Long-term glucocorticoid use leads to glucocorticoid-induced osteoporosis (GIOP) and fractures which require proper management. Little is known about the "real-world," long-term costs and effectiveness of anti-osteoporotic treatments. A retrospective analysis of data from the 1996-2004 Medical Expenditure Panel Survey was conducted to evaluate the "real-world" outcomes. Markov modeling with Monte Carlo simulations was used to yield long-term estimates of these outcomes. A total of 5,461 subjects met the study criteria for long-term glucocorticoid users (LTGS, average prednisone-equivalent dose=11.0 mg/day, average length=237 days), which represents 2.3% of the non-institutional U.S. population. The study subjects tended to be middle-aged (49.7 years old), female (61.4%) and white (86.2%). Overall 22.4% of LTGS users reported use of any anti-osteoporotic agent. Hormone replacement therapy (HRT) was the most frequently used in women followed by bisphosphonates, while bisphosphonates and calcitonin were used by men. Analyses of variance indicated some significant differences in characteristics of LTGS users among treatment groups which suggest a selection bias. Female LTGS users had higher prevalence rates (6.8%) of osteoporosis than males (1.0%), but the prevalence rates of osteoporotic fractures were similar (3.0%). The logistic regression analyses indicated that the use of oral glucocorticoid tablets does not significantly change the odds of osteoporotic fractures in study subjects (relative risk (RR)=1.146, 95% confidence interval (CI) 0.901-1.458 for subjects in the WELL state; RR=0.55, 95% CI 0.188-1.621 for subjects in the GIOP state; RR=1.241, 95% CI 0.532-2.893 for subjects in the GIFX state). The estimated 10-year and lifetime incremental cost per osteoporotic fracture avoided are $27,253-$35,692 (10-year) and $84,942-$91,075 (lifetime) in hypothetical female glucocorticoid users. HRT is the most cost-effective option for hypothetical females except that calcitonin is preferred for 65-year-old females receiving lifetime treatments. When HRT is excluded, calcitonin is the next most cost-effective option except that raloxifene is preferred for 30- and 50-year-old females receiving 10-year treatments. Calcitonin is the most cost-effective option for male glucocorticoid users. Bisphosphonates are less cost-effective which may be due to selection bias. Anti-osteoporotic treatments are recommended for all long-term glucocorticoid users, but the preferred option depends on gender, age, length of treatments and budgets.

The purpose of this study was to describe and evaluate a health education program provided primarily for older women who have or suspect they have osteoporosis. The health education program evaluated is provided by the Ostop Society of British Columbia (Ostop). One of the goals of the study was to provide Ostop with descriptive information about the organization's members, their participation in the organization's education program and their evaluation of the value of the information sources provided by the organization. A second goal was to evaluate the relationships between variables which may explain how Ostop functions as a provider of osteoporosis health education. Bandura's social learning theory was used to provide a theoretical explanation of the Ostop education program, to identify study variables and to generate the research questions. The variables that were expected to be related to the members' level of knowledge about osteoporosis were selected personal characteristics, the amount of participation in Ostop, and members' perceptions about the value of the different sources of information provided by Ostop. The same variables plus members' level of knowledge about osteoporosis were expected to be related to the level of participation in health behaviors believed to help prevent or slow the progression of osteoporosis. The study sample consisted of 120 women members of Ostop, randomly selected from a membership list which contained the names of 261 women members of Ostop. All of the members included on the list lived close enough to Vancouver, British Columbia to attend the lecture series offered by Ostop. The study group is a random sample of Ostop members but may not accurately represent all women with or at risk of developing osteoporosis. Ostop is a special interest group which tends to attract as members well educated women with at least some prior awareness of and concern about the condition. The data were collected by means of a mailed questionnaire which was developed for this study. The content of the questionnaire was based on the recent osteoporosis research literature, and the advice of a variety of content experts. Prior to conducting the study, the researcher pilot tested the questionnaire using nine Ostop members. The descriptive information demonstrated that members are typically post-menopausal women in their sixties and seventies who have osteoporosis and who have an educational attainment of at least graduation from high school. The respondents were well-informed about osteoporosis and were more likely to practice health behaviors related to calcium intake than to perform the recommended amount of exercise. One important finding was that 66% of the respondents reported daily intakes of calcium which exceeded the highest recommended daily intake. This is of concern in light of research findings that excessive calcium intake is associated with the development of kidney stones in some women. Regression analysis of the study variables demonstrated that: 1. the number of Ostop-provided information sources identified by respondents as being useful was positively and significantly (p≦.05) correlated with knowledge level. 2. Both age and menopause status were negatively and significantly (p≦.05) correlated with knowledge level. 3. The only variable which was correlated significantly (p≦.05) with the performance of osteoporosis-related health behavior was knowledge level. This was a weak positive correlation of .234. These results suggest that Ostop’s present educational program may be helping women gain knowledge about osteoporosis and that having knowledge about osteoporosis is one factor which is associated with the practice of recommended health behavior. Social learning theory was used to explain the results and to suggest ways in which Ostop may be able to increase the effectiveness of its educational efforts. Suggestions were also made about other ways to provide osteoporosis health education and about directions for further research. / Education, Faculty of / Educational Studies (EDST), Department of / Graduate

