The Influence of Osteoporosis Education and Bone Mineral Density Testing on
Calcium Intake and Exercise in Young Postmenopausal Women

Sherry Preston
B.S.N., University of Victoria, 1996

Project Submitted In Partial Fulfillment Of
The requirements For The Degree Of
Masters Of Science
m

Nursing: Family Nurse Practitioner

The University of Northern British Columbia
April2009

VNlvERS

BRlT'ISffYH ofNORTHERN
COLUMBIA
LIBRARy

Prince George, B.C.

Influence of BMD Testing on Calcium & Exercise

2

Abstract
For postmenopausal women osteoporosis and fracture are a major threat to functional
independence and quality of life that has the potential to precipitate the end of life. Calcium,
vitamin D and exercise have been shown to increase bone density, reduce falls and prevent
fractures. Studies have shown that personal knowledge of bone density has a positive
influence on treatment interventions in postmenopausal women yet studies considering the
personal knowledge of bone mineral density (BMD) testing on osteoporosis preventative
behaviours (OPBs) are less clear. This paper evaluated the influence of education and
knowing personal knowledge of BMD testing on calcium intake and exercise of young
postmenopausal women between the ages of 50-65 years of age. The outcomes of the review
found education with BMD testing is more effective with influencing an increase intake of
calcium and vitamin D. The lower the BMD measurement the more significant the increase
was of calcium and vitamin D intake. The findings on the influence of education with BMD
on exercise were non-conclusive showing no influence of education and BMD testing on
exercise and in one study indicating a negative influence that resulted in lower participation
time with exercise.
The outcomes of this project point to a gap in public knowledge of osteoporosis
particularly as it relates to the importance of calcium intake and exercise with bone health.
As well, the importance of earlier osteoporosis risk screening is highlighted for young
postmenopausal women. There is a need to develop a useful clinically based osteoporosis
screening survey for this population that addresses not only those at risk for osteoporosis, but
also should consider the impact of health beliefs, health screening anxiety and perceived
barriers for engaging in preventative health behaviours. Primary care providers should be

Influence of BMD Testing on Calcium & Exercise

3

aware of the positive and negative influences of sharing BMD test results and the importance
of follow-up in the primary care setting. Screening for osteoporosis risk is a priority in young
postmenopausal women with the ultimate goal of reducing fractures thereby reducing
morbidity, mortality and improving quality of life and decreasing the burden on the health
care system.

Influence of BMD Testing on Calcium & Exercise
TABLE OF CONTENTS
Abstract

2

Table of Contents

4

Osteoporosis: Scope of the Problem

6

Osteoporosis Prevention: Early Detection and Diagnosis

9

Bone Mineral Density
Bone Health: Osteoporosis Preventative Behaviours

10
12

Calcium and Vitamin D

12

Physical Activity/Exercise

16

Changing Health Behaviour
Revised Health Belief Model
Review: Influence of Education and BMD testing on Calcium Intake and Exercise

19
19
22

Sources and Search Process

22

Findings

22

Overview

29

Practice Implications

30

Osteoporosis Knowledge Gap

30

Personalized Feedback

32

Health Screening Anxiety

33

Perceived Barriers

35

Osteoporosis Risk Screening

36

Recommendations for Northern Health

37

Develop Osteoporosis Screening Survey

37

4

Influence of BMD Testing on Calcium & Exercise
Adopt Implications for Practice

39

Offer BMD Testing

42

Conclusion

42

References

45

5

Influence of BMD Testing on Calcium & Exercise

6

THE INFLUENCE OF OSTEOPOROSIS EDUCATION AND BONE MINERAL
DENSITY TESTING ON CALCIUM INTAKE AND EXERCISE IN YOUNG
POSTMENOPAUSAL WOMEN
Osteoporosis: Scope of the Problem
Osteoporosis is a common, chronic bone disease that lies silently in waiting. This
disorder is complex and characterized by asymptomatic loss of bone density with structural
deterioration of bone tissue that can result in bone fragility and with low impact trauma can
lead to fractures (Brown & Josse, 2002). In Canada it is estimated that 1.4 million people
suffer from osteoporosis and the estimated cost of treating persons with osteoporosis and
resulting fractures is 1.9 billion each year (Osteoporosis Canada, 2008). Osteoporosis is
classified as either primary which is caused by advancing age or secondary which is caused
by other factors such as medications and disease processes. The focus here is primary
osteoporosis in young postmenopausal women.
Although, the prevalent universal risk factor for bone loss and osteoporosis is
advancing age, the physiological changes of menopause cause women to be predominantly at
higher risk with one in four women developing osteoporosis (Osteoporosis Canada, 2008). At
the age of 50, a Caucasian woman has at least a 40% risk of developing a new fracture in her
remaining lifetime and women account for 75 % of hip fracture cases (Brown & Josse, 2002;
National Institute of Health (NIH) Consensus Development Program, 2000) The impact of
osteoporosis on mortality and morbidity on aging individuals is high. It has been estimated
that osteoporosis attributes to 90% of all hip and spine fractures in older women (The North
American Menopause Society [NAMS], 2006). As well, it is estimated that 20% of hip

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fractures results in death within one year of fracture and 50% of those persons who do
survive live with some level of disability (Osteoporosis Canada, 2008).
The Fracture Intervention Trial (FIT) highlights the significance of the higher relative
risk of mortality in relatively healthy older women who suffered a clinical vertebral fracture
or a hip fracture. This study included 6,457 postmenopausal women age 55-81years with low
bone mineral density (BMD) scores less than 1.6 standard deviations (SD) below the young
normal mean of young healthy woman. The study followed women for an average of 3.8
years and showed the relative risk of dying post fracture was almost six-fold greater
following hip fracture and nine-fold greater with previous history of vertebral fracture
(Cauley, Thompson, Ensrud, Scott, & Black, 2000). The likelihood of surviving a hip
fracture is often dependent on the number of pre-existing co-morbidities and there is no clear
understanding of whether the hip fracture was the independent cause or the sign in a series of
events signifying increasing age related decline (Magaziner et al., 1997; Wolinsky,
Fitzgerald, & Stump, 1997). Regardless of which perspective is regarded, it is clear that the
impact of a hip fracture is a life altering event.
There is no denying that the mortality risk for hip fractures is substantial yet, spine
fractures can result in equally if not more devastating impact on health status. Impaired
functioning from vertebral fractures often occurs silently and as many as two thirds of
persons with vertebral fractures will not seek medical attention (Gehlbach et al., 2000).
Regrettably, the resulting deformities such as thoracic kyphosis, loss of height, and
restriction with movement may be perceived as normal consequences of the aging process
(Gehlbach et al., 2000). Ross (1997) suggests that as many as half of all patients with
clinically identified fractures may be asymptomatic; however, many other individuals may

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experience acute or chronic back pain and declining physical function that increases
progressively with the number of vertebral fracture endured. There is surmounting evidence
to show that those individuals with existing vertebral fractures are at increased risk of future
fractures. In fact, the literature suggests that those individuals suffering from vertebral
fractures have a five-fold increased risk of future vertebral fractures that most often occur
within the first year (Black, Arden, Palermo, Pearson, & Cummings, 1999; Lindsay et al.,
2001) and as well they have a 2.8 fold increased risk of hip fracture (Lindsay et al., 2001). To
compound matters further vertebral fractures are not limited to musculoskeletal discomfort
and declining mobility, severe vertebral fractures can also restrict pulmonary function
capacity that can contribute to the high mortality outcomes (Schlaich et al., 1998).
There is little doubt that Jiving with osteoporosis fractures is associated with declining
health-related quality of life (Silverman, Minshall, Shen, Harper, & Xie, 2001) and not unlike
other chronic disorders osteoporosis contributes to negative psychological effects. Living
with osteoporosis is associated with higher incidences of loss of self esteem, reduced social
activity, poor well-being and depressed mood (Bianchi et al., 2005). Even women with
history of wrist fracture, which is viewed as less disabling than hip or vertebral fractures and
occur more often in the young postmenopausal woman, report poor health status post fracture
(Barrett-Connor et al., 2008). Nevertheless, regardless of fracture site, the impact of
osteoporotic fractures for postmenopausal women has implications for future disability and
quality of life.
The impact of osteoporosis is a major public health concern and osteoporosis will
continue to be more of a burden socially and economically with an aging population. Once
osteoporosis is established it is difficult to reverse (Hanley & Josse, 1996) and the mortality

