . The intervention group demonstrated a small increase in self-efficacy . More intensive patient interventions or intervention aim ed at other aspects of the care process may be required to bring about changes that lead to a reduction in fractures OBJECTIVE To develop and test a model based on B and ura 's social cognitive theory to predict healthy lifestyle behaviors for the prevention of osteoporosis . METHODS Participants were 354 girls , ages 8 - 11 years , recruited from area Girl Scout troops . Baseline data from a r and omized trial of behavioral interventions are presented . Measures of social support , knowledge , self-efficacy , dietary calcium intake , and weight-bearing physical activity ( WBPA ) were obtained via interviews and self-administered question naires . RESULTS A structural equation model was tested and fit the data well . Family social support , perceived self-efficacy for eating a calcium-rich diet , and knowledge of WBPA significantly predicted calcium intake . Friend and family support for exercise predicted WBPA . Self-efficacy partially mediated the relationship between family support and calcium intake , as confirmed by Holmbeck 's post-hoc probing strategy ( 2002 ) . CONCLUSIONS Suggestions are made for primary prevention interventions such as parent and peer involvement , health education , and problem-solving training Background Limited information is available on ways to influence osteoporosis risk in premenopausal women . This study tested four hypotheses regarding the effects of individualized bone density ( BMD ) feedback and different educational interventions on osteoporosis preventive behavior and BMD in pre-menopausal women , namely : that women are more likely to change calcium intake and physical activity if their BMD is low ; that group education will be more efficacious at changing behavior than an information leaflet ; that BMD feedback and group education have independent effects on behavior and BMD ; and , that women who improve their physical activity or calcium intake will have a change in bone mass over 2 years that is better than those who do not alter their behavior . Methods We performed a 2-year r and omized controlled trial of BMD feedback according to T-score and either an osteoporosis information leaflet or small group education in a population -based r and om sample of 470 healthy women aged 25–44 years ( response rate 64 % ) . Main outcome measures were dietary calcium intake , calcium supplement use , smoking behavior , physical activity , endurance fitness , lower limb strength and BMD . We used paired t-tests , one-way ANOVA and linear regression techniques for data analysis . Results Women who had feedback of low BMD had a greater increase in femoral neck BMD than those with normal BMD ( 1.6 % p.a . vs. 0.7 % p.a . , p = 0.0001 ) , but there was no difference in lumbar spine BMD change between these groups ( 0.1 % p.a . vs. 0.08 % p.a . , p = 0.9 ) . Both educational interventions had similar increases in femoral neck BMD ( Leaflet = + 1.0 % p.a . , Osteoporosis self-management course = + 1.3 % p.a . , p = 0.4 ) . Femoral neck BMD change was only significantly associated with starting calcium supplements ( 1.3 % p.a , 95%CI + 0.49 , + 2.17 ) and persistent self-reported change in physical activity levels ( 0.7 % p.a . , 95%CI + 0.22 , + 1.22 ) . Conclusion Individualized BMD feedback combined with a minimal educational intervention is effective at increasing hip but not spine bone density in premenopausal women . The changes in behavior through which this was mediated are potentially important in the prevention of other diseases , thus measuring BMD at a young age may have substantial public health benefits , particularly if these changes are sustained Osteoporosis is a major public health issue leading to significant morbidity , loss of independence and excess loss of life . It has been estimated that 13 to 17 million postmenopausal women have low bone mass or osteoporosis ( 1 , 2 ) . This is associated with almost 1.5 million fractures annually , including 300,000 hip fractures ( 2 , 3 ) . A review of the evidence by Cumming in 1990 ( 4 ) and subsequently published r and omized clinical trials have shown that calcium and /or vitamin D supplements may play a role in the prevention and treatment of osteoporosis by slowing the rates of bone loss in postmenopausal and elderly women ( 5–9 ) . However , there are a limited number of calcium and /or vitamin D trials ( 10–13 ) and observational studies [ review of evidence by Cumming and Nevitt ( 14 ) and Kanis ( 15 ) ] , to support a role for calcium and vitamin D supplementation in the reduction of hip and other fractures . It has also been suggested that calcium and vitamin D supplementation may play a role in the reduction of colorectal cancer incidence ( 16–21 ) . To address these major health concerns of postmenopausal women , the Calcium-Vitamin D ( CaD ) trial of the Women ’s Health Initiative ( WHI ) was design ed to test the primary hypothesis that women who are r and omized to receive calcium and vitamin D supplementation will have a lower risk of hip fracture and secondarily , a lower risk of all fractures and colorectal cancer than women receiving corresponding placebo . The objective of this paper is Purpose . This study examined the effects of brief written educational material s on osteoporosis-related knowledge , beliefs , and behaviors . The study also examined whether observed effects varied as a function of one 's stage in the pre caution adoption process . Design . The study used an experimental research design . Setting . Participants were identified from North Carolina driver 's license records . Subjects . Of the 1476 women in the initial sample , 536 ( 36.3 % ) enrolled in the study and 307 completed all follow-up assessment s. Intervention . Participants were r and omly assigned to one of four groups . One group received an information packet containing general information about osteoporosis . One group received an action plan packet containing instructions on how to increase one 's level of exercise and calcium intake .  One group received both packets . The final group received neither packet . Measures . Primary study variables were beliefs related to osteoporosis , calcium , and exercise ; osteoporosis knowledge ; calcium and exercise stage ; calcium intake ; and exercise level . Results . Overall , receipt of the information packet was associated with changes in knowledge and beliefs ( F[18,283 ] = 2.11 , p < .01 ) irrespective of participants ' stage of change . No effects on behavior were observed . Conclusions . These findings suggest that brief written educational material s can facilitate knowledge and belief change but that they do not promote behavior change . The generalizability of these findings is limited by the low study response rate The National Institutes of Health 's consensus conference ( 1 ) defined osteoporosis as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk for fracture . Bone strength reflects the integration of two main features : bone density and bone quality .Bone quality refers to architecture , turnover , damage accumulation ( e.g. , microfractures ) , and mineralization . Although osteoporosis can affect any bone , the hip , spine , and wrist are most likely to be affected . Osteoporosis affects an estimated 44 million Americans or 55 % of people 50 years of age or older . Another 34 million Americans are estimated to have low bone mass , meaning that they are at an increased risk for osteoporosis . Osteoporosis can be diagnosed by the occurrence of fragility fracture . In patients without fragility fracture , osteoporosis is often diagnosed by low bone density .  Dual x-ray absorptiometry ( DXA ) is the current gold st and ard test for diagnosing osteoporosis in people without an osteoporotic fracture .  Dual x-ray absorptiometry results are scored as st and ard deviations ( SDs ) from a young healthy norm ( usually female ) and reported as T-scores . For example , a T-score of 2 indicates a bone mineral density that is 2 SDs below the comparative norm . The international reference st and ard for the description of osteoporosis in postmenopausal women and in men age 50 years or older is a femoral neck bone mineral density of 2.5 SD or more below the young female adult mean ( 2 ) . Low bone density , as measured by DXA , is an imperfect predictor of fracture risk , identifying fewer than half the people who go on to have an osteoporotic fracture . Screening guidelines for women are well established ( 3 ) , and the American College of Physicians ( ACP ) recently published guidelines on screening for men ( 4 ) . This guideline presents the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis . Medications used to treat osteoporosis may affect different parts of the skeletal system differently , and efficacy for vertebral fractures does not necessarily imply efficacy for nonvertebral fractures . The target audience for this guideline is all clinicians and the target patient population is all adult men and women with low bone density or osteoporosis . These recommendations are based on the systematic evidence review by MacLean and colleagues ( 5 ) and the Agency for Healthcare Research and Quality sponsored Southern California Evidence -Based Practice Center evidence report ( 6 ) . The drugs currently approved for prevention of osteoporosis include alendronate , ib and ronate , risedronate , zoledronic acid , estrogen , and raloxifene . The drugs currently approved for treatment of osteoporosis include alendronate , ib and ronate , risedronate , calcitonin , teriparatide , zoledronic acid ( in postmenopausal women ) , and raloxifene . Testosterone , pamidronate , and etidronate are not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Methods The literature search