Comparison of bone mineral density measurements at different sites: applications for primary care providers.

Bone densitometry is an effective screening tool for osteoporosis; however, problems may exist when patients present with high variability between readings at different sites. The purpose of this study was to compare bone mineral density measures of the femur, spine and whole body using dual-energy x-ray absorptiometry. While correlations between anatomic regions were high, substantial variability existed for participants which presents the potential for misdiagnosis and confusion. Densitometry screening using both spine and femur is recommended; information regarding readings that are variable are provided. Applications for bone mineral density screening and counseling are presented for primary care physicians.

Use of decision rules for osteoporosis prevention and treatment: implications for nurse practitioners.

PURPOSE: To describe the current literature regarding the benefits of bone mineral density (BMD) screening and to discuss clinical decision rules for BMD screening. DATA SOURCES: Extensive review of the scientific literature regarding osteoporosis, BMD screening, and current clinical decision rules. CONCLUSIONS: Osteoporosis is a disease characterized by deterioration of bone and increased susceptibility to fractures, crippling, and disfigurement. BMD testing is the best predictor for osteoporosis and associated fractures; however, routine global BMD testing is cost-prohibitive. A need exists for a selective and practical clinical decision rule for referral for testing. IMPLICATIONS FOR PRACTICE: Several effective clinical decision rules are presented, and their uses and applications are described. The osteoporosis self-assessment tool is recommended by the authors because of its predictive power and ease of use.

Comparison between 60 matched pairs of postmenopausal black and white women: analysis of risk factors related to bone mineral density.

PURPOSE: Osteoporosis is a systemic disease in which bone density is reduced, leading to weakness of the skeleton and increased vulnerability to fractures. The purpose of this study was to compare known or suspected risk factors (medical, gynecological, and lifestyle characteristics) related to bone loss between 60 matched pairs of black and white postmenopausal women. METHODS: The two racial groups were matched one for one on selective anthropometric variables [age (years), standing height (cm), and body weight (kg)] in order to equate age and body size between groups. Information on risk factors was obtained from an orally administered questionnaire and body composition variables (in addition to those used for matching) assessed by anthropometry and total body dual energy X-ray absorptiometry (DXA). Four skinfold sites (chest, triceps, mid-axillary, and abdomen) were measured with Harpendon calipers and four body circumferences (chest, forearm contracted, waist, and gluteal) were assessed with a Gulick tape. DXA radius, spine, femur, and whole body measurements were obtained on a Hologic QDR-2000 with software version 7.20. RESULTS: White women reported significantly higher proportions of alcohol use, family history of broken bones, and a greater utilization of hormones, calcium and vitamins than did black women. Black women reported a greater numbers who had other diseases (i.e., overactive thyroid, diabetes, rheumatoid arthritis, or kidney stones). Although age and body weight were similar in both groups, black women had greater lean tissue and less body fat than white women. Blacks had significantly higher bone mineral density across all body sites with the exception of the mid- and ultra-distal radius. CONCLUSION: On the basis of these data, it was concluded that part of the difference often observed in bone density between black and white postmenopausal women might be due to lifestyle factors.

Literacy, medical care, and health status in Tennessee.

Based on the most recent information, Tennessee is facing an enormous problem with literacy and health outcomes. As a result, the healthcare industry is vulnerable because of patients' inability to understand and follow a plan of treatment. This in part has resulted in poor healthcare and increased costs in providing care. By implementing strategies such as those outlined in Table 1, strides can be made in improving the healthcare provided to Tennesseans and reducing costs associated.

American Academy of Family Physicians patient education materials: can patients read them?

BACKGROUND AND OBJECTIVES: A large proportion of US adults struggle with limited literacy skills, which affect their ability to fully function in health care settings. This study evaluated the readability of English language American Academy of Family Physicians (AAFP) patient education materials. METHODS: A random sample of 171 AAFP patient education materials was selected from a list of 518 health topics available via the Internet. The SMOG grade formula was used to measure readability of the written patient education materials. RESULTS: The mean SMOG grade level of AAFP patient education materials was 9.43 +/- 1.31 (range=6-12). This is higher than the average reading skills of US adults. CONCLUSIONS: Our results support and extend the findings of other readability studies across many medical specialties, all of which find that patient education materials are written at a difficulty level that is too high. The AAFP and individual family physicians should strive to improve communication with their patients by providing educational materials that are written at an appropriate reading level.

Risk factors for osteoporosis among middle-aged women.