Influence of BMD Testing on Calcium & Exercise

9

and morbidity outcomes only serve to highlight the importance of early prevention
interventions. Declining estrogen levels for women during menopause leads to rapid bone
loss that is estimated at a rate of 0.3-0.5 % beginning at age 40 years with more rapid loss
occurring after menopause that is estimated as high as ~ 2% per year for the first 6-10 years
with bone loss slowing to 1-2% per year into the sixth decade of life (Borer, 2005). For
Caucasian women menopause occurs at a mean age 51 years placing women at earlier risk
for osteopenia, osteoporosis and fragility fractures (Brown & Josse, 2002). In general, the
risk of osteoporosis fractures doubles every seven to eight years after the age of 50 (NAMS,
2006) stressing the importance of early prevention and intervention. Early prevention
includes education that focuses on modifiable osteoporosis preventative behaviours (OPBs)
with early detection of osteoporosis and treatment interventions that will assist to reduce rate
of bone loss and the incidence of osteoporosis and resulting fractures.
Osteoporosis Prevention: Early Detection and Diagnosis
The 2002 Clinical Practice Guidelines for Diagnosis and Management of
Osteoporosis in Canada (updated 2006) recognizes the importance of screening before a
fracture event and recommends that all women and men over 50 years of age should be
assessed for osteoporosis risk factors. Those individuals found to have one major risk factor
or two minor risk factors should be referred for BMD testing. Bone mineral density testing
establishes the diagnosis of osteoporosis and is used to as a predictor of fracture risk.
Advancing age is a major risk factor and routine BMD is recommended for women ~ 65years
for assessment of bone health provided having the BMD screening test will impact medical
management (Brown & Josse, 2002). Despite these guideline recommendations for screening
osteoporosis beginning at age 50 (Brown & Josse, 2002; NOF, 2008), osteoporosis screening

Influence of BMD Testing on Calcium & Exercise 10
including rates of BMD testing and post fracture assessments are suboptimal in primary care
(Gehlbach et al., 2000; Gill & Hoffman, 2003; Port et al., 2003)
Bone Mineral Density Testing
Bone mineral density testing is an instrument used to measure size, shape and
geometry of bones (Nguyen, Center, & Eisman, 2008). Bone mineral density scores correlate
with bone strength and diagnose osteoporosis and provide a measurement that can predict
risk of fracture (Nelson, Hefland, Woolf, & Allen, 2002). Bone mineral density scores are
expressed in units of standard deviation (SD) above or below the norm compared to either
the expected BMD for patient's age and sex (Z-score) or the expected BMD for young
female adult mean (T-score). The data resource for 'young female adult mean' is the mean
BMD of American Caucasian healthy women between the ages of 20-29 (WHO, 2007). It is
the dual energy x-ray absorptiometry (DXA) T-score that is recommended for diagnostic use
for postmenopausal women and men over 50 years of age whereas, Z-scores are
recommended for pre-menopausal women, children and ethnic populations. The World
Health Organization (WHO) diagnostic classification establishes normal BMD measurement
as within 1 SD above or below that of a young normal adult mean and is recorded as T-score
at -1.0 or above. Low bone mass also described as osteopenia is aT-score between -1.0 and2.5 and osteoporosis is aT-score at or below -2.5 (NOF, 2008; WHO, 2007)
Many techniques are available to assess BMD at different sites however the clinical
gold standard for diagnosing and monitoring patients' BMD is dual-energy x-ray (DXA) of
the hip and spine or forearm (WHO, 2007). Peripheral dual-energy x-ray absorptiometry
(pDXA) measures bone density at peripheral skeletal sites of the forearm, finger, or heel.
This technique is limited, one reason is due to a lack of sufficient evidence pDXA is not

Influence of BMD Testing on Calcium & Exercise 11
recommended for fracture assessment in men and another reason is that pDXA T-scores are
not equivalent to the T-scores derived from central DXA (NOF, 2008) thus diagnosis should
be confirmed by central DXA. Even so, these instruments are portable and results are
reproducible and capable of accurately predicting overall risk of fracture (NOF, 2008).
Peripheral DXA devices provide practical alternative as a screening tool for those individuals
at risk for low bone mass and because of portability the device could be used in rural settings.
As well, these devices are often utilized as a reliable tool of measurement in research studies.
Even though, the WHO's BMD criterion is widely accepted as being diagnostic for
osteoporosis, BMD measurement should not be used as the sole indicator of fracture risk
(WHO, 2007). There are a variety of concerns with BMD testing, one concern is that BMD
measures mineral in bone alone and does not determine bone structure which is also an
important component of bone health (BC Ministry of Health, 2005). As well, BMD
measurements have a high specificity but low sensitivity meaning that it works well for
predicting high risk of fracture when osteoporosis is present; however, there are a substantial
proportion of fractures that occur in women who lie in the low risk groups (Kanis & WHO
Study Group, 1994; WHO, 2007; Nguyen et al., 2008). This makes BMD an ineffective
screening tool for fracture risk for the general population and although BMD is an important
determinant in predicting absolute fracture risk, bone fragility is affected by other skeletal
and non-skeletal factors. Some of the other risk factors that require clinical screening include
fracture history, genetics particularly pertaining to body size (tall and/or low body mass
index) and maternal history of fracture after age 50, lifestyle behaviours and assessment for
secondary causes (NAMS, 2006; Taylor et al., 2004).

Influence of BMD Testing on Calcium & Exercise 12
Bone Health: Osteoporosis Preventative Behaviours
Osteoporosis education provides important information that assists health
professionals and the public to make informed decisions about bone health and treatment
modalities (NOF, 2002). The National Osteoporosis Foundation (2008) includes within their
major recommendations counseling individuals age 50 and older on modifiable OPBs.
Specifically counseling should address adequate intake of calcium, vitamin D, appropriate
exercise and avoidance of tobacco and excessive alcohol intake. For the purpose of this
project the focus is on the influence of modifiable risk factors calcium, vitamin D and
exercise on bone health.
Calcium and Vitamin D
Calcium is a major component of mineralized tissue and optimal bone health is reliant
on adequate absorption of calcium. Calcium is required for bone growth and development
and it is also critical for normal nerve and muscle function, heart contraction and blood
clotting (Kapit, Macey, & Meisami, 2000). Despite being a hard substance bone is active
living tissue in which the structure is a result of two counteracting processes of destruction
and formation. Osteoclast activity is responsible for resorption of bone and osteoblast activity
is responsible for bone formation. This process of bone turnover is a complex process that
maintains skeletal strength, enables repair of micro fractures caused by stress .and strain and,
is critical for calcium homeostasis (Nguyen et al., 2008). Calcium along with phosphate form
matrixes that develop into calcification and lead to strong bone structure. Ninety-nine percent
of calcium is contained in our bones and teeth and serves as a reservoir to maintain calcium
homeostasis when plasma calcium is low (Lanham-New, 2006). Low blood calcium signals a
chain reaction that stimulates the parathyroid glands to increase release of parathyroid

Influence of BMD Testing on Calcium & Exercise 13
hormone (PTH) thereby increasing osteoclast (destructive) activity responsible for rate of
bone absorption and remodeling.
The preferred source of calcium is from foods as other essential nutrients for bone
health are found in calcium enriched foods (Nieves, 2007). Diary products are a primary
source of calcium yet, when total intake of calcium is inadequate supplementation can be
beneficial and for the postmenopausal woman adequate amounts of calcium can decrease the
rate of bone loss by approximately 1% per year (Nordin, 1997). Higher calcium intake
equates to high calcium retention that promotes bone gain during growth, maintains bone
strength and reduces bone loss in the elderly (Heaney, 2000). Optimal intake of calcium is
important across the lifespan and studies have shown that once calcium intake declines the
benefits on bone mass also declines (Lee et al., 1997). Adequate calcium intake is crucial yet
calcium cannot be discussed without considering the importance of vitamin D.
Vitamin D is integral to the absorption of calcium and calcium homeostasis. Vitamin
D is a non-specific term to describe various forms of steroid molecules. The most relevant
forms are vitamin D2 (ergosterol) obtained from plant sources, such as mushrooms and
vitamin D3 (cholecalciferol) found in foods such as eggs yolks, fish oils and fortified food
products. The main source of vitamin D3 is synthesized through the skin when ultraviolet
light energy from sunlight is absorbed. In order for the body to utilize these inactive forms of
vitamin D, they require metabolizing by the liver to form 25-hydroxyvitamin D (calcifediol)
or 25(0H)D that is stored in the liver as a non-active form. This inert form of vitamin D3
requires further conversion by the kidneys to form 1, 25-dihydroxy vitamin D (calcitriol)
which is an active, potent form of vitamin D that increases calcium absorption from the
intestine (Bowman R., 2007; Kapit et al., 2000). As well, when nutritional calcium intake is

