Determinants of osteoporosis prevention in low-income Mexican--American women. (Original Article).

Background: Prevention is the most cost-effective means of managing osteoporosis. However, little is known about osteoporosis-related preventive practices in Mexican-American women. We examined factors that might influence women's decision to start preventive measures for osteoporosis.

Methods: Information was gathered through a cross-sectional survey of low-income Mexican-American women who were seen at two clinics in southern Texas.

Results: Of the 270 participants, 37% reported calcium supplementation, and 41% reported regular weight-bearing exercise to prevent osteoporosis. Fifty (41%) of the postmenopausal women were currently using hormone replacement therapy. Only 15% of the premenopausal and 13% of the postmenopausal women recalled that their health care provider had counseled them about prevention. Multivariate analysis showed that public education, bone densitometry evaluation, knowledge of osteoporosis, and counseling were determinants of prevention.

Conclusion: Although osteoporosis is a preventable condition, our findings suggest that the majority of Mexican-American women do not receive adequate preventive measures or counseling about osteoporosis. Furthermore, we found that their health care provider's counseling about osteoporosis was a major determinant of osteoporosis prevention in these women.

**********

Key Points

* Prevention is the most cost-effective means of managing osteoporosis.

* Counseling by health care providers is a major determinant of osteoporosis prevention in low-income Mexican-American women.

* The majority of low-income Mexican-American women do not receive adequate counseling for osteoporosis prevention.

Osteoporosis is a disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. (1) Each year, more than 1.5 million Americans have osteoporosis-related fractures accompanied by pain, deformity, and loss of independence. (2) Among women aged 80 years and older, 27% have osteopenia at one skeletal site, and 70% have osteoporosis. Sixty percent of the osteoporotic group have had one or more fractures of the proximal femur, vertebra, distal forearm, proximal humerus, or pelvis. (3) Prevention is the most cost-effective means of managing this disease and includes adequate nutrition, weight-bearing exercise, and use of bone antiresorptive agents. These measures focus mainly on preservation or restoration of bone mass. (4-8) Of the nutrients, calcium is the most important for preventing and treating osteoporosis, and sufficient data exist to recommend specific dietary calcium intake at various stages of life . In adults, calcium intake should be maintained at 1,000 to 1,500 mg/d, yet only approximately 50 to 60% of this population meets this recommendation. (9) Adequate dietary calcium is required to maximize the development of peak bone mass within an individual's genetic potential and to reduce bone resorption later in life. (10) Besides adequate nutrition, strong evidence indicates that physical activity early in life contributes to higher peak bone mass and may slow bone loss attributable to disuse in older adults. (11) In addition, regular exercise promotes mobility, agility, and muscle strength, all of which may help prevent falls. (12) Of the pharmacologic agents approved for prevention of osteoporosis, hormone replacement therapy (HRT) is the most cost-effective. (13) Women receiving HRT for more than 7 years have a 50% lower incidence of osteoporotic fractures than do nonusers. (14) Recently, results from the national osteoporosis risk assessment study showed that the odds of postmenopausal osteoporosis were greater for Hispanic women than for white women (odds ratio [OR], 1.31) (15) This finding suggests that Mexican-American women, a large community in the United States, (16) are at risk for osteoporosis unless adequate prevention is implemented. Thus, the purpose of this study was to identify factors that might influence Mexican-American women's decision to start preventive measures against osteoporosis and to assess their level of knowledge of and attitudes toward this condition.

Patients and Methods

Participants

This cross-sectional survey was based on a convenience sample of Mexican-American women who were recruited from both a community medical clinic in Laredo, TX, and a university rheumatology clinic in San Antonio, TX. The interviews were conducted between January and June 2001. Health care providers or medical residents who provided patient care under the direct supervision of a faculty member referred patients evaluated in the rheumatology clinic. These clinics offer medical care to predominantly low-income patients. Mexican-American women 18 years of age and older were eligible for participation in the study. Participants at each site received an explanatory letter attached to the questionnaire describing the purpose of the study, voluntary participation, and confidentiality. After receiving informed consent, participants completed a 45-item questionnaire available in English or Spanish. All women who were eligible for inclusion in the study agreed to complete the questionnaire. The average completion time pe r questionnaire was 15 minutes.

