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Development, Implementation, and Evaluation of a Pediatric
Educational Program for the Promotion of Bone Health
Beth Keller, BSN, RN
Creighton University
College of Nursing
Financial Disclosure
I, Beth Keller, do not have a financial interest, arrangement, or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject
of this presentation.
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Learning Objectives
• Describe the importance of increasing the peak bone mass in childhood and adolescent years.
• Identify interventions for increasing peak bone mass.
• Discuss the effectiveness of a bone health educational program in elementary students.
Why Bones?
• NUR 650 Advanced Pathophysiology Across the Lifespan
– Dr. William Hunter
– Osteoporosis
• Young population focus
– Prevention
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Background
• What is Osteoporosis?1
– “Porous Bone”
– Deterioration of bone structure
– Low bone mass
– Increase bone fragility
– Increase fracture risk
Background• In the US, 54 million people have osteoporosis1
• 50 years and older:
– 50% women will have osteoporotic fracture1
– 25% men will have osteoporotic fracture1
– 20 ‐ 30% mortality rate within 1st year after hip fracture2
• 1/3 patients still in nursing home 1 year after hip fracture2
• Vertebral fractures twice as common3
• 19 billion dollars a year in related costs1
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Background
• 40‐fold increase in bone mineral content from birth to adulthood4
• 40% of adult bone mass accrual ‐ 4 years surrounding peak height velocity5
• Peak Bone Mass ‐ highest bone mass4,5
• In older adults, bone loss greater than bone replaced1
• Menopause6
– 10% average loss of bone mass
Significance• Healthy People 2020
– Osteoporosis7
• No specific bone health guidelines for children
• National Osteoporosis Foundation encouraging children and adolescents to achieve optimal peak bone mass8
• Calcium, Vitamin D, weight bearing exercise, and not smoking or drinking alcohol8
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Clinical Problem
• Minimal education in Laramie, Wyoming to pre‐adolescents and adolescents regarding osteoporosis prevention and building strong bones
• Osteoporosis: DXA Scan 2.5 standard deviations below reference value9
• Bone loss constant within one person10,11
– Study followed women for 22 years11
• Able to estimate osteoporosis onset10
• Increase PBM by 10% ‐ delay onset by 13 years10
• Children with lower BMD have increased fracture rates during childhood12
PBM, BMD, & Osteoporosis Literature Review
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Calcium and Vitamin D Literature Review
• Twins 9 – 13 years old13
– 800 mg Calcium and 400 IU Vitamin D vs placebo
– Increase in BMD 6 months later
• Females 8 to 12 years old14
– BMD increased 5.5% verses 3.3%
Weight Bearing Exercise Literature Review
• Higher BMD in children15, 16
– Increased exercise time15
–Moderate to high intensity exercises16
• Exercises with a larger load applied at a rapid rate5
– Jumping repetitions5
• CDC17
– Exercise 1 hour every day
–Weight‐bearing – 3 hours/week
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Not Smoking Literature Review• Smoking effects…..18
– Decreases blood supply to bones
– Decreases number of osteoblasts
– Interferes with calcium absorption
– Breaks down estrogen faster
– Hinders vitamin D activation
– Damages ovaries thus decreases hormone production
• Smaller BMD in females that had tried smoking before age 1319
• Weight‐bearing bones more affected by smoking20
Alcohol Intake Literature Review
• Alcohol effects….21
– Inhibits osteoblast production
– Stimulates osteoclasts production
• Binge drinking – data lacking22
• Chronic consumption22
– Increases fracture healing time
– Decreases BMD
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• Better Bones Buddies23
– 64% students drank more milk
• Needs for Bones24
–More interest in 4th and 5th graders
Educational Programs Literature Review
Theoretical Framework
• Health Belief Model25
• Person will change their health behavior based on the illness severity, susceptibility, preventative benefits, and barriers
• Children
– Osteoporosis 50 years from now
– Fracture risk now
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Purpose/Aims
• The purpose of this scholarly project was to develop, implement, and evaluate an educational program for promotion of bone health in elementary students.