Influence of BMD Testing on Calcium & Exercise 14
low, vitamin D will increase osteoclast activity thereby increasing bone calcium to the
plasma (Wolff, Jones, & Hansen, 2008).
Through out the lifespan calcium demands vary and are influenced by age, hormones,
drugs and genetics (National Institutes of Health [NIH] Consensus Development Program,
1994). The highest demand for calcium and vitamin Dis for the postmenopausal woman yet
studies have shown that the average calcium intake of the North American diet is far below
the amount recommended for optimal bone health. Depending on clinical practice guidelines
resourced recommended daily calcium intake for postmenopausal women ranges from
1200mg to 1500mg (Brown & Josse, 2002; NOF, 2008); however, the National Health and
Nutrition Survey estimated the mean daily calcium intake of women 2:: 60 years of age to be
563mg (Ma, Johns, & Stafford, 2007). This nutritional data also examined dietary and
supplemental calcium consumption of men and women 2:: 19 years as it related to risk of
osteoporosis and further analysis found that those individuals with osteoporosis had a higher
consumption of daily calcium, which is beneficial yet, the daily reported calcium
consumption remained below recommendations at 944mg (Ma et al., 2007).
Low calcium intake for postmenopausal women is compounded by two issues: the
first is the amount of calcium absorbed by the body varies widely, 17-58% with an average
of 35% (Wolf et al., 2000) and than absorption rates may decline further as estrogen declines
in the postmenopausal women (Heaney & Recker, 1986). Secondly, individuals with
suboptimal intake of calcium are also likely to have suboptimal intake of vitamin D (Boonen
et al., 2004). Insufficient intake of vitamin D correlates with lower calcium absorption and in
women with severe vitamin D deficiency only 10 to 15% of dietary calcium ingested is
absorbed (NAMS, 2006). Hypovitaminosis Dis common in the general population

Influence of BMD Testing on Calcium & Exercise 15
particularly in postmenopausal women, the older adult, and in people with high melanin skin
pigmentation. Insufficient sun exposure related to living in northern latitudes and/or
institutionalization are also known contributors, as well as, protective clothing, sunscreen and
certain drugs that affect bioavailability of vitamin D (Chapuy et al., 1997; Gaugris et al.,
2005; Holick, 2006). Although, optimal serum 25(0H)D (vitamin D) status has yet to be
established (Holick, 2007), studies have shown that supplementing vitamin D in individuals
with low 25(0H)D is associated with improved body sway and muscle strength that can
reduce the risk of falls and ultimately fractures (Jackson, Gaugris, & Hosking, 2007; Pfeifer
et al., 2009).
Of note, several recent large studies have suggested that calcium and vitamin D
supplementation is not effective in reducing future risk of fractures in community dwelling
~ 70 years of age (Grant et al., 2005; Porthouse et al., 2005). The conflicting evidence

has heightened interest in the significance of vitamin D, particularly as it relates to age,
vitamin D thresholds, and the relationship with PTH levels (Adami, Viapiana, ldolazzi, &
Rossini, 2008; van Schoor et al., 2008). That being said, consideration should be given to the
large body of evidence that suggests that calcium and vitamin D, if taken with sufficient
levels of compliance, does reduce the risk of fracture (Rizzoli et al., 2007). As well, it is
important to consider that calcium and vitamin D is not recommended as a sole means of
treatment for osteoporosis (Brown & Fortier, 2006) and evidence still supports the
recommendations to include calcium with vitamin D as adjunct therapy to pharmacological
interventions (Brown & Fortier, 2006; Rizzoli et al., 2007).

Influence of BMD Testing on Calcium & Exercise 16
Physical Activity/Exercise

Although, bone mass is influenced largely by genetics (Deng et al., 2000; Makovey,
Nguyen, Naganathan, Wark, & Sambrook, 2007; Nguyen et al., 2008; Rizzoli, Bonjour, &
Ferrari, 2001), physical activity has a significant impact on maintaining skeletal integrity and
bone strength through out the lifespan. Physical activity during times of rapid growth, such
as during pre- and peripubertal periods, has the effect of enhancing peak bone density (Hind
& Burrows, 2006; MacKelvie, Khan, Petit, Janssen, & McKay, 2003) whereas, during

adulthood physical activity has a lesser influence and inevitably with progressive aging there
is loss in bone density (Karlsson & Ahlborg, 2006). Moderate physical activity during times
of peak bone turnover has been shown to have lasting benefits into older age (Pesonen et al.,
2005; Rideout, McKay, & Barr, 2006); consequently, those women with low BMD before
menopause are at greater risk for developing lower BMD postmenopausally. Essentially, the
likelihood that postmenopausal women will develop osteoporosis depends on both optimal
peak bone mass, which occurs by the third decade of life and the rate of bone loss in later
years (Nlli Consensus Development Program, 1994).
The mechanical forces of physical activity cause mechanical strain from muscle
contractions and ground reaction forces that affect bone mass. Physical activity that force
individuals to work against gravity are referred to as weight bearing exercises and examples
include jogging, Tai-Chi, stair climbing, dancing and tennis (NOF, 2008). These forces on
bone produce a cellular response that increases bone formation and resistance to bone
fracture (Smith & Clark, 2005). There is an understanding that osteoclasts and osteoblasts
have genetically predetermined strain thresholds that adapt to the mechanical environment
and signal bone formation, removal or repair (Smith & Clark, 2005). When strain thresholds

Influence of BMD Testing on Calcium & Exercise 17
are surpassed modeling activity occurs increasing bone strength and mass. When mechanical
forces are below strain threshold modeling activities are turned off and, in environments
where there is a lack of stimulus or disuse, lower remodeling set points are turned on causing
loss in bone mass (Rubin & Lanyon, 1984 ). Remodeling can be controlled by short periods
of loading force (Rubin & Lanyon, 1984) and bone mass is maintained when bone formation
and resorption are at equilibrium (Gong, Zhang, Zhu, & Yang, 2006). Accordingly, bone
fragility is a consequence of bone removal being greater than replacement.
Physical activity and rate of remodeling of bone have implications on the rate of bone
loss for postmenopausal women. A meta-analysis review of 16 RCTs and nine non-RCTs
suggested that exercise training programs prevented or reversed bone loss up to 1% per year
in both the lumbar spine and femoral neck for both pre- and postmenopausal women (Wolff,
van Croonenborg, Kemper, Kostense, & Twist, 1999). A more recent non-RCT examined the
impact of both low-volume high resistance strength training and high impact aerobics over
three years on 48 early postmenopausal women with osteopenia and found that BMD was
maintained at spine, hip, and calcaneus but not at the forearm. Also important to note from
this was that those women in the exercise group experienced decreased pain frequency and
intensity in the spine while women in the control group experienced an increase in pain
(Engelke et al., 2006). Exercise is beneficial and has been shown to slow the rate of bone loss
for postmenopausal women and in some instances reverse it yet, not all types of exercise
have equal bone strengthening outcomes and there is increasing interest in what constitutes
optimal exercise strategies for bone health.
Primarily, different types of physical activity produce different straining forces that
affect different parts of the skeleton differently (Brown & Josse, 2002). For example, a

Influence of BMD Testing on Calcium & Exercise 18
Cochrane review of 18 RCTs examining effectiveness of exercise on healthy postmenopausal
women showed aerobics, weight bearing and resistance exercises were effective in increasing
the BMD of the spine while walking was shown to be effective in both BMD of the spine and
hip (Bonaiuti et al., 2002). Conversely, a meta-analysis of eight RCTs showed that walkingonly for postmenopausal women had a significant, positive effect on BMD on the femoral
neck yet, no significant effect on the preservation of BMD at the spine (Martyn-St. James &
Carroll, 2008). Overall there is consensus that evaluating exercise strategies is problematic in
that exercise trials tend to be of short duration with small sample sizes and have diverse
methodologies, even so, these reviews as well as others (Palombaro, 2005) support the notion
that regular physical activity is beneficial for individuals at risk for osteoporosis.
There is no denying that bone quality decreases with age and poor bone quality is an
important factor contributing to absolute risk for fracture but, the matter is complicated
further because older women also have an increased tendency for falls (Nelson et al., 2002).
The aging woman's tendency towards falls is high; falls in women at age 65 years is about
30% per year and increases to 50% per year at age 80 years (Boonen et al., 2006). Taking
this into account there has been an increase interest with the benefits of exercise as it pertains
to fall prevention. The benefits of physical activity, including resistance training, reaches
beyond the skeleton and studies have shown that exercise improves muscle strength, agility,
posture and balance (Hourigan, Nitz, Brauer, O'Neill, & Wong, 2008) that ultimately reduce
the risk of falls and fractures (Boonen et al., 2006; Swanenburg, Douwe de Bruin,
Stauffacher, Mulder, & Uebelhart, 2007).