Background Lactose intolerance is a common condition which individuals are not able to completely digest lactose. Each individual has varying degree of lactose intolerance varying level of symptoms experienced. Due to the symptoms of lactose intolerance, lactose intolerant individuals are likely to eliminate milk and dairy products from their diet. Actually, milk and other dairy products are the preferred food sources of calcium for most people. It is essential to maintain adequate calcium intake everyday for the proper growth and development of bones. Individuals who avoid milk and dairy products from diet may not meet the daily requirements for calcium. Therefore, the lactose intolerant individuals are at a higher risk of osteoporosis. Calcium supplementations are an alternative source of calcium for lactose intolerant individuals who have low calcium intake to meet their daily needs. Objectives This review is to assess the impacts and effect of calcium supplements on bone density and bone fracture risk in lactose intolerant individuals. Methodology HKU library database, PubMed, and reference screening for trials published in English from 1990 to May 2014. Randomized, controlled trials of individuals using calcium supplements (calcium carbonate and calcium citrate malate) and placebo group with bone fractures and bone mass density as outcome measure. Finding Adding calcium supplements into a low calcium diet reduces the rate of bone loss and prevents bone fractures. Evidence for calcium supplements in significant reduction of bone mass density; however, the impact of calcium supplements on bone fracture risk remains unclear. Conclusion Based on my review, it shows that there is an association between the use of calcium supplementations and retardation of the rate of bone loss as well as reduction in bone fracture risk in individuals with low dietary calcium and are generally compliance with the treatment. To get enough calcium through diet is encouraged over calcium supplements. / published_or_final_version / Public Health / Master / Master of Public Health

Osteoporosis is a serious health problem worldwide and most commonly affects postmenopausal women (World Health Organization, 1994). Of the variety of complications associated with osteoporosis in postmenopausal women, osteoporotic fracture is the most prevalent and serious one. It affects their quality of life and puts heavy burden on the healthcare system in Hong Kong. Since osteoporosis exercise program can help to reduce bone loss, it seems to be an effective strategy to prevent and manage osteoporosis in postmenopausal women. The purpose of this study is to develop an evidence-based osteoporosis exercise education program for postmenopausal women, based on the best available evidence, with an aim of helping them to prevent and manage osteoporosis through the prevention and reduction of bone loss and its related fractures. A search of literature from four databases, including Pubmed (1997 to August 2011), CINAHL Plus (1937 to August 2011), Cochrane Library (1996 to Issue 8 of 2011) and EMBASE Classic + EMBASE (1947 to August 2011), was done to identify relevant randomized controlled trials (RCTs). The methodology checklist for RCTs developed by the Scottish Intercollegiate Guidelines Network (SIGN, 2008) was used to evaluate the quality of the selected studies. A total of nine studies met the inclusion criteria and did not violate the exclusion criteria. The findings of these studies showed that exercise intervention or program significantly reduced postmenopausal women’s likelihood of having fracture and also improved their bone mass density slightly. Among the reviewed studies, programs were most commonly implemented within a 12-month period and two 60-minute supervised exercise sessions were delivered per week. The potential of implementing the proposed program, based on the evidence from the literature review, to local practice was assessed. Based on the assessment, the proposed program is necessary and beneficial for postmenopausal women. An evidence-based osteoporosis exercise education program is developed based on the best available evidence. The SIGN grading system was utilized to provide grades for the recommendations in the guideline. An effective and adequate communication with potential stakeholders to gain their support and cooperation for the proposed program is essential. In addition, a tailor-made pilot test is also crucial for ensuring the successful implementation of the proposed program. The pilot study will be conducted in a local practice and the targeted participants are 124 postmenopausal women. Data analysis will be done by the paired t-test. The proposed evidence-based osteoporosis exercise education program will be considered as effective if (1) there is a reduction of bone loss and an increase in physical activity level in postmenopausal women, and (2) there is an increase of confidence and self-perceived skill on the prevention of management of osteoporosis in nurses. / published_or_final_version / Nursing Studies / Master / Master of Nursing