OBJECTIVE: To investigate the risk factors for osteoporosis among a sample of middle-aged women. METHODS: Adipose tissue and bone mineral density levels at the left femur, lumbar spine, and total body were assessed using dual-energy x-ray absorptiometry (DXA). Subjects (n=342) were surveyed regarding a variety of osteoporosis-related risk factors. Forward stepwise multiple regression procedures were utilized. RESULTS: Menstrual status, hormone replacement therapy, adipose tissue, and dairy product intake were retained in the regression models. CONCLUSIONS: Osteoporosis prevention programs need to emphasize the importance of hormonal status and body composition in addition to obtaining adequate calcium intake.

Evaluation of decision rules for identifying low bone density in postmenopausal African-American women.

OBJECTIVE: While African-American women tend to have greater bone mineral density (BMD) than caucasian women, they are still at risk of developing osteoporosis later in life. Clinical decision rules (i.e., algorithms) have been developed to assist clinicians identify women at greatest risk of low BMD. However, such tools have only been validated in caucasian and Asian populations. Accordingly, the objective of this study was to compare the performance of five clinical decision rules in identifying postmenopausal African-American women at greatest risk for low femoral BMD. METHODOLOGY: One hundred-seventy-four (n=174) postmenopausal African-American women completed a valid and reliable oral questionnaire to assess lifestyle characteristics, and completed height and weight measures. BMD at the femoral neck was measured via dual energy x-ray absorptiometry (DXA). We calculated sensitivity, specificity, positive predictive value, and negative predictive value for identifying African-American women with low BMD (T-Score < or = -2.0 SD) using five clinical decision rules: Age, Body Size, No Estrogen (ABONE), Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Self-Assessment Tool (OST), Simple Calculated Osteoporosis Risk Estimation (SCORE), and body weight less than 70 kg. RESULTS: Approximately 30% of African-American women had low BMD, half of whom had osteoporosis (BMD T-Score < or = -2.5 SD). Sensitivity for identifying women with a low BMD (T-Score < or = -2.0 SD) ranged from 65.57-83.61%, while specificity ranged from 53.85-78.85%. Positive predictive values ranged from 80.95-87.91%, while negative predictive values ranged from 48.44-58.33%. CONCLUSION: Our data suggest that the clinical decision rules analyzed in this study have some usefulness for identifying postmenopausal African-American women with low BMD. However, there is a need to establish cut-points for these clinical decision rules in a larger, more diverse sample of African-American women.

The effect of 15 weeks of exercise on balance, leg strength, and reduction in falls in 40 women aged 65 to 89 years.

OBJECTIVE: Risk of falling increases as people age, and decreased leg strength and poor balance have been implicated as contributors. Our aims were to:1) assess the efficacy of a fall-prevention exercise program on balance and leg strength in women aged 65 to 89 years and 2) conduct a 1-year follow-up to determine the effect of exercise on fall rates. METHODS: Forty women were classified by falling history and fear of falling and assigned to exercise and control groups using stratified randomization. We used the Berg Balance Scale, Get-up and Go, Functional Reach, and Wall-Sit Tests to evaluate changes in balance and leg strength before and after a supervised 15-week exercise program (31-hr sessions/week). We conducted 1-year follow-up telephone interviews and compared the number of falls reported by exercise and control groups.The study used a 2 x 2 (exercise/control by pretest/post-test) factorial design with the testing times being a repeated factor, so we used analysis of variance (ANOVA) to evaluate differences between the 2 groups across testing times. Power analysis computed a priori with STPLAN software (Version 4.2) showed that a sample size of 40 was necessary to determine statistical differences in balance and leg strength. RESULTS: Exercise subjects showed significant improvement on 5 of 14 items (5.2%, p < or = 05 to 34.4%, p < or = .01) in the Berg Balance Scale and on the total score (6.8%, p < or = .05). Leg strength increased significantly (p < or = .05) on post-test as measured by the Wall-Sit Test. Control subjects reported 6 falls and exercise subjects no falls during the follow-up year, but this difference was not significant using Fischer's exact test (p=.106). CONCLUSION: The exercise program resulted in increased balance and leg strength, but did not result in a significant difference in falls during the follow-up period. Further research with a larger and possibly older sample is needed to more adequately investigate this question. Health care providers who work with older women should provide exercise programs in which balance and leg strength are emphasized.

Patients' attitudes regarding physical characteristics of family practice physicians.