Influence of BMD Testing on Calcium & Exercise 19
Changing Health Behaviour
Health education as cited by Griffith (1972) can be defined simply as "attempts to
close the gap between what is known about optimum health practice and that which is
actually practiced" (Glanz, Lewis, & Rimer, 1997, p. 7). This early definition suggests
information concerning beneficial health practices does not necessarily decrease problematic
health behaviours. Health information may increase awareness and may motivate individuals
to avoid or change health behaviours yet, information alone does not guarantee participation
in preventative health behaviours. For example, despite public health campaigns on health
risks of smoking that have been ongoing for the last 35 years, less than 20% of smokers are
intending to take action and quit smoking within the next 30 days (Prochaska & Prochaska,
1999). Although there has been progress in reducing smoking rates in the general population
the knowledge that cigarettes are hazardous to one's health did not prevent, change or stop
the problematic health behaviour for those individuals that smoke. Changing health
behaviours is complex and additional self-influences evolving from self-efficacy play a
central role with motivation and action (Bandura, 2004). Theories on health behaviour serve
to explain why people change and maintain preventative health behaviours, as well they
assist health care professionals with selecting effective educational interventions and
strengthens research applicability to the clinical setting (Glanz et al., 1997; McKenzie,
Neiger, & Smeltzer, 2005).

Revised Health Belief Model
One of the most frequently and widely used theoretical models for health prevention
and modifying health behaviour is the health belief model (HBM). The HBM is founded in
value-expectancy theory and was introduced in the 1950's from a need to explain why public

Influence of BMD Testing on Calcium & Exercise 20
health programs were not succeeding in preventing or detecting disease (Glanz et al., 1997).
The model has evolved over time and by the 1980's the model was revised to include selfefficacy (Strecher & Rosenstock, 1997). It is self-efficacy that provides incentive to act and
is rooted in the core belief that one has the power to produce the desired changes (Bandura,
2004). Rosenstock, Stretcher, and Becker (1988) revised HBM proposes that success for
health behaviour change depends on people having:
1. sufficient motivation or incentive to make health issue relevant
2. belief they are susceptibility to the disease and feel threatened by their current
behaviour patterns
3. belief that engaging in the health behaviour recommendation is beneficial and will
reduce the perceived threat at an acceptable cost financial or otherwise
4. self-efficacy, the confidence or conviction to overcome the barriers to implement the
change
It is evident that changing problematic health behaviour is complex and multi-

factorial. People seek knowledge in general to gain understanding, to solve relevant problems
and/or simply to know the world around them (Rodgers, 2005). For some people increased
health knowledge of risk and benefits of disease may be enough to create a reason for change
in their behaviour (Bandura, 2004); yet, increased knowledge and/or insight concerning
beneficial preventative behaviours does not necessarily prevent problematic health
behaviours or change health beliefs or health behaviours for others (Prochaska, DiClemente,
& Norcross, 1992; Sedlak, Doheny, & Jones, 2000). Considering the HBM it is reasonable to
postulate that personal knowledge of individual health risk may be more influential at
engaging individuals to partake in osteoporosis preventative behaviours.

Influence of BMD Testing on Calcium & Exercise 21
Studies have shown that personal knowledge of bone density may have a positive
influence on treatment interventions in postmenopausal women (Fitt et al., 2001; Marci,
Viechnicki, & Greenspan, 2000). Marci et al. (2000) also found that BMD testing with
osteoporosis risk assessment improved a variety of osteoporosis preventative behaviours
(OPBs) including an increase in dietary calcium intake and exercise. Rohr, Clements, and
Sarkar (2006) surveyed 234 older women and found that women increased their calcium
supplementation after screening with BMD testing and counseling; however, treatment
interventions requiring physician prescription did not increase after screening regardless of
BMD status. The information pertaining to the influence of BMD testing as a motivating
factor for change of OPBs is mixed.
The importance of early detection, adequate intake of calcium and vitamin D and
exercise for maintaining or slowing the rate of bone loss in postmenopausal women has been
highlighted. There is merit in early osteoporosis risk screening before a fracture occurs.
Baseline BMD testing is recommended for women are ~ 65 years of age and as mentioned
using BMD testing as a general screening tool is controversial, in part due the inability of
BMD testing to identify all individuals at risk for fracture (WHO, 2007); however it can be
hypothesized that osteoporosis general knowledge with personalized knowledge of BMD
measurement may be more effective with influencing participation with OPBs. The aim of
this project was to seek out research articles that would answer the question: for young
postmenopausal women between the ages of 50-65 years of age will education interventions
with BMD testing be more effective at influencing calcium intake and exercise when
compared to educational interventions without BMD testing?

Influence of BMD Testing on Calcium & Exercise 22
Review: Influence of BMD on Calcium Intake and Exercise
Sources and Search Process
The search included CINAHL, Ovid MEDLINE daily update and Cochrane Library
for English language articles with the following headings and text works: osteoporosis, bone
health, postmenopausal, education, health education, education strategies, bone density, bone
mineral density, densitometry X-ray, osteoporosis prevention, lifestyle, exercise, calcium and
calcium supplementation diet and dietary. As well, references from relevant articles were
reviewed. The initial search process was expanded to include organization web sites
including the National Osteoporosis Foundation and Osteoporosis Canada. Abstracts and
articles were reviewed and selected by the writer only. Those articles that did not address the
target population of young postmenopausal women between the ages of 50-65 years were
eliminated leaving four studies for evaluation.
Findings
The longitudinal RCT by Estok, Sedlak C. A., Doheny, and Hall (2007) examined the
influence of personal knowledge of osteoporosis status of 203 healthy community based
women. Osteoporosis knowledge, health beliefs, self-efficacy scale, calcium intake and
exercise levels were pre-assessed in both groups. The experimental group had DXA of
lumbar spine and femur and both groups completed additional calcium and exercise intake
reports at 6 and 12 months. Both sample groups were relatively similar with a mean age of 57
years, 91% Caucasian, mean body mass index (BMI) 27.80, 87% did not smoke and 76% had
some level of post secondary education. Initial mean daily calcium intake for experimental
group was 606mg/day and in the controlled group 620mg/day which is within expected
reported intakes of others studies. Initial time allocated to weight bearing exercise in the

Influence of BMD Testing on Calcium & Exercise 23
experimental group was 81 minutes/week and in the control group the allocated time for
exercise was 65minutes/week. Both groups were well below health maintenance
recommendations of 30minutes of activity per day (BC Ministry of Health, 2005). Personal
knowledge of BMD testing results were shared with participants and it is unclear what level
of counseling occurred with sharing DXA information.
The outcomes showed that women in the experimental group at six months had a
significantly higher calcium intake at 916mg/day when compared to the control group at
635mg/day. The greatest change observed was in calcium intake behaviours in those women
who were told they had osteopenia or osteoporosis (p < .05) suggesting that personal
knowledge of osteoporosis risk does have some partial effect on perceived susceptibility of
osteoporosis. However, it is also important to note that by 12 months both groups, control
and intervention, had increases in daily calcium intake. Even though, the study concluded
that knowing BMD results did not empirically mediate an effect of knowledge or health
beliefs of osteoporosis, the details of the statistic models and analysis showed that women in
this study who had positive pathways of knowledge and health beliefs of osteoporosis
recognized the benefits of calcium and exercise. This certainly has implications for public
health policy and mass media concerning closing the gap of what is known about
osteoporosis. Also, this study points out that more than half (57 %) of these relatively healthy
women had low bone density scores. Thirteen percent of these women were diagnosed with
osteoporosis and 45 % were osteopenic, underscoring the importance of osteoporosis
screening in a primary health care setting.
The quasi-experimental pilot study by Sedlak, Doheny, Estok, and Zellar (2005)
examined the influence of knowledge of BMD results with tailored or customized