done by MacLean and colleagues for the systematic review ( 5 ) included studies from MEDLINE ( 1966 to December 2006 ) , the ACP Journal Club data base , the Cochrane Central Register of Controlled Trials ( no date limits ) , the Cochrane Data base of Systematic Review s ( no date limits ) , Web sites of the United Kingdom National Institute of Health and Clinical Excellence ( no date limits ) , and the United Kingdom Health Technology Assessment Program ( January 1998 to December 2006 ) . The review ers limited their search to English- language publications and human studies . They derived evidence for comparative benefits of various treatments exclusively from r and omized , controlled trials , whereas they included evidence from other types of studies for short- and long-term harms . Two physicians independently abstract ed data about study population s , interventions , follow-up , and outcome ascertainment by using a structured form . For each group within a r and omized trial , a statistician extracted the sample size and number of persons reporting fractures . Two review ers , under the supervision of the statistician , independently abstract ed information about adverse events . The statistician or the principal investigator resolved disagreements . This guideline is based on an evaluation of 76 r and omized , controlled trials , 4 of which were identified in the up date d search , and 24 meta-analyses that were included in the efficacy analyses . The analyses of adverse events included 491 articles , representing 417 r and omized trials , 25 other controlled clinical trials , 11 open-label trials , 31 large observational studies , and 9 case reports of osteonecrosis among bisphosphonate users . MacLean and colleagues ' background article ( 5 ) includes details about the methods used for the systematic evidence review . The ACP rates the evidence and recommendations by using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system with minor modifications ( Table 1 ) . In addition , the evidence review ers used predefined criteria to assess the quality of systematic review s and r and omized trials , based on internal and external validity assessment s detailed in the Quality of Reporting of Meta-Analyses ( QUOROM ) statement ( 7 ) . Table 1 . The American College of Physicians ' Guideline Grading System The objective of this guideline is to synthesize the evidence for the following questions : What are the comparative benefits in fracture reduction among and also within the following treatments for low bone density :  bisphosphonates , specifically alendronate , risedronate , etidronate , ib and ronate , pamidronate , and zoledronic acid ; calcitonin ; estrogen for women ; teriparatide ; selective estrogen receptor modulators ( SERMs ) , specifically raloxifene and tamoxifen ; testosterone for men ; vitamins and minerals , specifically vitamin D and calcium ; and the combination of calcium plus vitamin D ? How does fracture reduction result ing from treatments vary among individuals with different risks for fracture as determined by bone mineral density ( borderline , low , or severe ) , previous fractures ( prevention vs. treatment ) , age , sex , glucocorticoid use , and other factors ( such as community-dwelling vs. institutionalized or vitamin Ddeficient vs. not ) ? What are the short- and long-term harms ( adverse effects ) of these therapies , and do these vary by specific sub population s ? Comparative Benefits of Drugs versus Placebo in Fracture Reduction Evidence from 24 meta-analyses ( 830 ) and 35 additional r and omized trials published after the meta-analyses ( 3165 ) described the effect of 9 of the 14 agents ( alendronate , etidronate , risedronate , calcitonin , estrogen , teriparatide , raloxifene , calcium , and vitamin D ) on fracture incidence . For 4 agents ( ib and ronate , pamidronate , zoledronic acid , and tamoxifen ) , the review ers found no meta-analyses and instead gathered the evidence from 14 r and omized trials ( 6679 ) . No studies were found that reported fracture rates for testosterone . Three r and omized trials ( 35 , 80 , 81 ) and 1 meta- analysis ( 82 ) evaluated the combination of calcium plus vitamin D  on fractures .  