• The aims were:
– Increase knowledge about osteoporosis and its prevention in elementary students
– Increase calcium intake in the students
Setting Methodology
• Laramie, Wyoming
• Population 30,81626
• Majority Caucasian26
• Small percentage of Asian, Hispanic, Native American, Pacific Islanders, African‐American26
• 7 of 8 elementary schools
– 4th – 6th grades
– Ages 9 – 12 years
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Intervention Methodology
• Spring 2018 – Contacted schools
• Written consent – School principals
• IRB approval
• Reverse consent – parents
• Teacher name, number
Intervention Methodology
• Healthy Bones Knowledge Questionnaire (HBKQ)27
– Reliability: 0.69
• Calcium Food Frequency Questionnaire (CFFQ)28
– Reliability: 0.74
– Validity: 0.43
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Intervention Methodology
• Pre‐HBKQ
• One hour interactive program
• Power Point
• Visual Aid
• Bone facts, PBM, calcium, vitamin D, weight‐bearing exercises, not smoking, not drinking alcohol, osteoporosis, preventing fractures
• Pre‐CFFQ
• Returned in one month: post‐HBKQ & post‐CFFQ
Building Strong Bones Today your children heard a presentation about how to build strong bones given by a nurse practitioner student, Beth Keller. Building strong bones is important in order to prevent osteoporosis, a condition where bones become brittle and fragile as one ages. As an adolescent reaches adulthood, the bones in the body reach peak bone mass (PBM). PBM is the highest bone mass a person will have in his or her lifetime. If the PBM is low then there is an increased risk of developing osteoporosis later in life. By increasing the PBM by 10%, the onset of osteoporosis could be delayed by 13 years.
I realize it is hard to convince children at this age to build strong bones in order to prevent something that could happen 40 to 50 years down the road. Studies have shown that children with lower PBM have an increased risk for fractures. By building strong bones, children can decrease the risk of fractures now. Please realize building strong bones decreases the risk of fractures, it cannot completely rule out the possibility of fracturing a bone.
Calcium 1300 mg / day
Sources of Calcium: Broccoli (8 oz) 60 mg Oranges (1 whole) 55 mg Soy Beans (8 oz) 175 mg Canned Salmon (3 oz) 180 mg Mac & Cheese (1 pkg) 325 mg Cheese Pizza (1 piece) 115 mg Beans (4 oz.) 160 mg Low-fat plain yogurt (6 oz) 310 mg Mozzarella (1 oz) 210 mg Cheddar (1 oz) 205 mg Vanilla ice cream (4 oz) 85 mg Milk (8 oz): Whole milk 280 mg 2% Milk 295 mg Almond Milk 80 – 451 mg Rice Milk 191 – 283 mg Soy Milk 0 - 451 mg Coconut Milk 0 – 466 mg
Some milk brands are fortified with calcium, some aren’t. READ THE LABELS!!
Calcium values listed are estimates and may vary between different brands.
Vitamin D
600 IU / Day Helps the body absorb calcium
Weight Bearing Exercises
60 minutes, 3 times/week Running Jumping Tennis
Don’t Smoke Smoking causes:
Decreased blood supply to bones Decreased bone forming cells
Decreased absorption of calcium Decreased activation of vitamin D
Don’t Drink Alcohol Alcohol causes:
Decreased bone forming cells Increased bone absorbing cells
Thank you. Beth Keller, RN
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Findings
School HBKQ CFFQ
Beitel 31 34
Indian Paintbrush 48 47
Linford 44 43
Montessori 19 20
Slade 32 30
Spring Creek 49 44
UW Lab School 26 24
Total: 249 242
• Table: Number of pairs of questionnaires
• HBKQ
– Pre: 90%
– Post: 95%
• CFFQ
– Pre: 87%
– Post: 94%
Findings
Pre‐HGKQ Post‐HBKQ
Score 41.54% 50.65%
Standard Deviation 9.75 13.82
Pre‐CFFQ Post‐CFFQ
Mean Calcium (mg/day)
1,039 1032
Standard Deviation 584 609
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Findings
• Repeated‐measures ANOVA
• HBKQ
– 9% improvement (p<0.001)
– 95% CI [7.03%, 11.2%]
• CFFQ
– No change (p=0.897)
– 95% CI [‐109mg, 96mg]
Evaluation
• Increased knowledge
• Why no increase in calcium intake?
– Already high calcium intake
• Average Pre‐CFFQ intake 1,039 mg
–Meals controlled by parents
• Sustainability
– Schools
– Own practice
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Strengths and Limitations
• No long term follow up
– 1 month
• Large number of children
• Cooperation of schools
• Age group was interested and participated well
DNP Implications
• Prevention of osteoporosis
• Prevention of fractures
• Well child visits
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Questions?