Distal radius fracture (DRF) is one of the most common fall-related osteoporotic (OP) fracture and is an early predictor of subsequent falls and OP fractures among people with DRF. The majority of older people with DRF present with low bone mineral density (BMD) and there is often transition to reduced muscle strength, poor balance, fear of falling and physically inactive lifestyle after fall-related DRF. This thesis consists of three manuscripts which are aimed to explore the recovery patterns and the role of modifiable risk factors in predicting subsequent falls, OP fractures and BMD in patients with DRF. The first manuscript explores the recovery patterns in modifiable risk factors for falls and OP fractures over four years in patients with DRF. Our study findings showed that patients with DRF experienced both short-term (6 months) and long-term (4 years) improvement in fracture specific pain/disability, physical activity, fear of falling, BMD and general health status; although the majority of the recovery was achieved at six months after DRF. The second manuscript is a cross-sectional study identifying modifiable risk factors for BMD in patients with DRF. The unaffected hand grip strength was identified as the independent predictor of BMD explaining 17% and 12% of total variability in the BMD-femoral neck and BMD-total hip, respectively. Among age-stratified women with DRF, balance and unaffected hand grip strength were identified as independent determinants of BMD explaining 10% and 32% of the total variability in BMD-femoral neck among 50-64 year and 65-80 year old, respectively. The third manuscript is a longitudinal study identifying modifiable risk factors for subsequent falls and OP fractures at four years after DRF. The results suggest that nearly 24% of patients reported one or more subsequent falls (in the last six months) and 19% of patients experienced at least one subsequent OP fracture after DRF. Patients with poor balance, low BMD, fracture specific pain/disability of >81 points on patient-rated wrist evaluation questionnaire and presence of a prior history of multiple falls (≥2) had three times higher odds of subsequent falls. When adjusted for BMD, age and gender, only prior falls was identified as a significant independent predictor of subsequent falls. We were not fully powered to explore association of various modifiable and non-modifiable risk factors with subsequent fractures. However, we found that patients with osteopenia or osteoporosis had clinically four times higher odds of subsequent OP fractures than patients with normal BMD. / Thesis / Doctor of Philosophy (PhD) / Wrist fractures are the most common fall-related fragility fractures and often an early indicator of future falls and fractures. This thesis project described recovery patterns in various risk-factors at 4-years after wrist fracture and explored their association with bone mineral density (BMD) and subsequent falls and fractures. We found that the majority of recovery in fracture-specific pain/disability, fear of falling and health-status takes place within six months, although small changes were also noted between 6 months-4 years. People with low unaffected hand grip-strength might have low BMD. Furthermore, people with poor balance, greater fracture-specific pain/disability, osteopenia or osteoporosis and a prior history of multiple falls (≥2) had nearly 3 times higher odds of secondary falls and those with osteopenia or osteoporosis had 4 times higher odds of a secondary fracture. We believe this information will help therapists/clinicians to identify people at risk of future falls/fractures and offer preventive services.

