Project Healthy Bones: An Osteoporosis Prevention Program for Older Adults

Introduction

By the year 2030, there will be 70 million Americans over the age of 65, and people 85 years and older are the fastest-growing segment of the population, according to estimates from the American College of Sports Medicine (Goodwin, 2000).

Osteoporosis is a serious condition in which bones become thinned, brittle and easily broken. Because osteoporosis develops gradually and progresses slowly, it is called the "silent disease," and people often don't know they have it until after their 60's. American women over age 65 have a 50% chance of suffering from osteoporosis; men have a 20% chance (Looker et al., 1995; Melton, 1995). The lifetime risk of fracture in women older than 50 years is nearly 40%. For men older than 60 years, lifetime risk is as high as 25% (Lie, 2000).

Hip fracture is predictive of another patient-oriented outcome: mortality. Within 1 year of hip fracture, there is 20% excess mortality in women and 30% excess mortality in men (Cooper, 1997). Nearly $14 billion is spent as a result of the 1.5 million fractures that occur annually in this country (Seeman, 2000).

Armed with the knowledge that osteoporosis and osteoporosis-related disability can be prevented, the New Jersey Department of Health and Senior Service (NJDHSS) initiated a wellness exercise program for older women and men at risk for osteoporosis. Project Healthy Bones began as a state-administered grant program in 1997.

Project Healthy Bones, a 24-week exercise and osteoporosis education curriculum, uses safe and proper exercise training principles based upon the latest scientific research to lead older women and men in group exercise, including strength training with weights and expanded balance exercises. Osteoporosis education in the area of dietary calcium, calcium supplementation, osteoporosis prevention, and treatment strategies as well as home safety and falls prevention are part of the program.

Partnership

Through a request for proposal from the NJDHSS, grants were made directly to 17 agencies to pilot the program. Rutgers Cooperative Extension received one of the original 17 grants. Rutgers Cooperative Extension was in a unique position to provide the community outreach aspect of the program, which consisted of nutrition education, osteoporosis prevention and treatment education, home safety, and falls prevention. The family and consumer sciences educator provided the weekly outreach portion of the program.

During the pilot year, the Rutgers Cooperative Extension Family and Consumer Sciences Educator served as the project coordinator. In the second year of the program, an administrative partnership was created, allowing Project Healthy Bones to expand to nearly 100 sites throughout the state. The success of Project Healthy Bones can be attributed directly to the unique partnership established in the state to provide and administer the program. Partners include the New Jersey Department of Health and Senior Services, the Association of Retired and Senior Volunteer Program Directors, Inc. (RSVP), a non-profit association with projects in each of the states 21 counties, and the Saint Barnabas Health Care System.

The New Jersey Department of Health and Senior Services administers Project Healthy Bones at the state level. RSVP's role is administering Project Healthy Bones at the local level. This includes recruiting volunteers to serve as peer leaders, linking at-risk older adults with classes in or near their communities, securing sponsors and sites for classes, and ensuring that the classes operate smoothly. The Saint Barnabas Center for Health and Wellness provided certified exercise physiologists, who possess extensive experience working with older adults, to train peer leaders in the exercise portion of Project Healthy Bones.

Rutgers Cooperative Extension assumed the educational component in regard to nutrition, osteoporosis prevention and treatment, home safety, and falls prevention. It also provided aging and health promotion in the initial grant period and continues to provide the nutrition education component at seven sites in Hunterdon County, New Jersey.

More than 1,400 older New Jerseyans currently participate in the program. Waiting lists exist in most counties as classes elect to continue to meet after completing the 24-week cycle.

The collaboration of a state department, a large health care system, a statewide non-profit organization, and Cooperative Extension Service is unique in providing a health promotion/disease prevention program. This collaboration serves as a model that can be replicated for osteoporosis prevention education and other health care initiatives. The pilot program at the site in Kingwood, Hunterdon County will complete its fourth year in June, 2001. The participants have become a peer-support network and have bonded to nurture and encourage positive health behaviors in each other.