Measurements

Data were collected on the sociodemographic variables of age, body mass index, marital status, level of education, employment status, family income, public assistance, smoking, and alcohol use. We obtained information about risk factors for osteoporosis by asking participants about their menopausal status, history of hysterectomy, previous fragility fractures (hip, spine, and forearm), maternal history of hip fracture, and use of oral corticosteroids for at least 3 months. In addition, we asked participants whether they had had osteoporosis diagnosed or whether they had ever had a bone densitometry test. We determined the impact of public education and health care provider counseling about osteoporosis prevention, inquiring whether participants had received public information (television, radio, newspaper, or magazine) about this condition during the past month and whether they had been counseled by their health care providers about "ways to prevent osteoporosis" during the past year.

Two scales were developed to measure Mexican-American women's level of knowledge and attitudes about osteoporosis. The knowledge scale consisted of 12 closed-ended questions: six on background knowledge and six on risk factors for osteoporosis. The attitude scale, which reflects patients' interest and receptiveness, consisted of nine questions using the Likert method: six on attitudes toward osteoporosis prevention and three on attitudes relative to learning about osteoporosis. The internal consistency reliability of the items for knowledge and attitude, based on Cronbach's a coefficient, (17) was 0.68 and 0.74, which was considered an acceptable level of reliability. These scales were converted to standardized scores from 0 to 100 with higher scores indicative of higher knowledge and a more positive or receptive attitude toward osteoporosis prevention.

Statistical Analyses

Quantitative variables were expressed as means and standard deviations. We used contingency tables to compare the frequency distribution of calcium supplements, HRT, and exercise with sociodemographic and clinical variables. Simple logistic regression analysis was used to further estimate the association of the independent variables, the knowledge and attitude scales, with use of calcium supplements, exercise, and HRT. In the univariate analyses, variables significantly associated with these preventive measures (P [less than or equal to] 0.20) were entered into a multiple logistic regression model using the backward stepwise method. Results of the logistic regression modeling are presented as adjusted OR and 95% confidence intervals (CIs); significance level was set at P = 0.05. For the knowledge and attitude scales, we compared the mean score values of the participants by sociodemographic factors and osteoporosis prevention measures using the Kruskal-Wallis test. Statistical analyses were performed using SAS software package (SAS Institute, Inc., Gary, NC).

Results

A total of 270 women completed the questionnaire. The mean age of the participants was 44 [+ or -] 14.6 years (age range, 18-77 yr) with a mean body mass index of 29 [+ - or -] 5.7 kg/[m.sup.2]. Of the 270 participants, 143 (54%) were premenopausal, and 122 (46%) were postmenopausal at the time they completed the questionnaire (Table 1). The results of the women's knowledge and attitude scales by sociodemographic variables and selected preventive measures are shown in Table 2. The mean standardized knowledge score was 45.3 [+ or -] 20.9, and the mean attitude score was 79.7 [+ or -] 13. The prevalence of preventive measures and health care provider counseling about osteoporosis by age group is shown in Figure 1.