Bisphosphonates Good- quality evidence showed that alendronate , etidronate , ib and ronate , and risedronate prevent vertebral fractures . In addition , evidence from good- quality studies demonstrated that both alendronate and risedronate prevent nonvertebral and hip fractures . Two large r and omized trials showed that zoledronic acid prevents vertebral and nonvertebral fractures in high-risk population s and reduces the risk for hip fracture ( 67 , 74 ) . Ib and ronate has not been shown to reduce nonvertebral fractures ( 68 ) . Of the 6 fairly small trials that looked at vertebral fractures , 1 demonstrated a statistically significant reduction in fractures with pamidronate relative to placebo ( 0.14 [ 95 % CI , 0.03 to 0.72 ] ) ( 73 ) . However , after these data were pooled , the pooled risk estimate for fractures for pamidronate relative to placebo was not significant ( 0.52 [ CI , 0.21 to 1.24 ] ) ( 6 ) . Calcitonin Fair- quality evidence shows that calcitonin reduces vertebral fractures ( 83 , 84 ) . Good- quality evidence indicates that calcitonin does not reduce nonvertebral fractures ( 13 , 16 ) . Estrogen Good- quality evidence shows that estrogen reduces the incidence of vertebral ( 29 , 85 ) , nonvertebral ( 86 ) , and hip fractures ( 85 ) . Teriparatide Good- quality evidence shows that teriparatide prevents vertebral fractures . The evidence related to teriparatide preventing nonvertebral fractures is mixed ; 1 large r and omized trial showed a reduction in nonvertebral fractures ( 34 ) but 2 small trials did not ( 87 , 88 ) . SERMs Good- quality evidence shows that raloxifene prevents vertebral fractures , but that tamoxifen has no effect on vertebral fractures ( 8991 ) . In addition , both raloxifene and tamoxifen had no effect on hip fractures ( 91 ) . Tamoxifen is not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Testosterone No studies reported fracture rates for testosterone . Calcium and Vitamin D In the studies evaluated by MacLean and colleagues ( 5 ) , the evidence for the effect of calcium alone on reduction of fractures is complex . Most studies of pharmacologic agents for osteoporosis include calcium and vitamin D as part of the treatment regimen . Evidence from 1 meta- analysis ( 27 ) and several r and omized trials ( 35 , 48 , 51 , 92 ) showed no significant difference between calcium and placebo in preventing vertebral , nonvertebral , and hip fractures in postmenopausal women . However , nonadherence to therapy may influence this result , and 1 trial with a prespecified analysis of adherent patients found a reduction in fracture risk ( 48 ) . A recent meta- analysis ( 82 ) concluded that the relative risk ( RR ) for fracture with calcium alone was 0.90 ( CI , 0.80 to 1.00 ) , but it did not include a modestly large trial with negative results ( 35 ) . MacLean and colleagues ( 5 ) OBJECTIVE To provide 1-year outcomes for a r and omized controlled trial of a behavioral-educational intervention for the primary prevention of osteoporosis among 247 preadolescent girls . METHODS Girl Scout troops were r and omly assigned to one of two intervention groups-a group comprising girls only  ( n = 73 ) and  girls with their mothers  ( n = 94)- and a healthy-lifestyles control group ( n = 80 ) . Multilevel ( hierarchical ) models were employed to account for clustering of girls within troops . RESULTS Among girls who met the recommended levels of Ca at baseline , those in the intervention were significantly more likely to maintain or improve their intake at follow-up compared to controls . No significant group differences were found for changes in WBPA . CONCLUSIONS A behavioral intervention for the primary prevention of osteoporosis holds promise for maintaining adequate Ca intake among preadolescent females BACKGROUND Aromatase inhibitors ( AIs ) have improved the prognosis for breast cancer survivors and are now st and ard of care for postmenopausal women with hormone receptor positive early stage breast cancer . One side-effect , however , is a decrease in bone mineral density ( BMD ) and increased fracture risk . Since hormone replacement therapy ( HRT ) is contraindicated in these women , one prevention option is exercise combined with vitamin D and calcium . The effect of this intervention on drug-induced osteoporosis is unknown . METHODS A single-blind r and omized controlled trial will be undertaken to test the hypothesis that exercise combined with vitamin D and calcium can prevent the decrease in BMD associated with the use of AIs . Sixty postmenopausal women prescribed an AI for the treatment of breast cancer will be r and omized into either an exercise or control group . Participants r and omized to the exercise group will undertake a 12-month gym-based exercise program , 3 times per week involving resistance and impact training . Participants in the control group will be advised on the benefits of exercise for preventing osteoporosis , but not prescribed exercise . Both groups will receive vitamin D and calcium supplements . The primary outcome will be total hip bone mineral density measured via dual energy X-ray absorptiometry ( DXA ) . Study outcomes will be compared between groups at baseline , 6months and 12months . SUMMARY This study will investigate the effect of exercise in combination with vitamin D and calcium on prevention of drug-induced osteoporosis in postmenopausal women prescribed AIs for the treatment of breast cancer Objective : We have reported that a lifestyle intervention with mothers  improved calcium intake and physical activity in both mothers and their children . In this study , we aim ed to describe the