Osteoporosis self-management: Choices For Better Bone Health.

Abstract: Despite recent pharmacologic advances in the prevention and treatment of osteoporosis, the disease remains incurable. Effective disease management ultimately lies in the hands of the individual patient, who must take responsibility for key health behaviors related to bone health. One behavior modification strategy that has proven effective, but which has not previously been applied to osteoporosis, is "self-management." This article describes the principals, evolution, and initial outcomes of a new self-management program, Choices For Better Bone Health. Choices is a group education course directed to postmenopausal women who are at risk or already affected by osteoporosis, and has shown positive results in early evaluations.

Key Words: osteoporosis, quality of life, self-management, vertebral fracture

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Osteoporosis results in low bone mass and structural deterioration of the bone, ultimately leading to atraumatic fractures. In the United States alone, over 1.5 million fractures occur annually. Currently, this disease affects the lives of 44 million Americans, 10 million of whom already have osteoporosis, and 34 million of whom have low bone mass, a precursor to osteoporosis. (1) Postmenopausal women are among those at greatest risk of osteoporosis, but anyone of either gender or any race can develop this disease. In fact, 20% of people in the US who currently carry a diagnosis of osteoporosis are male. (2,3)

Osteoporosis is called the "silent thief" because it steals bone without immediate consequence or attention. It is not until the outcomes of this bone loss occur--that is, the fractures--that the problems caused by osteoporosis show through. Many people have what are called "silent fractures"; these are asymptomatic or mildly symptomatic vertebral fractures which do not cause people to seek medical care or diagnosis. However, it is essential to identify and treat osteoporosis as early as possible, especially before fractures occur. Prevalent fractures substantially increase the risk of future fractures. (4) And, even though vertebral fractures can be silent, subsequent fractures often cause severe acute pain and deformity in addition to other undesirable consequences. A water-fall of negative outcomes can occur with the first clinical or symptomatic fracture and becomes overwhelming if fractures continue to occur because of declining bone density or failure to modify bone health behaviors. (5)

In the last decade, medications have been developed to prevent and treat those people at risk of developing or who already have osteoporosis. Both antiresorptive and anabolic agents can reduce the risk of fractures. (6,7) Unfortunately, however, there is no cure for this disease. Thus, effective disease management for osteoporosis requires the individual to be willing to accept responsibility for adhering to recommendations in areas such as medication, exercise, and diet, and for avoiding potentially harmful behaviors such as smoking, drinking to excess, or inactivity. (8) Health care professionals can provide information about how best to increase bone density and decrease the risk of fractures, but they cannot force people to follow these strategies. Patient education alone is not sufficient to change key health behaviors. Only if a chronically ill person decides to take control of that illness can behavioral improvements occur. One method of helping a chronically ill person make those decisions is called "self-management." (9,10) Although self-management of chronic disease has been designed for use with other chronic illnesses for over a decade, no osteoporosis self-management program had ever been designed and implemented.

What is Self-management?

Self-management of chronic illness helps people take control of their own health and face the personal challenges each chronic disease creates. Originally based on Bandura's social learning theory and self-efficacy model, (11,12) self-management programs have been designed for a variety of chronic illnesses including asthma, (13) epilepsy, (14) diabetes, (15) fibromyalgia, (16) and arthritis. (17) Self-management has been used successfully in chronic disease management and can lead to both improvement in psychological outcomes and behavioral changes, as well as reduction of symptom severity. (18,19) To develop a self-management program that works, health educators need to identify the major challenges of a chronic illness, define viable ways in which patients can meet those challenges, and design teaching materials that convey essential information about the disease in language that is accessible to those people who have the disease.

With these guidelines in mind, we set out to design and test a self-management program for postmenopausal women with osteoporosis. Postmenopausal women were the initial target of the program because they are at high risk of developing osteoporosis. We believed that we could (1) educate these women about the disease and its outcomes, (2) provide them with behavioral strategies for maximizing bone health and minimizing symptoms such as chronic pain, depression, and social isolation, and (3) use a group setting to teach and reinforce these behaviors. This program was designed to help people control their osteoporosis and addresses three essential tasks: medical, psychological, and social management. Post-menopausal women who could face the challenges of osteoporosis and learn to manage the different aspects of this challenging disease would have--in the long run--improved quality of life.