Calcium Supplementation

Overall, 101 (37%) of the 270 participants reported a daily intake of calcium supplements. Postmenopausal women reported calcium supplementation more frequently than premenopausal women (20.7 versus 16.7%, P = 0.008). Forty-five percent of the women taking calcium stated that their health care provider had counseled them about osteoporosis prevention. Moreover, women who received care at the rheumatology clinic were no more likely to take calcium than those who were seen at the community clinic (19.6% versus 17.7%, P = 0.90). The univariate analysis showed that women were more likely to take calcium if they were postmenopausal (OR, 2.19; 95% CI, 1.33-3.63), had had osteoporosis diagnosed (OR, 4; 95% CI, 1.85-8.66), had received a bone densitometry evaluation (OR, 4.08; 95% CI, 2.30-7.24), were using HRT (OR, 2.77; 95% CI, 1.63-4.72), had received public information about osteoporosis (OR, 2.57; 95% CI, 1.45-4.54), and had been counseled about osteoporosis prevention (OR, 3.17; 95% CI, 1.84-5.45). Logistic reg ression identified four variables that independently distinguished current calcium users from nonusers (Table 3). Calcium supplementation was strongly associated with bone densitometry evaluation, with these women being four times more likely to take calcium supplements compared with those who have never had this evaluation. In addition, health care provider counseling and public service information about osteoporosis emerged as significant predictors of reporting calcium supplement use. Finally, women who had received public information about osteoporosis were 3.5 times more likely to report use of calcium supplements.

Exercise

Of the 270 participants, 112 (41%) reported regular weight-bearing exercise at least three times per week. Only 34 (30%) of these women recalled that their health care provider had counseled them about osteoporosis prevention. A significant number of women who exercised were postmenopausal (54%) and overweight (83%), defined as a body mass index greater than 25. Twenty-five percent of the participants were current smokers, and 28% consumed alcoholic beverages at least once a month. Bivariate effects of the independent variables on the odds of regular exercise showed that Mexican-American women are more likely to exercise if they are postmenopausal (OR, 1.72; 95% CI, 1.06-2.80), use calcium supplements (OR, 1.69; 95% CI, 1.03-2.79), and have a higher knowledge of osteoporosis (OR, 1.02; 95% CI, 1.01-1.03) and a positive attitude toward this condition (OR, 1.03; 95% CI, 1.01-1.05). Furthermore, we found that corticosteroid therapy (OR, 0.57; 95% CI, 0.33-0.99) and being a smoker (OR, 0.48; 95% CI, 0.28-0.81) a re predictors negatively associated with regular exercise. The results of the multivariate analysis are presented in Table 3.

Hormone Replacement Therapy

Of the 122 postmenopausal women, 50 (41%) reported current HRT use. Sixty-four (52%) of these women had had hysterectomy, 35 (28%) reported a bone densitometry evaluation, and 21 (17%) had been found to have osteoporosis. Only 19 women (31%), however, had been counseled about osteoporosis prevention by their health care providers. Compared with non-HRT users, those receiving HRT were more likely to use calcium supplements (OR, 2.77; 95% CI, 1.63-4.72) and corticosteroids (OR, 1.94; 95% CI, 1.12-3.35), to have had a hysterectomy (OR, 4.42; 95% CI, 2.47-7.91), to have had a bone densitometry evaluation (OR, 3.01; 95% CI, 1.70-5.34), to have met other women with osteoporosis (OR, 2.35; 95% CI, 1.38-4.02), and to have been counseled about HRT use by their health care provider (OR, 2.35; 95% CI, 1.36-4.09). In the multivariate model, women who reported that they had been counseled about osteoporosis prevention by their health provider were almost three times as likely to report HRT use as women who reported that they had not been counseled. A history of hysterectomy and a bone densitometry evaluation were also predictors independently associated with HRT use (Table 3).