strategies and approaches used by these mothers to improve their children 's calcium intake and physical activity . Design : A qualitative study using semistructured interviews . Setting : Population -based convenience sample .Subjects : A sub sample of 39 mothers were taken from a population -based r and om sample of 354 mothers who had participated in the original osteoporosis-prevention trial . Results : Mothers described specific dietary changes they made to increase their children 's calcium intake . They also described strategies for improving calcium intake and physical activity such as raising awareness of the importance of calcium ; ensuring calcium-rich foods were accessible ; assessing their children 's likes and dislikes and working within these ; role modelling ; information provision ; taking a balanced approach to attempting behaviour change ; and encouraging activities that they could do with their children . Mothers emphasized the general importance of a balanced diet and lifestyle , rather than just focussing on lifestyle factors specific to osteoporosis prevention . Conclusion : Even without specific guidance , mothers are adept at developing strategies to apply to changing lifestyle behaviours in their children and identifying barriers to change . These results provide information , which could be incorporated into future interventions for lifestyle change in children and also provide further support for considering parent-focused approaches to this problem Summary Guidelines suggest identification of women at fracture risk by bone density measurement and subsequently pharmacotherapy . However , most women who sustain a hip fracture do not have osteoporosis in terms of bone density . The present non-pharmacological intervention among elderly women unselected for osteoporosis reduced hip fracture risk by 55 % providing an alternative approach to fracture prevention . Introduction Hip fractures are expensive for society and cause disability for those who sustain them . We studied whether a multifactorial non-pharmacological prevention program reduces hip fracture risk in elderly women . Methods A controlled trial concerning 60- to 70-year-old community-dwelling Finnish women was undertaken . A r and om sample was drawn from the Population Information System and assigned into the intervention group ( IG ) and control group ( CG ) . Of the 2,547 women who were invited to the IG , 1,004 ( 39 % ) and of the 2,120 invited to the CG , 1,174 ( 55 % ) participated . The IG participated in a fracture prevention program for 1 week at a rehabilitation center followed by review days twice . The CG received no intervention . During the 10-year follow-up , both groups participated in survey question naire by mail . Outcome of interest was occurrence of hip fractures and changes in bone – health-related lifestyle . Results During the follow-up , 12 ( 1.2 % ) women in the IG and 29 ( 2.5 % ) in the CG sustained a hip fracture ( P = 0.039 ) . The determinants of hip fractures by stepwise logistic regression were baseline smoking ( odds ratio ( OR ) 4.32 ( 95 % confidence interval [ CI ] 2.14–8.71 ) , age OR 1.15/year ( 95 % CI 1.03–1.28 ) , fall history OR 2.7 ( 95 % CI 1.24–5.9 ) , stroke history OR 2.99 ( 95 % CI 1.19–7.54 ) and participating in this program OR 0.45 ( 95 % CI 0.22–0.93 ) . Starting vitamin D and calcium supplement use was more common in the IG compared with the CG . Conclusions The results suggest that this non-pharmacological fracture prevention program may reduce the risk of hip fractures in elderly Finnish women Half of all postmenopausal women will have an osteoporosis-related fracture during their lives , including one quarter who will develop a vertebral deformity ( 1 ) and 15 % who will suffer a hip fracture ( 2 ) . Hip fractures are associated with high mortality rates and loss of independence ( 3 , 4 ) . Although many vertebral fractures are detected only incidentally on radiography , some cause severe pain , leading to 150 000 hospital admissions per year in persons older than 65 years of age , 161 000 physician office visits , and more than 5 million days of restricted activity in those 45 years of age or older ( 5 ) . Low bone density has been used to predict risk for fractures as well as to diagnose osteoporosis . Osteoporosis has been defined as a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue , leading to enhanced bone fragility and a consequent increase in fracture risk ( 6 , 7 ) . This definition emphasizes that , in addition to bone mass , the structure of bone is an important factor in the pathogenesis of fractures . A World Health Organization working group ( 8) proposed that osteoporosis should be diagnosed in epidemiologic studies when  bone mineral density  is 2.5 SDs or more below the mean for healthy young adult women at the spine , hip , or wrist ( corresponding to a T-score 2.5 ) or when patients have a history of atraumatic