Influence of BMD Testing on Calcium & Exercise 24
interventions verses knowing BMD results without customized interventions. All 124
postmenopausal women received DXA of lumbar spine and femur, an osteoporosis
questionnaire was completed consisting of osteoporosis-preventing behaviours survey,
osteoporosis knowledge test, health belief scale and self efficacy scale. Both groups received
a follow-up letter explaining results and another osteoporosis questionnaire at 6 months. The
intervention group was contacted by telephone and interviewed by a nurse conveying results
of BMD, and were assessed for present participation of OPBs and provided with customized
plan of intervention to improve OPBs. Although the control group was larger than the
intervention group, both groups were representative of each other. Mean age was 56.2 years,
BMI 28, 90.3% were Caucasian and 73.4% had some level of post secondary school
education. Initial mean calcium intake for intervention group was 587mg/day and the
controlled group was 614mg/day. Initial mean weight bearing exercise for intervention group
96 minutes/week and the controlled group was 81.47 minutes/week.
Sedlak et al.'s (2005) study showed both control and intervention groups had
significant increase in mean daily calcium intake. Daily calcium intake increased to 1039
mg/day (p = .008) for the intervention group and increased to 916 mg/day (p = .001) for the
control group; however, combined prescore/postscore interaction was non-significant (p =
0.642). The influence of BMD results with tailored interventions on exercise was surprising,
especially considering this population group of 50-65 year olds, the intervention group
decreased exercise from 96 minutes/week to 59 minutes/week while the non-tailored group
increased exercise slightly from 81 minutes/week to 87 minutes/week. Tailored interventions
with BMD measurements had a negative effect by increasing perceived barriers to calcium
intake and exercise, particularly exercise. It is unclear from this study if those women with

Influence of BMD Testing on Calcium & Exercise 25
lower bone density were more likely to reduce exercise levels. Seemingly for the reader, the
perception of exercise contributing to worry and risk of falling is a real one. Similarly, to the
previous study, this study also showed a high rate of bone density loss (59%) in the young
postmenopausal woman, 43% of participants were osteopenic and 16% of participants were
osteoporotic.
The RCT by Rolnick, Kopher, Jackson, Fischer, and Compo (2001) examined the
influence of osteoporosis education with or without BMD testing on postmenopausal women
54-65 years of age. The sample size of 508 postmenopausal women was selected from a large
care organization. Measurements included a simple calculated osteoporosis risk estimation
(SCORE), osteoporosis knowledge survey and an attitudes test prior to education session and
at six months. Although the article does talk to 'beliefs' it was not clear if the HBM has been
used as the theoretical foundation, only an assumption can be made that components of HBM
were utilized to assess participant's beliefs concerning osteoporosis. Both groups attended a
2-hour nurse practitioner lead education session and 207 participants also received a pDXA
of the wrist. Attendance rates were significantly affected with 29% being absent in the
education only group and participants expressed disappointed with not being selected for
BMD testing. Demographically this group was slightly older than the other sample group
presented so far, over half of the women were > 60 years of age, 97% were Caucasian and
although no participants were on hormone replacement (HRT) during the study 30% reported
being on HRT in the past; up to as early as one month ago.
The findings of Rolnick et al.'s (2001) study showed that regardless of BMD
availability more than half of the women in both groups reported OPBs changes pertaining to
diet, exercise and calcium intake. Health belief patterns were influenced more in the group

Influence of BMD Testing on Calcium & Exercise 26
with education plus BMD testing. The BMD intervention group were more likely to discuss
osteoporosis prevention initiatives with their care provider and showed a significant increase
with calcium and vitamin D intake (p < 0.001) and with initiating osteoporosis
pharmaceutical interventions (p < 0.001). Similarly, to previous studies those women who
were diagnosed with osteopenia or osteoporosis had higher percentages of calcium and
vitamin D intake when compared to participants with normal BMD results. Although not
empirically significant, this study showed a decrease in exercise (57% to 51%) for
participants with osteopenia but slightly increased (57% to 61%) for participants with
osteoporosis. As well, the perceived risk of osteoporosis increased as the intervention group
with BMD testing was more likely to report taking steps towards preventing osteoporosis
was important to their well being.
Rolnick et al. (2001) also reported high rates of suboptimal BMD results, 44% of
participants were either osteopenic at (35%) or osteoporotic (9% ). The overall rates are lower
than the previous two studies reviewed with low bone density rates at 57%-59% and this
difference may be attributable to past use of HRT by 30% of participants in this sample
group. Also worth noting, out of the 505 fully completed simple calculated osteoporosis risk
estimations (SCORE), the results indicated that 358 (71%) participants were at risk of
fracture. In some aspects, this is not surprising as this sample group was generally higher at
risk population. In review of osteoporosis risk factors of this group three participants had
already reported hip fracture, another 35 participants reported wrist fracture, 28 had
rheumatoid arthritis and 108 were below 130lbs/57kg which is also a risk factor that
correlates with low bone density (Brown & Josse, 2002). In review, 113 of participants

Influence of BMD Testing on Calcium & Exercise 27
already had one major risk factor and the study did not report incidence of maternal history
of fracture.
The British article, Wallace, Boxall, and Riddick (2004) reports on three studies of
different designs. The intent of the combined studies was to examine the influence of BMD
screening on exercise and diet, attitudes of women with osteoporosis and the impact of nurse
education on attitudes and dietary self-care. The first study includes 129 outpatient women
referred to a bone density clinic and included perimenopausal women under the age of 65.
Although, this study did include perimenopuasal women, the study was included in the
review because the likelihood of having a large number of women under age 50 being sent
for BMD testing is low. This first study in Wallace et al. (2004) was the primary focus for the
review and was a before and after design. All participants completed dietary frequency
questionnaires (0-3 months), checklists for exercise (0-1-3 months), osteoporosis patient
knowledge (0-2 weeks-3 months), health belief scale (0-2 weeks-3 months) and risk
assessment scale (within 2 wks). The nutrition survey was mailed out one week prior to
BMD scan and it is unclear whether "usual health risk advice" was provided during visit to
BMD clinic. Although the other two studies were not the focus of this review they are of
interest. Both of those studies included older postmenopausal women ;::: 70 years of age,
sample sizes that were too small for statistical analysis, different methodologies and focus
was directed toward education variances.
Unlike the other studies Wallace et al.'s (2004) study indicated that 57% of women
had a high intake of daily calcium of at least 1500 mg/day and this correlated with high
knowledge scores concerning calcium sources at 84%. Even so the osteoporosis
susceptibility scores in this group showed only 23% believed calcium was a strong influence

Influence of BMD Testing on Calcium & Exercise 28
on fracture risk. When assessing exercise, the study reported 74% of women participated in
weight-bearing exercise of at least 60 minutes/week and the low amount of time allocated for
exercising correlated with lower knowledge scores pertaining to the importance of exercise.
For example, only 32% of participants knew that walking can decrease the risk of falls and
only 40% knew that walking is better for bones than swimming. This is validated in
reviewing susceptibility surveys as only 19% thought exercise would be important with
preventing risk of fracture. The assessment of health beliefs showed that the perceived
overall risk of fracture was low as 61 % did not expect a bone fracture in the next five years
and they did not expect the risk to change. The study results support the notion that
participants did not perceive the disease process a threat serious enough to warrant change in
OPBs. The low perception of susceptibility was also supported by the other two studies in
this article and one of those studies included 25 women previously diagnosed with
osteoporosis. Although, participants reported knowing benefits of calcium intake and
exercise in knowledge surveys, the participants' perceptions of personal risk of osteoporosis
remained low and OPBs did not change after osteoporosis screening.
The overall conclusions of this first study reviewed by Wallace et al. (2004) were that
no significant changes with OPBs following BMD scan. It was unclear how participants were
informed of their BMD measurement and how or if there was follow up for those with
abnormal results. This study did not report rates of low bone density. In contrast to previous
studies reviewed, this study viewed BMD screening alone as a variant and concluded that the
action of BMD screening has no impact health behavioural change. The results of all three
studies within this article pointed out that women are more willing to change diet than
exercise and that perceived low personal risk of fracture as well as, low perception of