Discussion

Prevention strategies to reduce risk of osteoporosis include adequate nutrition, behavioral modifications, and pharmacologic intervention. Among the nutrients, calcium has a unique role in the maintenance of bone status and may be a factor in optimizing bone health from childhood through late adulthood. Despite the evidence supporting the positive effects of dietary calcium on bone, national surveys indicate that calcium intake in women of all age groups is consistently lower than current recommendations. (18) Dixon et al, (19) using data from the National Health and Nutrition Examination Survey III, showed that among Mexican-American women aged 25 to 64, only 14.5% of those who did not speak English and 15.5% of those who did met the recommended calcium dietary allowance. Moreover, it has been estimated that $2.6 billion in direct medical cost of osteoporotic fractures would be avoided if women older than 50 years of age would consume approximately 1,200 mg supplemental calcium. (20) Studies in premenopausal women have also shown that calcium supplementation of approximately 1,000 mg/d can prevent bone loss at all clinically relevant skeletal sites. (21, 22) The results of this study suggest that the majority of both premenopausal and postmenopausal Mexican-American women do not take calcium supplements as a measure to preserve their bone mass. Furthermore, the rates of calcium supplements reported by women at high risk for osteoporosis, such as those taking corticosteroids, were inadequate, despite the evidence that calcium supplements 800 to 1,000 mg/d and vitamin D 250 to 500 IU/d may prevent bone loss in the lumbar spine and hip in patients receiving long-term, low-dose corticosteroid therapy. (23)

We found that bone densitometry evaluation emerged as a strong determinant of calcium supplementation and HRT in Mexican-American women. A low bone mineral density report has been shown to influence health-related behavior in postmenopausal women, including initiating calcium supplements, increasing dietary calcium, decreasing caffeine, increasing exercise, decreasing smoking, and taking precautions against falls. (24) Studies in predominantly white postmenopausal women have also shown that the result of bone densitometry has a substantial effect on decisions about HRT. (25,26) Densitometry results may be useful for women whose decisions about HRT are made on other grounds, if the results encourage them to undertake other beneficial preventive measures. (26) Although most physicians (approximately 75%) would recommend calcium supplements and weight-bearing exercise in younger patients for the prevention of osteoporosis, (27) we found that only 15% of the premenopausal women and 13% of the postmenopausal women reported that they had been counseled about osteoporosis prevention. Furthermore, health care providers' counseling practices about osteoporosis prevention were similar at the university and community clinics (14.8% versus 14.4%). However, women who reported counseling about osteoporosis prevention were almost three times as likely to report calcium supplementation and HRT use as women who reported that they had not been counseled by their health care provider. Therefore, health care providers' discussion about osteoporosis prevention had a major impact in the decision of these Mexican-American women to start both calcium supplements and HRT use. Similar findings in women from other ethnic groups have also shown the substantial role of health care providers' counseling in the decision of women to initiate HRT. (28,29)

The prevalence of HRT use among postmenopausal women in this study was slightly higher (41%) than rates in similar populations. (30,31) Among Mexican-American women, rates of HRT have ranged from 4.7% in a population-based survey (30) to 12.7% in a survey of low-income women evaluated in an urban hospital-based clinic. (31) The prevalence of HRT use in our sample of postmenopausal Mexican-American women was similar to that observed in white women. (32) One explanation for the higher rate of HRT use, as suggested by other studies, may be that a significant number of postmenopausal women were younger (33) and had undergone hysterectomy. (34,35) Therefore, they were more likely to take HRT for menopausal symptoms. In addition, almost half of the postmenopausal women had received advice from their health care provider about HRT, which may have provided an opportunity to discuss the benefits of HRT. Our findings also suggest that Mexican-American women do not have adequate knowledge of osteoporosis and its associa ted risk factors. However, they show a positive attitude toward osteoporosis, and they are willing to start any investigation or treatment to prevent this condition. We observed a greater knowledge about osteoporosis among women who had a college education, a history of hysterectomy, or exposure to another woman with osteoporosis. Interestingly, the main sources of knowledge about osteoporosis for Mexican-American women apparently were public information and contact with patients who had osteoporosis. In addition, public information appears to be a major determinant for a positive attitude toward osteoporosis. Furthermore, women who reported following any of the osteoporosis preventive measures investigated consistently showed more knowledge of osteoporosis and a positive attitude toward regular exercise. However, neither greater knowledge about osteoporosis nor a positive attitude toward the condition was a major determinant of prevention, with the exception of those women in whom more knowledge of osteoporo sis was associated with regular weight-bearing exercise. We believe this is the first study to evaluate Mexican-American women's level of knowledge about osteoporosis and attitudes toward it.