Project Healthy Bones Features

Project Healthy Bones has a wellness focus and is built on the idea that self-esteem, peer support, and incremental successes are necessary to change behavior and that having fun should be part of the process. Project Healthy Bones uses the approach of older adults as peer advocate trainers. A peer advocate trainer acts as a role model and has a better understanding of beliefs, limitations, and fears of older participants.

The objectives of Project Healthy Bones are to:

• Improve strength, balance, and flexibility in older women, using balance and strength training exercises.
• Educate older women on the importance of exercise, nutrition, safety, and drug therapy and lifestyle factors as they relate to osteoporosis.
• Train peer advocates as leaders for Project Healthy Bones.

Guidelines for the Project Healthy Bones program are as follows.

1. The program runs for 6 months per session, a minimum of a 1.5-hour class per week. Participants are expected to exercise on their own outside of class, as well.
2. Class size is limited 10-15 participants, targeting individuals who perceive themselves at risk for osteoporosis and who are willing to make a long-term commitment.
3. Project Healthy Bones is offered at the same site for the length of the program. The site should be easily accessible for older adults. An ideal site would be a senior center or elder housing. A well-lit room with armless stable chairs is best.
4. The trainer should show sincere enthusiasm, optimistic attitude, ability to think clearly, good motivational and leadership skills, willingness to follow program design, compatibility with older adults, healthy appearance, and patience.
5. The peer advocate trainer goes through a 1-day train-the-trainers workshop on how to implement Project Healthy Bones and on how to lead balance and strength exercises.
6. Weights are used for the exercise component of the program. At a minimum, participants need ankle cuffs with removable 1-pound pellets that allow for progression as participants become stronger.
7. Peer trainers and participants receive a manual with osteoporosis educational information.
8. Participants are required to have a release from their doctor.
9. Participants are required to receive education on nutrition, the role of calcium in osteoporosis, supplements, osteoporosis prevention and treatment, home safety, and falls prevention.

Evaluation

Participants tracked weekly exercise progression on a reporting form. The balance exercises include an introductory (1) and advanced (2) level. The strength training exercises were tracked by the amount of weight lifted. Two hundred and seventeen exercise tracking forms were analyzed. The analysis showed substantial progression from exercise level 1 to level 2 and a statistically significant increase in amount of weight lifted. These improvements were evident in participants completing between 12 and 23 weeks of the program and those completing the entire 24-week cycle.

To evaluate the dietary intervention segment of the program, participants completed a "calcium challenge," 3-day diet recall. Analysis of the dietary assessment showed that, of 57 participants completing 12-23 weeks of the program, 39 or 68% increased their calcium intake. Of 16 participants completing 24 weeks of the program, 7 or 44% increased their calcium intake.

Conclusion

The Family and Consumer Sciences program area of the Cooperative Extension Service is in a premier position to provide the educational outreach component of nutrition, osteoporosis prevention and treatment, aging and health promotion, and falls prevention in a community program such as Project Healthy Bones. Cooperative Extension has the system in place to collaborate with agencies in securing grant funding to plan, develop, and implement an osteoporosis outreach education such as Project Healthy Bones.

References

Cooper, C. (1997). The crippling consequences of fractures and their impact on quality of life. American Journal of Medicine. 103(2A):12S-17S.

Goodwin, W. (2000). Aerobic and Strength Exercise: Essentials for the Older Adult. American College of Sports Medicine [On-line]. WebMD/Lycos. Available: http://www.webmed.lycos.com/contents/article/1676.51110.

Lie, D. (2000). Staying current with osteoporosis. American Academy of Family Physicians 52nd Annual Scientific Assembly. September 2000. Dallas, TX.

Looker, A.C., Johnston C. C. Jr, Wahner, H.W., Dunn, W.L., Calvo, M.S., Harris, T.B., Heyse, S.P., & Lindsay, R.L. (1995).Prevalence of low femoral bone density in older U.S. women from NHANES III. J Bone Miner Res. 10(5):796-802.

Melton, L.J.III. How many women have osteoporosis now? J Bone Miner Res. 1995; 10(2):175-177.

Seeman, E. 2000. The World Congress on Osteoporosis 2000. An overview. World Congress on Osteoporosis: Chicago, IL.