fracture ( 9 ) . By the World Health Organization definition , up to 70 % of women older than 80 years of age have osteoporosis ( 10 ) . Age is also an important factor in the relationship between bone density and the absolute risk for fracture . Older women have a much higher fracture rate than younger women with the same bone density because of increasing risk from other factors , such as bone quality and tendency to fall ( 11 ) . Despite the high prevalence of osteoporosis and the effect of fractures on mortality , independence , and quality of life , it is not clear whether it is appropriate to screen asymptomatic postmenopausal women . Recent systematic review s and guidelines disagree about which women should be screened and when ( 12 - 20 ) . This disagreement reflects , in part , gaps in the evidence . For example , most guidelines recommend using risk factors to select patients for bone density testing , but because of inadequate data there is no consensus on which risk factors to use . As part of the U.S. Preventive Services Task Force up date of its 1996 recommendation ( 21 ) , we examined evidence on the benefits and harms of screening postmenopausal women for osteoporosis . Specifically , we addressed the role of risk factors in identifying high-risk women , techniques of bone density testing to identify fracture risks , effectiveness of treatment in reducing fracture risk , and harms of screening and treatment . Methods Additional methods used for this review , including determination of the quality of studies ( 22 ) , are detailed in Appendix Tables 1 , 2 , and 3 and in a separate report ( 23 ) . The analytic framework and key questions are detailed in the Appendix Figure . Relevant studies were identified from multiple search es of MEDLINE ( 1966 to May 2001 ) , HealthSTAR ( 1975 to May 2001 ) , and Cochrane data bases ; reference lists of systematic review s ; and experts . We also sent letters to manufacturers of bone density devices requesting additional information about the performance of their instruments , but we received no new data . Two review ers read each abstract to determine its eligibility . We included English- language abstract s that contained original data about postmenopausal women and osteoporosis and addressed screening or the effectiveness of risk factor assessment , bone density testing , or treatment . We considered screening to be the process of assessing postmenopausal women without known osteoporosis for risk of osteoporotic fractures by identification of risk factors , including low bone density . Postmenopausal women were those who had experienced surgical or natural menopause , regardless of age . Women with preexisting atraumatic fractures were not considered in the screening population because they had confirmed osteoporosis according to the World Health Organization definition . For studies of prediction , we selected articles that reported the relationship between risk factor assessment methods or bone density tests and bone density , bone loss , or fractures . We review ed studies of medications used for treatment and present results for bisphosphonates . We focused on r and omized , controlled trials of therapies reporting radiographically verified , nontraumatic fracture outcomes because fractures are a stronger measure of effectiveness than bone density . We excluded studies of primary prevention of osteoporosis , such as the role of nutrition , calcium consumption , and physical activity . We also excluded secondary causes of osteoporosis , such as corticosteroid use and certain chronic diseases , and studies that did not provide sufficient information to allow determination of the method for selecting patients and for analyzing data . Investigators read the full-text versions of the retrieved papers and reapplied the initial eligibility criteria . To assess the internal validity of individual studies , we applied a set of criteria developed by the third U.S. Preventive Services Task Force ( Appendix Table 1 ) ( 22 ) . In this paper , we highlight studies that are applicable to current practice st and ards , have high- quality internal validity ratings , and are most generalizable to the U.S. population of postmenopausal women under consideration for screening . We created an outcomes table to summarize the number of  hip and vertebral fractures  prevented based on age-specific prevalence rates and treatment effects obtained from results of the review ed studies . We conducted a sensitivity analysis to determine the influence of risk factors on the number needed to screen . This research was funded by the Agency for Healthcare Research and Quality under a contract to support the work of the U.S. Preventive Services Task Force . Agency staff and Task Force members participated in the initial design of the study and review ed interim analyses and the final manuscript . Additional reports were distributed for review