BACKGROUND: This study examined patient perceptions and attitudes toward various aspects of the male and female physician's professional appearance in the family practice setting. METHODS: Four hundred ninety-six patients from two family practice clinics in Knoxville, Tennessee, completed a valid and reliable questionnaire. Questionnaires were offered to all patients on registering at their respective clinic during a 2-week period. RESULTS: Most patients had no preference regarding the age or sex of their medical care provider. A nametag, white coat, and visible stethoscope were the most desirable characteristics, whereas sandals, clogs, and tennis shoes were the least desirable items. Younger patients were generally more accepting of casual attire than were older patients. Office clinic location was the most important predictor of preferences in six of the significant characteristics. CONCLUSION: Our findings support the results of both studies published two decades earlier and more recently. Patients prefer a traditionally dressed physician as opposed to one who is dressed more casually.

Development and content validation of family practice residency recruitment questionnaires.

BACKGROUND AND OBJECTIVES: The residency recruitment process involves a substantial time and financial commitment on the part of medical students and residency programs. This paper describes the development and content validation process of two written questionnaires designed to assess the application and interview process at our family practice residency program. METHODS: Two written questionnaires were developed after completion of a literature review and from areas deemed important by our academic faculty. Drafts of each questionnaire were sent to nine jurors to assess content validity. Content reviewers provided both a qualitative and a quantitative assessment of each questionnaire. RESULTS: The inclusion of both open- and closed-ended questions/items was deemed necessary and appropriate by the panel of content jurors. Assessing faculty, residents, curriculum, program's reputation, geographic location, and spouse/family influence were considered the most important factors to include on the questionnaires when assessing a family practice residency program. CONCLUSIONS: With increasing pressure to fill positions across many family practice residency programs, it is important for faculty involved in the recruitment process to recognize that both factors within and out of their control contribute to the selection process.

Osteoporosis coverage in selected women's magazines and newspapers, 1998-2001.

OBJECTIVE: To evaluate the accountability of osteoporosis information available in selected mass-circulating women's magazines (n=8) and a sample of newspapers (n=2). METHODS: Osteoporosis articles (n=132) were assessed for sources of information used, incidence/prevalence statistics, risks factors, and prevention measures. RESULTS: Expert sources were highlighted in the majority of articles, whereas incidence/ prevalence statistics were described in less than half of the articles. Risk factors and prevention measures were outlined in most articles; however, much of the information presented was ambiguous and incomplete. CONCLUSIONS: It appears that the reporting of osteoporosis in women's magazines and newspapers is not entirely balanced; thus, future coverage should provide greater detail when reporting risks and preventive measures.

Lifetime physical activity and calcium intake related to bone density in young women.

OBJECTIVE: Osteoporosis is a significant public health problem associated with increased mortality and morbidity. Our aim in this cross-sectional study was to investigate the relationship between lifetime physical activity and calcium intake and bone mineral density (BMD) and BMC (bone mineral content) in 42 regularly menstruating Caucasian women (age 21.26+/-1.91 years, BMI 23.83+/-5.85). METHODS: BMD and BMC at the lumbar spine (L2-L4), hip (femoral neck, trochanter, total), and total body were assessed by dual energy x-ray absorptiometry (DXA). Lifetime history of physical activity and calcium intake was obtained by a structured interview using valid and reliable instruments. RESULTS: Measures of both lifetime physical activity and calcium intake were highly correlated. In stepwise multiple regression analyses, lean mass was the most important and consistent factor for predicting BMD and BMC at all skeletal sites (attributable r2 = 28.8%-78.7%). Lifetime physical activity contributed to 3.0% of the variation in total body BMD, and life-time weight-bearing physical activity explained 15.1% of variance in lumbar spine BMC. Current calcium intake predicted 6% of the variance in BMD at the femoral neck and trochanter. CONCLUSIONS: We found lean mass to be a powerful predictor of BMD and BMC in young women. Because lean mass can be modified to some extent by physical activity, public health efforts must be directed at increasing physical activity throughout the lifespan. Furthermore, our results suggest that adequate calcium intake may help to enhance bone mass, thus decreasing the risk of osteoporotic fracture later in life.

Osteoporosis prevention in college women: application of the expanded health belief model.

OBJECTIVE: To examine personal characteristics and expanded health belief model (EHBM) constructs associated with the practice of osteoporosis-protective behaviors among a random sample of nontraditional college women. METHODS: A valid and reliable written mail questionnaire assessing osteoporosis knowledge, EHBM constructs, weight-bearing exercise (EX), and dietary calcium intake (CA) was completed by 273 women. RESULTS: A high proportion of women did not meet current guidelines for EX (50.7%) or CA (67.8%). Exercise self-efficacy and barriers to exercise were the best predictors of overall EX and CA behaviors. CONCLUSION: The EHBM was useful in predicting EX and CA.