Influence of BMD Testing on Calcium & Exercise 29
seriousness of osteoporosis prevents people from adopting more stringent preventative care
behaviours.
Overview

The purpose of this review was to answer the question, for young postmenopausal
women between the ages of 50-65 years of age, will education interventions with BMD
testing be more effective at influencing calcium intake and exercise when compared to
educational interventions without BMD testing? This review supports the notion that
osteoporosis education with BMD is more effective at influencing calcium and vitamin D
intake than education alone and the more abnormal the bone density the more significant the
increase in calcium and vitamin D intake (Estok et al., 2007; Rolnick et al., 2001; Sedlak et
al., 2005). However, the influence of education and BMD on exercise is non-conclusive
(Estok et al., 2007; Wallace et al., 2004) having no influence on increasing exercise and in
fact knowing bone density may have a negative influence, lowering participation in exercise
(Rolnick et al., 2001; Sedlak et al., 2005).
All the articles for review incorporated the essence of the HBM and utilized a number
of similar measurement instruments to assess the relationship between BMD screening on
generalized knowledge, health beliefs and the two OPBs of exercise and calcium intake for
this population group of young postmenopausal women; however, there are differences with
quality, quantity and consistencies with their analysis. The mode and quality of knowledge
imparted to participants, both generalized osteoporosis knowledge and personal knowledge
ofBMD results, varied with each review. The study groups were self-selected thus the
women who chose to participate may be more interested in their health which may be
different from the general population. This review includes only two RCTs that provide the

Influence of BMD Testing on Calcium & Exercise 30
highest level of validity and reliability of evidence; yet, collectively the studies do present
clinically relevant considerations that should influence how osteoporosis educational
interventions are approached and provides insight to the implications of BMD testing for this
specific population.
Implications for Practice
Osteoporosis Knowledge Gap
The findings of the review showed that participants' calcium intake increased as
osteoporosis general knowledge increased, regardless of knowing BMD measurement. Even
though, the increase in calcium intake and vitamin D was statistically significant with
abnormal BMD measurements, overall the findings indicate that increasing generalized
osteoporosis knowledge does directly influence calcium and vitamin D intake (Estok et al.,
2007; Rolnick et al., 2001; Sedlak et al., 2005) suggesting that a lack of knowledge acts as a
barrier and constrains participation with OPBs. This finding is also supported by a recent
survey examining barriers to calcium supplementation for women 20-64 years of age, the
survey suggested that one of the primary reasons women, 55% in this survey, have high rates
of non-use of supplementation was not knowing it was necessary (Tyler et al., 2008).
Calcium supplementation was also reported as a low priority in 77% of the non-users (Tyler
et al., 2008).
The evidence also points to lack of knowledge pertaining to benefits of exercise for
increasing bone strength and prevention of falls (Wallace et al., 2004 ). There is a gap in
information pertaining to the importance of bone health with preventing or reversing bone
loss. It would be useful for heath care providers to be knowledgeable or refer to community
resources that utilize optimizing exercises that improve balance, strength and agility and

Influence of BMD Testing on Calcium & Exercise 31
decrease the risk the falls. In the Sedlak et al. (2005) study that included tailored
interventions according to the BMD measurement showed a negative association between
BMD testing and exercise that elicited worry about the risk of falls. These results suggest that
exercise interventions may require more personalized involvement and would also suggest
that further research is needed in this area to better understand the relationship between bone
fragility associated with osteoporosis, BMD testing and exercise.
Wallace et al. (2004) suggest that despite good intentions low susceptibility and low
perception of the severity of osteoporosis constrained actual change in behaviours. The
perception that osteoporosis is not preventable and is an older persons disease may contribute
to this misconception. Another survey examining health beliefs of 128 women

~ 52 years

about disease screening found that women ranked osteoporosis as lower in severity than
colorectal or breast cancer and felt ambivalence towards osteoporosis screening as being able
to prevent disease (Dassow, 2005). It is apparent that there is a gap in women's basic
knowledge about osteoporosis as well as misperceptions concerning susceptibility and
seriousness of osteoporosis as a disabling and deadly disease. Health education both formal
and as delivered in the primary care setting should be geared towards increasing osteoporosis
general knowledge that addresses the benefits of adequate calcium and vitamin D intake and
exercise for preventing falls and fractures.
Individuals have a responsibility to improve their own bone health through proper
nutrition and exercise. As well, primary health care providers also have a role to educate
themselves and their patients about prevention, detection, diagnosis and treatment of
osteoporosis (U.S. Public Health Service, 2004 ). There is a multitude of ways to connect to
up to date information. One way is by accessing on line information such as Osteoporosis

Influence of BMD Testing on Calcium & Exercise 32
Canada's web site that allows access to free downloads of their journal Osteoporosis Update
and other reference resources. As well, health care providers can take the opportunity to
attend an osteoporosis conference or make note of information sessions from specialist
related to bone health that can be teleconferenced to various communities in the region.
In the primary care setting, a multi-disciplinary approach is beneficial, both for the
health care providers and high risk populations. Primary care providers, nurses,
physiotherapists, dietitians and pharmacists have contact with clients and families at different
points of entry into the health care system, a drop in group medical appointment (DIGMA)
connects them together as a team. This model provides an opportunity for clients to have
their questions answered accurately and consistently. As well, they ~

the opportunity to

share and listen to each others experiences and coping strategies that promotes selfmanagement skills. The opportunity to provide health education to groups provides an
avenue to narrow the osteoporosis information gap that could service not only, women in this
target population but, also to different age groups across the lifespan.
Personalized Feedback
Undoubtedly, how the BMD result is shared with clients does influence their decision
on whether to engage in OPBs and osteoporosis preventative therapies. Wallace et al. (2004)
as well as, another study by Kirk, Nichols, and Spangler (2002) indicates that BMD testing
alone does little to motivate engagement with OPBs. The other three studies in this review
included BMD testing with personalized feedback, osteoporosis information pamphlet and/or
educational sessions and were more effective at influencing calcium and vitamin D intake
(Estok et al., 2007; Sedlak et al., 2005; Rolnick et al., 2001). As well, both RCTs indicated
with statistical significance that those postmenopausal women with an abnormal BMD were

Influence of BMD Testing on Calcium & Exercise 33
more likely to increase their calcium intake than those women with a normal BMD result
(Estok et al., 2007; Rolnick et al., 2001). Women need to understand the implications of
their BMD measurement. Fitt et al. (200 1) reported a positive influence of BMD on
increasing osteoporosis preventive therapy and highlighted the importance of patient
understanding and discussing the results with a primary care provider as critical components
with initiating osteoporosis preventative therapy. Individuals knowing BMD measurement
does not equate to understanding their susceptibility and the seriousness of osteoporosis. The
more the patient understands and appreciates the benefits of the recommended health
behaviour as it relates to their own health, the more likely they are to change the at risk
behaviour.
Health Screening Anxiety
The findings of increasing worry in these studies poses unanswered questions
concerning the impact on BMD screening on exercise behaviours. Sedlak et al. (2005)'s
study showed that individualized feedback on BMD and customized intervention strategies
increased the perception of barriers, particularly to exercise. The intervention group was
small (n = 23); however, these findings are supported by other studies (Marci et al., 2000;
Rubin & Cummings, 1992) that suggested that fear and worry of falling may only increase
after knowing results of BMD and lead women, even young women < 65 years of age, to
limit activities. Health care providers should be aware of the possibility of negative influence
of BMD testing. Counseling approaches should balance both positive and negative attributes
ofBMD result and recommendations (Wroe, Salkovskis, & Rimes, 2000). The worry of falls
also highlights the importance of discussing fall prevention by reducing hazards and problem
solving safe ways to participate in increasing activities.