We note several limitations of our study. First, health care provider counseling, screening, and preventive measures were determined by patient recall rather than by chart review and may have underestimated the actual rate of patient counseling. Second, several bone antiresorptive agents for osteoporosis prevention have been approved and could have been prescribed to these women. (36) However, because these agents are costly, we limited the pharmacologic prevention measures to HRT.

Conclusion

In Mexican-American women, a bone densitometry evaluation, knowledge about osteoporosis, history of hysterectomy, public education, and health care provider counseling are determinants of osteoporosis prevention. Our findings should encourage health care providers to increase their counseling practices regarding the prevention of osteoporosis.

[FIGURE 1 OMITTED]

Table 1

Characteristics of 270 survey respondents (a)

                                    Community  University
                                     clinic      clinic
                                    (n = 127)  (n = 143)
Characteristics                      No. (%)    No. (%)

Mean age (years) (b)                48 (13.2)   40 (14.9)
Mean BMI (kg/[m.sup.2]) (b)         30 (6.9)    28 (4.2)
Married                             63 (49.6)   84 (58.7)
Education
  Elementary                        31 (24.0)   26 (18.1)
  High school                       76 (59.8)   75 (52.4)
  College                           20 (15.7)   42 (29.3)
Employment
  Yes                               44 (34.6)   73 (51.4)
  No                                83 (65.3)   69 (48.5)
Public assistance
  Yes                               36 (28.3)   75 (52.4)
  No                                91 (71.6)   68 (47.5)
Family annual income
  > $20,000                         40 (31.4)   34 (23.7)
  < $20,000                         87 (68.5)  109 (76.2)
Life-style
  Smoking currently                 37 (29.1)   56 (39.1)
  Alcohol consumption               18 (14.1)   66 (46.1)
Health-related variables
  Hysterectomy                      46 (36.2)   22 (15.3)
  Postmenopausal                    61 (54.1)   61 (42.6)
  Osteoporotic fractures             8 (6.2)    38 (26.5)
  Maternal history of hip fracture  16 (12.5)   33 (23.0)
  Steroid use for > 3 months        55 (43.3)   28 (19.5)
  Bone densitometry                 27 (21.2)   42 (29.3)
Osteoporosis prevention
  Calcium supplements               48 (37.7)   53 (37.0)
  Hormone replacement therapy use   28 (22.0)   36 (25.1)
  Regular weight-bearing exercise   51 (40.1)   61 (42.6)

(a)BMI, body mass index.

(b)Values are mean ([+ or -] standard deviation,).

Table 2

Knowledge about and attitudes toward osteoporosis among Mexican-American
women (n = 270) (a)

                                          No. of     Knowledge score,
Characteristics                        participants     mean (SD)

Education

 Elementary                                 57         42.2 (21.7)
 High school                               151         44.0 (20.9)
 College                                    62         51.5 (19.3) (b)

Income

 > $20,000                                  74         51.3 (19.5) (b)
 < $20,000                                 195         43.3 (21.0)

Smoker

 Yes                                        93         41.8 (20.2)
 No                                        177         47.1 (21.1)(b)

Alcohol use

 Yes                                        84         44.3 (19.1)
 No                                        186         45.8 (21.8)

Hysterectomy

 Yes                                        68         49.9 (26.1) (b)
 No                                        202         43.8 (18.7)

Fractures

 Yes                                        46         45.1 (17.8)
 No                                        224         45.4 (21.6)

Osteoporosis counseling

 Yes                                        80         49.3 (20.3)
 No                                        190         43.8 (20.9)

Menopausal status

 Premenopausal                             148         44.2 (17.9)
 Postmenopausal                            122         46.5 (23.7)