The goal of any self-management program is to empower the individual to progress along a continuum of health behaviors. Empowerment is necessary before long-term changes in behavior can be made, and typically emerges when individuals believe that they themselves can change these behaviors; this is called self-efficacy. Self-efficacy cannot be achieved without time and reinforcement. Therefore, to learn, the individual must make a long-term commitment to a self-management program and must continue to practice self-management techniques long after the program itself has been completed.

Choices For Better Bone Health

Osteoporosis causes pain, deformity, and impaired physical and psychosocial functioning, each of which creates personal challenges for the women who suffer from it. The community-based group self-management program developed for postmenopausal women with osteoporosis is called Choices For Better Bone Health. (20) A major goal of Choices is to motivate patients to adhere to health behaviors that maintain or improve their long-term health status. The sessions in Choices emphasize the individual's central role in managing her disease and provide her with the disease-specific information and behavioral skills necessary to do so.

Choices was designed by a core development team with substantive input from the Choices Advisory Board (CAB). The CAB included specialists in nearly every area of osteoporosis management including physicians, nurses, physical and occupational therapists, and experts in fashion and the psychosocial consequences of osteoporosis. This multidisciplinary approach tried to ensure that Choices would address challenges from all aspects of osteoporosis and fractures.

Choices session format

Successful and permanent health behavior changes need time and reinforcement to occur. In designing Choices, we recognized that a single session would not provide sufficient time for behavior change. Therefore, Choices For Better Bone Health was designed for five 2 to 3 hour sessions given over a 5 to 10 week period. Each session includes lecture and discussion, individual and group work. Choices sessions are designed to be led by two facilitators: one, a health care professional who works with osteoporosis patients (physical or occupational therapist; social worker; physician), and the other, a person who has osteoporosis. This combined facilitator team offers participants both objective knowledge about osteoporosis and strong empathy for suffering brought on by osteoporosis. Detailed facilitator notes are provided as guidelines for those presenting the course. As noted above, Choices was designed to be a group program, with 10 to 15 participants per group.

Choices sessions are standardized so that participants know from the first day on what components to expect in each class. Each session is presented in two parts. The first includes the key learnings which are important to the bone health message for that session. The second part includes five steps of behavioral change, known in Choices as the 5 Cs of Bone Health Behavior. The 5 Cs of Choices are:

* Comprehend the importance of the new bone health behavior

* Choose between behavioral alternatives (past versus bone-healthy behavior)

* Conquer the challenges brought about by the new behavior

* Communicate behavioral choices to others (eg, family, friends)

* Commit to changing the selected behavior

Session titles, key learnings, and bone health behaviors are presented in Table 1.

Evaluation

Two evaluations have been conducted for Choices For Better Bone Health. (20-22) The first, the Alpha test, was designed to test the need for the course and the acceptability of its format and content on session 1 only. (20) The Beta test included all five sessions and had the following objectives: (1) to gather participant input on the course content and format of Choices; (2) to test the need and acceptability of the course materials and formats for all five sessions; (3) to test the utility and completeness of the facilitator notes; and (4) to test the outcomes questionnaires that had been developed for the evaluation of Choices. (21) The results from these evaluations have been published elsewhere (19-21) and suggest that the format and content of Choices were unanimously well accepted by participants and facilitators. Limitations of these tests include small sample size, and homogenous sample with regard to social class, education, and race. Additional testing is still ongoing.

Conclusion

Choices For Better Bone Health is a well-received group education course based on self-management strategies for postmenopausal women with osteoporosis. The strengths of Choices include its strong theoretical basis, its use of a facilitator team rather than a single facilitator, its format, which encourages reinforcement of concepts and behaviors, its group format, and its attention to changing behavior in addition to teaching information. Although a final evaluation has not been completed, data from earlier assessments seem promising. This self-management approach allows individuals to take charge of their own bone health and to engage in behavioral changes that can improve the quality of their skeletons and the quality of their lives.