to content experts and revised accordingly before preparation of this manuscript ( 23 , 24 ) . The authors are responsible for the content of the manuscript and the decision to su bmi t it for publication . Results Studies of Screening We identified no studies about the effectiveness of screening in reducing osteoporotic fractures . Without direct evidence from screening studies , recommendations about screening need to rely on evidence that risk factor assessment or bone density testing can adequately identify women who could ultimately benefit from treatment . Risk Factor Assessment Hundreds of studies report associations between risk factors and low bone density and fractures in postmenopausal women ( 24 ) . The most comprehensive study of risk factors in a U.S. population is the Study of Osteoporotic Fractures , a good- quality prospect i ve study of 9516 women 65 years of age and older ( 25 ) . In this study , 14 clinical risk factors were identified as significant predictors of hip fracture in multivariable models ( age ; maternal hip fracture ; no weight gain ; height ; poor self-rated health ; hyperthyroidism ; current use of benzodiazepines , anticonvulsants , or caffeine ; not walking for exercise ; lack of ambulation ; inability to rise from a chair ; poor scores on two measures of vision ; high resting pulse ; and any fracture since 50 years of age ) . The relative risk for hip fracture per decrease of 1 SD in calcaneal bone density was 1.6 ( 95 % CI , 1.3 to 1.9 ) . This was comparable to the magnitude of the relative risks of most of the other significant predictors in the model , which ranged from 1.2 to 2.0 . Women with at least 5 of the 14 risk factors had increased rates of hip fractures compared with those who had 0 to 2 risk factors at all levels of calcaneal bone density . To determine which risk factors could be important in women younger than 65 years of age , we review ed eight observational studies of risk factors and fractures of various types conducted in population s in which at least 50 % of participants were younger than 65 years of age . Table 1 lists risk factors that were statistically significant predictors for fractures in multivariable models ( 26 - 33 ) . These results could not be quantitatively combined because risk factors were defined differently in each study . Table 1 . Risk Factors for Fractures in Women 5065 Years of Age Results of risk factor studies have been used to assess risk in individuals . We identified 10 cross-sectional studies that described methods of determining risk for low bone density for individual women based on selected clinical risk factors ( Table 2 ) ( 34 - 43 ) . The most common method ologic limitations of these studies are lack of validation and lack of generalizability because of small numbers of patients or nonrepresentative patients . We also identified 8 studies of clinical risk factors to determine fracture risk ( Table 2 ) ( 44 - 51 ) . None of these studies received a good rating for internal validity . Four studies evaluated hip fracture outcomes , two evaluated vertebral fractures , and two evaluated all types of fractures . These studies described the association of risk factors with fractures known to have occurred already ( four casecontrol studies ) or how well they would predict fractures in the future ( four prospect i ve cohort studies ) . Table 2 . Studies of Risk Factor Assessment A recent study compared the performance of five clinical decision rules for bone density testing among 2365 postmenopausal women 45 years of age or older who were enrolled in a community-based study of osteoporosis in Canada ( 52 ) . These rules included guidelines from the National Osteoporosis Foundation ( 53 ) ; the Simple Calculated Osteoporosis Risk Estimation ( SCORE ) rule ( age , weight , ethnicity , estrogen use , Background : Adequate calcium consumption during early adulthood can help prevent osteoporosis in women . Purpose : The effects of gain-framed , targeted messaging on calcium intake were examined over 12 months . Methods : Young women ( 18–19 years ) not consuming sufficient calcium were r and omly assigned to receive st and ard care material s ( control ) or gain-framed , targeted material s ( experimental ) .  