Osteoporosis is one of the most common diseases experienced in the older adult population. This condition is not only costly to manage and treat, particularly so when osteoporotic fractures occur, but also negatively impacts functional health and health-related quality of life for many individuals. This indicates the need for more to be done to prevent osteoporosis from developing initially. While bone mineral density (BMD) testing recommendations are in place for women aged 65 and older and men aged 70 and older to diagnose osteoporosis, there currently are no BMD testing recommendations for preventive or screening purposes in the general, healthy, adult population. One potential screening tool for bone strength is a peak vertical jump test. Peak vertical jump height can be used as a proxy for lower body muscle power, which has been identified as an influential factor in determining bone mass and geometry, both of which are critical aspects of bone strength. This study ascertained the relationship between muscle power and bone strength, as well as the capacity of a peak vertical jump test to identify young adults with below-average areal BMD (aBMD). A total of 303 young adults (18 to 22 years, n=136 males, n=167 females) participated in these cross-sectional analyses. DXA was used to assess aBMD for total hip and femoral neck, and DXA images were used to calculate femoral neck section modulus (FN Z) values. Peripheral quantitative computed tomography (pQCT) was used to assess indices of bone strength at the tibia. Cortical bone area (CoA) and density-weighted polar section modulus strength-strain index (SSIp) were assessed at the 38% midshaft site, and bone strength index (BSI) was assessed at the 4% midshaft site. Lower body muscle power was predicted using peak vertical jump height and the Sayers et al. (1999) equation. Data were analyzed using Pearson bivariate and partial correlations to examine associations among bone strength outcomes and muscle power. Logistic regression was used to examine the probability of below-average bone strength based on muscle power. Receiver Operating Characteristic (ROC) curve analysis was used to show the tradeoff between sensitivity and specificity and to display the accuracy of a peak vertical jump test as an assessment tool for aBMD. Logistic regression indicated the odds ratio of below-average height-adjusted femoral neck aBMD decreased 5.4% for females and 3.6% for males per 50 Watts of power. ROC curve analysis showed the best sensitivity-specificity trade-off for identifying individuals with and without below-average aBMD was 5,038 Watts in males (sensitivity = 73.7%; specificity = 62.4%; AUC = 0.709, 95%CI = 0.572 - 0.847) and 3,261 Watts in females (sensitivity = 71.4%; specificity = 58.9%; AUC = 0.708, 95%CI = 0.586 - 0.829). These cut off values correspond to a vertical jump height of 54.39 cm and 36.16 cm for males and females, respectively. Taken together, the results of these analyses suggest acceptable sensitivity and specificity and moderate discriminate ability for using a measure of muscle power, assessed with a peak vertical jump test, to identify young adults with below-average aBMD.

The purpose of this study was to determine the effects of long-term weighted vest exercise on hip bone mass, functional ability and static balance in elderly women. This was a within subject exercise intervention study and included a 6-month control period. Twenty-three subjects (age 85 �� 6) were recruited and observed for 6-months, then debar a 9-month exercise program. Due to attrition during the control period, five subjects were recruited to add to the exercise group. Training entailed three supervised exercise sessions per week for nine-months designed to overload the lower extremity neuromuscular system. Training stimulus was one of two sets of six to twelve repetitions using weighted vests for progressive resistance. Measurements for bone mineral density (BMD) were assessed using dual energy x-ray absorptiometry (Hologic QDR-1000/W). Static balance measurements were made using the Biodex Stability System. Functional ability tests consisted of: leg strength and power (chair raises and sit to stand) and gait speed (tandem, wide and narrow gait and circular path) and was assessed monthly for six months. Comparisons were conducted using repeated measures analysis of variance. Significant improvements were observed for chair raises 13%, sit to stand 13%, tandem gait 30%, wide gait 22%, narrow gait 20% and circular path 20% following the exercise period. No significant changes were detected (p>0.05) for BMD at the femoral neck and trochanter, but BMD was maintained during the exercise period. Further, there was a trend for improved body composition in the exercise versus the control period. Static balance did not change following the observational or exercise period. In conclusion, a practical exercise program of lower extremity training using weighted vests for resistance improves functional ability in women over 75 years of age. Since improved may function transfer to improved postural stability, these results have important implications for design of exercise programs to reduce fall risk in the elderly. / Graduation date: 1997