Table 1. Choices For Better Bone Health session contents

Session number        Key learnings                   Bone health
and title                                             behaviors

Session #1: It's      Osteoporosis is not an          Getting enough
never too late        inevitable part of aging.       calcium and
                      It is never too early and       vitamin D is an
                      never too late to improve       important first
                      your bone health.               step in making
                      You can make your bones         bones healthier.
                      healthier.
Session #2: There's   You have choices of             You can take your
more you can do       osteoporosis medicines that     osteoporosis
                      can help make your bones        medicine as
                      healthier.                      recommended by
                      You and your health care        your health care
                      professional can select the     professional
                      right osteoporosis medicine
                      for you.
                      No one medicine is right for
                      everyone.
Session #3: Taking    Osteoporosis can lead to        You can manage
charge                changes in your social roles.   chronic pain and
                      Osteoporosis can cause          discomfort of
                      negative feelings and           osteoporosis.
                      thoughts.
                      A healthy outlook about your
                      osteoporosis can lead to
                      changes in those negative
                      feelings.
Session #4: Living    You can change your             You can do
safe and sound        environment to make it safer    exercises which
                      and prevent falls.              will reduce your
                      You can perform your daily      risk of falling
                      activities in ways which        and fractures.
                      reduce your risk of fracture.
Session #5: Putting   Your body changes with          You can develop a
it all together       osteoporosis.                   personal plan for
                      You can be stylish with         better bone health
                      osteoporosis.

Acknowledgment

The authors wish to thank Barbara E. Miller, PhD, without whose contributions Choices would not have been born.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9706-0551

References

1. America's bone health: the state of osteoporosis and low bone mass in our nation. 2002: Washington, DC: National Osteoporosis Foundation.

2. Orwoll ES, Bevan L. Phipps KR. Determinants of bone mineral density in older men. Osteoporos Int 2000;11(10):815-821.

3. Orwoll ES. Osteoporosis in men. Endocrin Metab Clin North Am 1998;27(2):349-367.

4. Silverman SL, Minshall ME, Shen W, et al. Health-Related Quality of Life Subgroup of the Multiple Outcomes of Raloxifene Evaluation Study. The relationship of health-related quality of life to prevalent and incident vertebral fractures in postmenopausal women with osteoporosis: results from the Multiple Outcomes of Raloxifene Evaluation Study. Arthritis Rheum 2001;44(11):2611-2619.

5. Fink HA, Ensrud KE, Nelson DB, et al. Disability after clinical fracture in postmenopausal women with low bone density: the fracture intervention trial (FIT). Osteoporos Int 2003;14(1):69-76.

6. Lippuner K. Medical treatment of vertebral osteoporosis. Eur Spine J 2003;12 Suppl 2:S132-S141.

7. Miller P. Analysis of 1-year vertebral fracture risk reduction data in treatments for osteoporosis. South Med J 2003;96(5):478-485.

8. Gold DT. The nonskeletal consequences of osteoporotic fractures. Psychologic and social outcomes. Rheum Dis Clin North Am 2001;27(1):255-262.

9. Holroyd KA, Creer TL. eds. Self-management of chronic disease: handbook of clinical interventions and research. Orlando, FL, Academic Press, 1986.

10. Schreurs KM, Colland VT, Kuijer RG, et al. Development, content, and process evaluation of a short self-management intervention in patients with chronic diseases requiring self-care behaviours. Patient Ed Counsel 2003;51(2):133-141.

11. Bandura A. Self-efficacy mechanism in human agency. Am Psychol 1982;37:122-147.

12. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs, NJ, Prentice Hall, 1986.

13. Beasley R, Cushley M, Holgate ST. A self management plan in the treatment of adult asthma. Thorax 1989;44:200-204.

14. Dilorio C, Hennessy M, Manteuffel B. Epilepsy self-management: a test of a theoretical model. Nurs Res 1996;45(4):211-217.

15. Day JL. Bodmer CW, Dunn OM. Development of a questionnaire identifying factors responsible for successful self-management of insulintreated diabetes. Diabet Med 1996;13(6):564-573.