BMD test (postmenopausal)

 Yes                                        44         49.0 (21.3)
 No                                         78         45.3 (24.8)

Public information about osteoporosis

 Yes                                       181         49.4 (20.4) (c)
 No                                         89         37.1 (19.6)

Know someone with osteoporosis

 Yes                                        93         50.3 (20.6) (b)
 No                                        177         42.7 (20.7)

Regular exercise

 Yes                                       112         50.1 (20.7) (b)
 No                                        158         41.9 (20.5)

Calcium supplements

 Yes                                        99         50.7 (20.4) (b)
 No                                        171         42.1 (20.7)

HRT use (postmenopausal)

 Yes                                        50         50.4 (21.4) (b)
 No                                         72         43.1 (20.4)

                                       Attitude score,
Characteristics                           mean (SD)

Education

 Elementary                              82.8 (12.9)
 High school                             79.2 (12.4)
 College                                 78.1 (14.2)

Income

 > $20,000                               78.8 (12.8)
 < $20,000                               80.1 (13.0)

Smoker

 Yes                                     77.1 (11.4)
 No                                      81.0 (21.8) (b)

Alcohol use

 Yes                                     76.6 (13.2)
 No                                      81.0 (21.8) (b)

Hysterectomy

 Yes                                     77.4 (14,0)
 No                                      80.4 (12.6)

Fractures

 Yes                                     78.4 (15.3)
 No                                      79.9 (12.5)

Osteoporosis counseling

 Yes                                     80.1 (11.7)
 No                                      79.6 (13.5)

Menopausal status

 Premenopausal                           73.6 (10.7)
 Postmenopausal                          74.1 (12.8)

BMD test (postmenopausal)

 Yes                                     70.0 (14.6)
 No                                      76.2 (11.4)

Public information about osteoporosis

 Yes                                     81.9 (11.3) (c)
 No                                      75.1 (15.0)

Know someone with osteoporosis

 Yes                                     80.2 (14.6)
 No                                      79.4 (12.1)

Regular exercise

 Yes                                     81.4 (13.6) (b)
 No                                      78.4 (12.4)

Calcium supplements

 Yes                                     80.9 (13.5)
 No                                      79.0 (12.7)

HRT use (postmenopausal)

 Yes                                     72.9 (12.6)
 No                                      74.3 (11.4)

(a)SD, standard deviation; BMD, bone mineral density; HRT, hormone
replacement therapy.

(b)P < 0.05.

(c)P < 0.0001.

Table 3

Independent predictors of osteoporosis prevention in Mexican-American
Woman (a)

                             Adjusted
                               odds                  P
Variables                     ratio     95% CI     Value

Calcium supplements

 Public information about      3.51    1.81-6.79   0.002
  osteoporosis
 Prevention counseling         2.66    1.44-4.93   0.001
 Bone densitometry             4.55    2.35-8.81  <0.0001
 Body mass index > 25          0.50    0.26-0.96   0.040

Exercise

 Corticosteroid therapy        0.53    0.30-0.94   0.028
 Smoker                        0.48    0.27-0.85   0.012
 Greater knowledge about       1.02    1.01-1.03   0.004
  osteoporosis
 Income > $20,000              0.47    0.25-0.86   0.014

Hormone replacement therapy

 Hysterectomy                  2.64    1.20-5.80   0.015
 Bone densitometry             2.48    1.03-5.96   0.042
 Prevention counseling         2.99    1.27-7.06   0.012
 Alcohol use                   0.19    0.06-0.57   0.003

(a)CI, confidence interval.

Accepted June 26, 2002.

Acknowledgment 

We thank Jacqueline Gandre for her assistance with manuscript preparation.

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From the Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX; Gateway Community Health Center, Laredo, TX; and Audie L. Murphy Division, South Texas Veterans Health Care System, San Antonio, TX.

Reprint requests to Carlos H. Orces, MD, Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9605-0458