The purpose of this study was to compare the levels of bone mineral density (BMD) of the whole body (WB) and proximal femurs of physically active men with spinal cord injuries (SCI) to nonactive men with spinal cord injuries. Also, the lean muscle mass (LMM) of active men with SCI was compared to the LMM of nonactive men with SCI. In addition, BMD values of the radii of physically active men with SCI were compared to that of able bodied men of the same age. The subjects N. 46 were between the age of 20-55 (��=37.83 �� 6.63 years), and were at least 2 years post spinal cord injury. Subjects with SCI were matched on similar level of lesion of the spinal cord, age, height, weight, and years post injury for the purpose of analyzing data. There were 14 active men with paraplegia and 14 nonactive men with paraplegia, 9 active men with quadriplegia and 9 nonactive men with quadriplegia. All BMD data was obtained utilizing a Hologic QDR 1000W dual energy x-ray absorptiometer. A two-factor (level by group) analysis of variance revealed no significant difference for all sites (Whole body, Total hip, radii, LMM) comparing the active and nonactive men with SCI. T-scores and z-scores generated from the Ho logic QDR 1000/W were analyzed using two-factor ANOVA (level by group). The active men with paraplegia had significantly higher BMD levels for all sites when compared to the other groups. These values may be explained by the number of incomplete injuries in the experimental group. Subjects in the physically active group did not clearly show a statistically significant difference on any of the dependent measures. However, values for the dependent measures were higher for the physically active group compared to the values of the nonactive group. / Graduation date: 1995

Building on Message Framing Theory and the Elaboration Likelihood Model (ELM), this study examined how message frame impacts viewer attention to and cognitive processing of osteoporosis prevention print ads. Attention was measured with eye tracking technology, which calculated participants’ number of fixations and dwell time. Cognitive processing was assessed through a textual masked-recall exercise. Sixty women, with a mean age of 21.25+/-2.61 years, viewed the same 36 ads; however, the message frame changed on a randomized, rotating basis, resulting in each group viewing 12 gain-, 12 loss-, and 12 neutrally-framed ads. One-way repeated measures analyses of variance revealed that message frame significantly impacted viewers’ number of fixations, F(2,118)=8.18, p<.01, η2= .12 dwell time, F(2,118)=9.84, p<.01, η2= .14 and masked-recall results, F(2,118)=22.28, p<.01, η2 = .27. Viewers’ number of fixations, dwell time and recall of gain-framed osteoporosis prevention ads was significantly higher than to loss- or neutrally-framed ads, p<.01. Message frame was also positively correlated with number of fixations, r=.29, p<.02 and dwell time, r=.42, p<.01. Findings may help expand theory related to message framing and the ELM, while contributing to advancements in eye tracking literature and health communications practice. / Thesis (Master, Kinesiology & Health Studies) -- Queen's University, 2009-08-27 16:13:32.848

Twenty-nine college females, aged 18-29, participated in a six month boron supplementation protocol to evaluate mineral and hormone status of athletes and non-athletes. All subjects were classified into activity and oral contraceptive groups as follows: athletes (n=16), non-athletes (n=13), oral contraceptives (n=12), and no oral contraceptives (n=17). Subjects were randomly assigned to receive a placebo or 3 mg of boron per day. Subjects' maximal oxygen consumption (VO₂max) was assessed as a baseline measurement and was used to confirm a difference between activity groups. Body fat, height, bone mineral density, and serum calcitonin and parathyroid also were baseline measurements. Subjects were measured at baseline and six months for the following: dietary intake, body weight, serum levels of 17-f-estradiol, progesterone, and testosterone, and plasma and urine levels of calcium, phosphorus, magnesium, and boron. Athletes had a Significantly greater VO₂max (p < 0.01) than did non-athletes. Subjects taking oral contraceptives had significantly lower serum estradiol (p < 0.05) as compared to subjects not taking oral contraceptives. Boron supplemented non-athletes had a significantly greater change in plasma calcium levels (p < 0.05) as compared to boron supplemented athletes, although the athletes had a significantly higher plasma calcium level (p < 0.05) at the baseline measurement. Control subjects (n=6) had a significantly greater change in dietary carbohydrate (p < 0.01) and protein intake (p < 0.05) as compared to subjects taking boron (n=23). Boron supplementation did not appear to significantly influence any of the parameters measured. However, boron supplementation combined with activity appeared to influence plasma calcium, while serum estradiol may be influenced by oral contraceptives. / Master of Science