Influence of BMD Testing on Calcium & Exercise 34
Rimes and Salkovskis (2002) add another perspective in regards to patient anxiety
and action on OPBs. This study incorporates the cognitive-behaviour model of health anxiety
and was developed based on a previous study by Rimes, Salkovskis, and Shipman ( 1999) that
found similar outcomes relating to women who received low BMD results, these women
were inclined to be more anxious at three months post screening than women who received
normal BMD results. Rimes and Salkovskis (2002) propose that certain people have
preexisting "maladaptive" assumptions about health and interpret health information as
threatening and participating in health screening tests only increases those anxieties. This
study's purpose was to examine the possibility of developing ways of predicting which
people are likely to experience anxiety so that health care providers are in a better position to
offer interventions aimed at reducing those anxieties.
As expected those women with pre-existing high health anxiety indicators showed
"an increase in worry about osteoporosis, perceived likelihood and need for reassurance
between the three and fourteen-month follow-ups, unlike those with low levels of preexisting health anxiety" (Rimes & Salkovskis, 2002, p. 366). Rimes and Salkovskis (2002)
conclude that variables derived from the cognitive-behavioural health model of health
anxiety are significant predictors in identifying differences in reactions to BMD screening.
Indicators related to specific illness beliefs and general health anxiety measures correlated
with increasing distress after BMD testing suggesting that these individuals would require
further follow-up. Also of interest, was the group of women with low health anxiety
indicators and low BMD results minimized the seriousness of the test result yet, they showed
higher levels of OPBs after three months post BMD testing suggesting that their anxieties
needed to be overcome before acting on recommended behaviours. The findings from the

Influence of BMD Testing on Calcium & Exercise 35
Rimes and Salkovskis (2002) study are insightful and support the evidence in this review.
Primary care providers should be aware of the potential for increasing anxieties after BMD
screening and that the results may have either a positive or negative effect on health beliefs
and OPBs.
Perceived Barriers
It can be surmised from the evidence that making changes in calcium intake takes less
effort and perceived barriers are easier to overcome. Wallace et aJ. (2004) points out that
"exercise was perceived to be the least comfortable change to make, with some regarding
their dietary changes as sufficient to justify no change in exercise" (p. 108). Generally,
calcium intake either through diet or supplementation is not time-consuming, is relatively
inexpensive and requires minimal level of commitment to change behaviour; whereas,
adopting exercise as a new health pattern can be time consuming, expensive and overall
requires a high level of personal commitment. The benefits of increasing calcium intake
verses engaging in exercise may have been perceived as less of a threat to their present
behaviour patterns and required lower confidence to succeed. The belief that participating in
exercise may increase the risk of falls and fractures only serves to reduce confidence for
incorporating exercise as a lifestyle change. Also of interest the second study in Wallace et
al. (2004) examining postmenopausal women with osteoporosis demonstrated low self-care
behaviours because they had little confidence that the changes were worthwhile. An effort
should be made to explore perceived barriers that may include lack of readiness,
misconceptions and gaps in knowledge. Collaboratively with clients, the objective should be
to explore effective strategies that reduce barriers and increase client confidence to move
towards participating with OPBs.

Influence of BMD Testing on Calcium & Exercise 36

Osteoporosis Risk Screening
The high rates of low bone density, 57%-59 % in relatively healthy women, is
alarming and highlights the value of early osteoporosis risk screening for women 50-65 years
of age (Estok et al., 2007; Sedlak et al., 2005). The below normal bone density rates in the
Rolnick et al. (2001) study were 44%, somewhat lower but may be attributed to past use of
HRT by a portion of these women. The prevalence of osteoporosis in Canadian women at age
50 is approximately 6% (Brown & Fortier, 2006) and varies from 16% to 30% in the
postmenopausal Caucasian women (Kanis & WHO Study Group, 1994) thus, the findings in
these two studies showing rates of osteoporosis at 13%- 16% may be in line or marginally
above expectations (Estok et al., 2007; Sedlak et al., 2005). The startling results are the
findings of osteopenia with rates at 43 %-45 %. It can be argued that together these two
studies screened a small sample (n = 225) of young postmenopausal women and the studies
should not be generalized to the public. However, selection for the FIT II study, recruited 25,
864 women between 54-81 years of age who volunteered to be screened with BMD and the
outcomes showed 16,594 (64%) of these women had low bone density scores ofT scores 2:1.6 below the young normal adult (Cummings et al. , 1998). Although, the mean age of the
FIT II study was older at 68 years, it is difficult to dispute that generally there is a higher
prevalence of low bone density for Caucasian postmenopausal women who express interest
in their bone health. There is potential bias in these studies given that these women
volunteered to be screened and may have an increased interest in their health and/or preexisting health concerns related to osteoporosis.
Even though, the rates of low bone density are higher in these studies than what is
expected in the general population, it is important to revisit the issue that osteoporosis

Influence of BMD Testing on Calcium & Exercise 37
screening rates are suboptimal in primary care (Gehlbach et al., 2000; Gill & Hoffman, 2003;
Port et al., 2003). Gehlbach, Fournier, and Bigelow (2002) estimate that physicians are only
identifying fewer than 10% of the women who have osteoporosis or vertebral fracture,
pointing out that a large proportion of postmenopausal women who are at risk for low bone
density are being missed. The implications of this review suggest that osteoporosis risk
screening for women age 50 and older should be viewed as part of best practice in the
primary care setting. As well, the writer would suggest osteoporosis screening should be
viewed as a priority for this population, in much the same way as breast and colorectal cancer
screening. It is acknowledged that for various reasons routine BMD testing is not
recommended for women < 65 years of age (BC Ministry of Health, 2005); however,
osteoporosis risk assessment screening and counseling is recommended beginning at age 50
(NOF, 2008). The Canadian Task Force on Preventative Health (2004) conclude that there is
fair evidence to recommend screening postmenopausal women in order to identify women
with low BMD and that treating osteoporosis can reduce the risk of fractures (Cheung et al.,
2004 ). If, primary care providers and the public are not thinking osteoporosis prevention then
fractures, resulting disabilities, mortality and health care costs will continue to rise. Public
health policy, mass media and primary care providers need to acknowledge osteoporosis as
important and prevention initiatives as relevant.
Recommendations for Northern Health
Develop Osteoporosis Screening Survey

Ideally, osteoporosis screening tools should provide standardization and clinical
objectivity on which postmenopausal women should be selected for BMD screening. To date,
despite many small comparative and validation studies of osteoporosis screening tools there

Influence of BMD Testing on Calcium & Exercise 38
is a lack of good discriminatory performance and they have not found widespread clinical
application (Nelson et al., 2002; O'Neill, 2007). The better known risk assessment tools such
as the Simple Calculated Osteoporosis Risk Estimation (SCORE), Osteoporosis Risk
Assessment Instrument (ORAl) and the Osteoporosis Self-assessment Tool (OST) set out
rules for determining who may be appropriate for BMD testing (Gourlay, Powers, Lui, &
Ensrud, 2008; Nelson et al., 2002; O'Neill, 2007). These assessment tools have been
primarily studied pertaining to older postmenopausal

~ 65 years and are not inclusive

with the most recent evidence pertaining to risk predictors. Although, SCORE and ORAl are
recommended for use in the primary care setting (Cadarette et al., 2000; Cheung et al., 2004)
both tools include HRT as a variable; HRT has become less relevant with declining use since
the adverse outcomes of the Women's Health Initiative study (Gourlay et al., 2008). Gourlay
et al. (2008) conducted an accuracy analysis of all three risk assessment tools and individual
risk factors (age, weight and prior fracture) to identify low BMD in 7,779 American women
~ 67 years of age. The article concluded that weight identified those with low BMD as

accurately as the ORAl and SCORE and there was no advantage to using a risk assessment
tool over assessing for low weight in older women> 65 years of age (Gourlay et al., 2008).
As well, Rolnick et al. (2001) in this review also pointed out that SCORE tended to overidentify many women at risk.
Recently, the WHO has developed the Fracture Risk Assessment Tool (FRAX) which
calculates individual's 10-year absolute fracture risk and can be used with or without BMD
results. The risk factors include prior fracture, age, weight, family history, smoking, alcohol
intake, as well as secondary causes of osteoporosis and known T-score of the femur which
modestly improves the predictability of the risk (O'NeiJJ, 2007). The FRAX model allows

Influence of BMD Testing on Calcium & Exercise 39
categorization of risk from low to high and targets people for economical cost-effective
interventions. The tool is available online at http://www.shef.ac.ukJFRAX and is
incorporated into the National Osteoporosis Foundation (2008) Clinician's Guide to

Prevention and Treatment of Osteoporosis (Watts, Lewiecki, Miller, & Bairn, 2008).
Although, this tool is more comprehensive and can be useful when assessing the older high
risk postmenopausal woman and assist with decision making on related interventions, it does
not fill the need for a standardized approach for selecting clients for BMD screening. There is
a lack of appropriate osteoporosis screening tools for the young postmenopausal woman and
this project points to a need to develop a useful clinically based osteoporosis screening
survey for this population.