16. Sandstrom MJ, Keefe FJ. Self-management of fibromyalgia: the role of formal coping skills training and physical exercise training programs. Arthr Care Res 1998;11:432-447.

17. Barlow JH, Turner AP, Wright CC. Long-term outcomes of an arthritis self-management programme. Br J Rheum 1998;37(12):1315-1319.

18. Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med 2003;26(1):1-7.

19. Gallant MP. The influence of social support on chronic illness self-management: a review and directions for research. Health Educ Behav 2003;30(2):170-195.

20. Silverman SL, Gold DT, Miller BE. Alpha and Beta test of Choices for better bone health: an osteoporosis self-management course. J Bone Miner Res 2000;15:S561.

21. Gold DT, Conditt MK, Silverman SL, et al. Bone health behaviors and self-efficacy: an analysis based on Choices for better bone health. Gerontologist 2002;42:59.

22. Silverman SL, Gold DT, Conditt MK, et al. Bone health behaviors and self-efficacy: an analysis based on Choices for better bone health. J Bone Miner Res 2002;17:S272.

RELATED ARTICLE: Key Points

* Effective prevention and management of osteoporosis can be achieved only with proper health behaviors.

* Self-management is a behavior modification strategy proven effective in the management of chronic disease other than osteoporosis.

* A recently-developed program called Choices For Better Bone Health has applied the techniques of self-management to osteoporosis with positive initial results among samples of at-risk populations.

RELATED ARTICLE: SCREENING FOR OSTEOPOROSIS.

Nelson B. Watts, MD

Director, University of Cincinnati Bone Health and Osteoporosis Center

Most guidelines recommend screening healthy older individuals (starting at age 65 for women and age 70 for men). Young people at "high risk" should also be tested, but there is a lack of consensus on what risk factors should be considered. Some suggestions include a family history of osteoporosis, a personal history of low-trauma fracture, cigarette smoking, and low body weight.

References for important guidelines are given below.

Physician's Guide to Prevention and Treatment of Osteoporosis. Washington DC: National Osteoporosis Foundation; 2003.

Binkley NC, Schmeer P, Wasnich RD, et al. What are the criteria by which a densitometric diagnosis of osteoporosis can be made in males and non-Caucasians? J Clin Densitom 2002;5(suppl):S19-S28.

Bray V. Osteoporosis screening guidelines. [International Society for Clinical Densitometry Web site, OsteoFlash, May 2003]. Available online at http://www.iscd.org/Visitors/osteoflash/index.cfm?Imonth = 5 & Iyear = 2003.

Cummings SR, Bates D, Black DM. Clinical use of bone densitometry. JAMA 2002;288:1889-1897.

Hodgson SF, Watts NB. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and management of postmenopausal osteoporosis, 2001 edition, with selected updates for 2003. Endocrine Practice 2003;9:544-564.

Khan AA, Brown J, Faulkner K, et al. Standards and guidelines for performing central dual X-ray densitometry from the Canadian panel of International Society for Clinical Densitometry. J Clin Densitom 2002;5:247-257.

Nelson HD, Helfand M, Woolf SH, et al. Screening for postmenopausal osteoporosis: a review of the evidence for the US Preventive Services Task Force. Ann Intern Med 2002;137:529-541.

US Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med 2002;137:526-528.

Deborah T. Gold, PHD and Stuart L. Silverman, MD, FACP, FACR 

From the Departments of Psychiatry & Behavioral Sciences, Sociology, and Psychology, Social and Health Sciences, the Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC, and from the Division of Rheumatology, Cedars-Sinai Medical Center, the David Geffen School of Medicine, University of California Los Angeles, and the Osteoporosis Medical Center Clinical Research Center, Los Angeles, CA.

Support for Dr. Gold was provided in part by grant AG-11268-09, the Duke Claude D. Pepper Center (OAIC), Center for the Study of Aging and Human Development, Duke University

Reprint requests to Deborah T. Gold, Ph.D., Box 3003, Duke University Medical Center, Durham NC 27710. E-mail: [e-mail]

Inquiries about obtaining Choices for Better Bone Health should be directed to Barbara E. Miller, Ph.D., at [e-mail].