Health belief model ( HBM ) constructs , calcium intake and markers of bone formation , resorption and bone mineral density were assessed at various time points throughout the year . Results : Calcium intake increased significantly more in the experimental versus the control condition ( p < 0.01 ) . Self-efficacy was the only HBM construct to improve significantly more in the experimental condition versus control ( p = 0.05 ) . The HBM did not mediate changes in calcium intake . Measures of bone health did not differ between conditions by the end of this nonpharmacological intervention ( p 's > 0.05 ) . Conclusions : It is possible to increase  young women 's calcium consumption through gain-framed , targeted messages 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 ≥65 years were r and omly 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 design ed to increase awareness of risk factors for the development of osteoporosis and falling . Question naires 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 sample s 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 inter- ventions , can contribute to behavioral changes in the prevention of falls and changed physical activity patterns amongst elderly people Osteoporosis treatment rates are declining , even among those with past fractures . Novel , low-cost approaches are needed to improve osteoporosis care . We conducted a parallel group , controlled , r and omized clinical trial evaluating a behavioral intervention for improving osteoporosis medication use . A total of 2684 women with self-reported fracture history after age 45 years not using osteoporosis therapy from US Global Longitudinal Study of Osteoporosis in Women ( GLOW ) sites were r and omized 1:1 to receive a multimodal , tailored , direct-to-patient , video intervention versus usual care . The primary study outcome was self-report of osteoporosis medication use at 6 months . Other outcomes included  calcium and vitamin D supplementation , bone mineral density ( BMD ) testing , readiness for behavioral change , and barriers to treatment . In intent-to-treat analyses , there were no significant differences between groups ( intervention versus control ) in osteoporosis medication use ( 11.7 % versus 11.4 % , p = 0.8 ) , calcium supplementation ( 31.8 % versus 32.6 % , p = 0.7 ) , vitamin D intake ( 41.3 % versus 41.9 % , p = 0.8 ) , or BMD testing ( 61.8 % versus 57.1 % , p = 0.2 ) . In the intervention group , fewer women were in the precontemplative stage of behavior change , more women reported seeing their primary care provider , had concerns regarding osteonecrosis of the jaw , and difficulty in taking/remembering to take osteoporosis medications . We found differences in BMD testing among the subgroup of women with no prior osteoporosis treatment , those who provided contact information , and those with no past BMD testing . In per protocol analyses , women with appreciable exposure to the online intervention ( n = 257 ) were more likely to start nonbisphosphonates  ( odds ratio [ OR ] = 2.70 ; 95 % confidence interval [ CI ] 1.26 - 5.79 ) compared with the usual care group . Although our intervention did not increase the use of osteoporosis therapy at 6 months , it increased nonbisphosphonate medication use and BMD testing in select subgroups , shifted participants ' readiness for behavior change , and altered perceptions of barriers to osteoporosis treatment . Achieving changes in osteoporosis care using patient activation approaches alone is challenging . © 2018 American Society for Bone and Mineral Research Osteoporosis and osteopenia may influence periodontal disease and tooth loss . Medications such as hormone replacement therapy and nutritional supplements that are used to prevent or treat osteoporosis have been evaluated for beneficial effects on oral health in a small number of human studies . Hormone replacement therapy ( HRT ) , which slows the rate of bone loss at skeletal sites such as the hip and spine , also appears to reduce the rate of alveolar bone loss in postmenopausal women .  HRT use is consistently associated with greater tooth retention and a reduced likelihood of edentulism in studies of elderly women . The number of studies on the effects of calcium or vitamin D intake on oral outcomes is limited , but suggest that higher intake levels are associated with reduced prevalence of clinical attachment loss and lower risk of tooth loss . Data from a prospect i ve study of oral health in men show a similar association between higher calcium intake and reduced alveolar bone loss . The number of teeth with progression of alveolar bone loss over a 7-year period was significantly lower among men whose calcium intake was at least 1,000 mg per day , compared to men with a calcium intake below this level . Future studies should confirm these findings and evaluate the oral effects of new medications for osteoporosis . If confirmed , the implication s for dental professionals may include an exp and ed array of medications for the treatment of periodontal disease and a greater emphasis on nutrition education for patients
Results indicate health behavior change is more likely to occur when patient-centered interventions design ed to increase knowledge and health beliefs , skills and abilities  , and  social facilitation  are delivered over time .
Little is known about the dimensions of osteoporosis prevention programs essential to changing health behaviors .
The purpose of this review was to determine the impact of select characteristics of structured osteoporosis prevention programs on calcium intake in women .