Adopt Implications for Practice
The implications outlined in this project highlight the importance of including more
than predictors for BMD screening in a risk assessment survey. Recognizing who is most at
risk is an important component and osteoporosis risk predictors do assist with the decision
making process on who would benefit from BMD screening; however, the survey should also
include an assessment of osteoporosis general knowledge, present levels of OPBs, health
beliefs and health anxiety predictors. The client should be able to prioritize which questions
are of importance to them ensuring that the client's needs are met and will determine if there
is a need for follow-up visits.
Besides standardizing care for osteoporosis the introduction of an osteoporosis
assessment survey is a preventative measure that provides an opportunity for primary care
providers to be proactive with providing self-management support to clients. Selfmanagement has been receiving increasing attention with a shift from a paternalistic care

Influence of BMD Testing on Calcium & Exercise 40
model towards patients being more actively involved with their care needs (Barlow, Sturt, &
Hearnshaw, 2002). This is in line with Provincial directives from the Centre on Aging;
resource reference www.coag.uvic.ca/cdsmp. The Centre on Aging is promoting a training
program for allied health care professionals that recommends the five A's approach that
encourages motivational interviewing. This approach includes strategies to assess, advise,
agree, assist and arrange with intention of promoting day to day self-management skills for
clients coping with chronic conditions. An osteoporosis risk survey enhances a consistent,
best practice approach that incorporates assessing for osteoporosis as part of routine care for
young postmenopausal women while highlighting osteoporosis as a priority. Considering that
mailed reminders significantly improve osteoporosis screening rates (Lafata et al., 2007),
osteoporosis risk surveys could be sent out via posted mail or on-line which can be
completed at specific age intervals for women ;::: 50 years or are flagged to be completed at
well women appointments. Osteoporosis screening surveys also serve to provide a guided
visit agenda which is also one of the objectives for promoting the self-management care
approach.
It is acknowledged that patients may not view osteoporosis as a priority health issue

however, primary care providers not highlighting osteoporosis education contributes to the
overall belief that osteoporosis is not preventable and is an acceptable part of aging. The
osteoporosis screening survey provides an opportunity to assess knowledge gaps and
misconceptions that may require clarification or advice on recommendations for behaviour
change. This project indicates that increasing knowledge pertaining to the benefits of
adequate intake of calcium and vitamin D does increase the intake of calcium and vitamin D.
As well, an osteoporosis risk survey indicating at risk predictors will assist with selection for

Influence ofBMD Testing on Calcium & Exercise 41
BMD referral. Asking about the clients concerns highlights the patient's interests and
provides opportunities to collaboratively discuss which OPBs behaviours they are motivated
to change. The process of setting goals the client agrees to or wishes to move forward with is
part of the motivational process and includes exploring perceived barriers, problem solving
and enhancing self-efficacy. The primary care provider has a role with assisting clients by
increasing motivation and developing action plans. Arranging follow-up is an essential part
of the process and is important particularly for at risk client that have been referred for BMD
testing. Consideration of the implications of osteoporosis risk screening and BMD testing has
been highlighted in this project and are outlined as follows:
Overview of Implications for Practice:
•

Increasing osteoporosis risk screening, a priority- high rates of abnormal bone density
in relatively healthy women demonstrating value of early osteoporosis risk screening
beginning at age 50.

•

Increase osteoporosis knowledge- knowledge gap concerning adequate calcium and
vitamin D intake and importance of exercise for bone health. Lack of generalized
knowledge of osteoporosis as a disabling and deadly disease.

•

Provide personalized feedback- increase level of understanding of BMD result and
provide balanced explanation of personal susceptibility and seriousness of osteoporosis

•

Assess health screening anxiety- negative influence of BMD screening on exercise,
potential fear of falling/worry resulting in decreasing activity

•

Explore perceived barriers- assess health beliefs, knowledge gaps, misconceptions,
readiness to change, develop strategies to reduce barriers and increase confidence

Influence of BMD Testing on Calcium & Exercise 42
Offer BMD Testing

It should be considered that availability of BMD scanning does influence women's
interest in participating in osteoporosis prevention programs. A screening and bone
maintenance program can serve as a resource for clients, and provides invaluable support for
professionals (Galsworthy, 1990). Rolnick et al. (2001) indicated that women were
disappointed when selected for the education session without BMD testing and this may have
contributed to the 29% absenteeism rate when compared 10% absenteeism rate in the
education plus BMD testing group. The findings of the Osteoporosis Population-Based Risk
Assessment (OPRA) Trial, also supports having BMD availability, this trial of 3,167 older
women compared strategies for how to allocate BMD testing and found that when BMD
testing was offered universally, with no limitations, in a fracture prevention program the
more influence there was on fracture rates, change in fracture risks and knowledge about
fracture (LaCroix, Buist, Brenneman, & Abbott III, 2005). Although, the OPRA trials
recruitment rates were low (21 %-42%) across intervention groups and the focus was on older
women (60-80 years) the women who participated overwhelmingly indicated a desire for
fracture prevention programs that offered BMD testing (LaCroix et al., 2005). This has
implications for group educational strategies for enhancing recruitment and increasing
attendance, access to BMD testing influences women's decisions to participate in
osteoporosis prevention programs and is effective at influencing OPBs.
Conclusion
For postmenopausal women osteoporosis and fracture are a major threat to functional
independence and quality of life that has the potential to precipitate the end of life. Calcium,
vitamin D and exercise have been shown to increase bone density, reduce falls and prevent

Influence of BMD Testing on Calcium & Exercise 43
fractures . Studies have shown that personal knowledge of bone density has a positive
influence on treatment interventions in postmenopausal women yet, the studies considering
the personal knowledge of BMD testing on OPBs are less clear. This project evaluated the
influence of education and knowing personal knowledge of BMD testing on calcium intake
and exercise of young postmenopausal women between the ages of 50-65 years of age. The
review found a positive influence of education and BMD that increased calcium and vitamin
D intake. It also showed that the intake of calcium and vitamin D was significant with
decreasing BMD measurements. The findings showed no influence of education and BMD
testing on exercise and in fact may have a negative influence resulting in lowering levels of
exercise or activity participation. The limitations of this project are the review included four
studies of which only two were RCTs. This review does suggest that further research is
warranted to better understand the relationship between osteoporosis, BMD screening and
exercise.
Personal knowledge of BMD does influence OPBs and all four aspects of the HBM
need to be in motion in order for health behaviours to be successful. The findings in this
review are supported by other studies and have implications for practice in the primary care
setting. The outcomes of this project point to a gap in public knowledge of osteoporosis
particularly as it relates to the important benefits of adequate calcium and vitamin D intake
and exercise for bone health. As well, the outcomes stress the importance of increasing
osteoporosis risk screening to identify those at risk and who would benefit from osteoporosis
medical interventions. There is a need to develop a useful clinically based osteoporosis
screening survey for this population group and a screening survey should address
osteoporosis predictors of risk, knowledge, health beliefs and pre-existing anxiety associated

Influence of BMD Testing on Calcium & Exercise 44
with health screening interventions. Health care providers should be aware of the impact of
personalized feedback, potential client anxiety and the importance of follow-up post BMD
testing in the primary care setting. Osteoporosis prevention should be a priority for young
postmenopausal women with the ultimate goals of reducing fractures thereby reducing
morbidity, mortality while improving quality of life and decreasing the burden on the health
care system.

Influence of BMD Testing on Calcium & Exercise 45

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