Osteoporosis: Pediatric disease with geriatric
consequences!29
Acknowledgements
• DNP Chairman: Dr. Joan Lappe
• DNP Committee: Luann Edwards, RN
• Statistician: Alex Hall, MA
• All of the teachers in the Albany County School System
• All of the students that listened to my presentation and answered the questionnaires
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References1. National Osteoporosis Foundation. (n.d.). What is osteoporosis and what causes it? Retrieved from https://www.nof.org/patients/what‐is‐osteoporosis/
2. NIH Osteoporosis and Related Bone Diseases National Resource Center. (2016). Handout on health: Osteoporosis. National Institute of Health (NIH). Retrieved from https://www.niams.nih.gov/health_info/bone/osteoporosis/osteoporosis_hoh.asp
3. American Academy of Orthopaedic Surgeons. (2009). Osteoporosis and spinal fractures. Retrieved from https://orthoinfo.aaos.org/en/diseases‐‐conditions/osteoporosis‐and‐spinal‐fractures/
4. Golden, N., Abrams, S., & Committee on Nutrition. (2014).Optimizing bone health in children and adolescents. Pediatrics, 134(4), 1229 –1243. doi 10.1542/peds.2014.2173
5. Gunter, K., Almstedt, H., & Janz, K. (2012). Physical activity in childhood may be the key to optimizing lifespan skeletal health. Exercise and Sport Sciences Reviews, 40(1), 13 – 21.
6. Recker, R., Lappe, J., Davies, K., & Heaney, R. (2000). Characterization of perimenopausal bone loss: A prospective study. Journal of Bone and Mineral research, 15(10). 1965 – 1973.
7. Office of Disease Prevention and Health Promotion. (n.d.). Arthritis, osteoporosis, and chronic back conditions. Healthy People 2020. Retrieved from https://www.healthypeople.gov/2020/topics‐objectives/topic/Arthritis‐Osteoporosis‐and‐Chronic‐Back‐Conditions
8. Weaver, C., Gordon, C., Janz, K., Kalkwarf, H., Lappe, J., Lewis, R., O’Karma, M., Wallace, T., & Zemel, B. (2016). The national osteoporosis foundation’s position statement on peak bone mass development and lifestyle factors: A systematic review and implementation recommendations. Osteoporosis International, 27, 1281 – 1386.
9. Unnanuntana, A., Gladnick, B., Donnelly, E., & Lane, J. (2010). The assessment of fracture risk. Journal of Bone and Joint Surgery, 92, 743 –753.
10. Bonjour, J., Chevalley, T., Ferrari, S., Rizzoli, R. (2009). The importance and relevance of peak bone mass in the prevalence of osteoporosis. Salud Publica de Mexico, 51(S1), 5 – 17.
11. Melton, L., Atkinson, E., Khosla, S., Oberg, A., & Riggs, B. (2005). Evaluation of a prediction model for long‐term fracture risk. Journal of Bone and Mineral Research, 20(4), 551 ‐ 556.
12. Kalkwarf, H., Laor, T., & Bean, J. (2011). Fracture risk in children with a forearm injury is associated with volumetric bone density and cortical area (by peripheral QCT) and areal bone density (by DXA). Osteoporosis International, 22, 607 – 616.
13. Greene, D. & Naughton, G. (2011). Calcium and vitamin‐D supplementation on bone structural properties in peripubertal female identical twins: A randomized controlled trial. Osteoporosis International, 22, 489 ‐ 498. doi 10.1007/s00198‐010‐1317‐z
14. Khadilkar, A., Kadam, N., Chiplonkar, S., Fischer, P., & Khadilkar, V. (2012). School‐based calcium‐vitamin D with micronutrient supplementation enhances bone mass in underprivileged Indian premenarchal girls. Bone, 51, 1 ‐ 7.
References15. Detter, F., Rosengren, B., Dencker, M., Lorentzon, M., Nilsson, J., & Karlsson, M. (2014). A 6‐year exercise program improves skeletal traits without affecting fracture risk: A prospective controlled study in 2621 children. Journal of Bone and Mineral Research, 29(6), 1325 – 1336.
16. Heidemann, M., Mogaard, C., Husby, S., Schou, A., Klakk, H., Moller, N., . . . Wedderkopp, N. (2013). The intensity of physical activity influences bone mineral accrual in childhood: The childhood health, activity and motor performance school (the CHAMPS) study, Denmark. BMC Pediatrics, 13, 32 – 39. doi: 10.1186/1471‐2431‐13‐32.
17. Center for Disease Control (2018). Youth Physical Activity Guidelines. Retrieved from https://www.cdc.gov/healthyschools/physicalactivity/guidelines.htm
18. Cusano, N. (2015). Skeletal effects of smoking. Current Osteoporosis Reports, 13, 302 – 309. doi 10.1007/s11914‐015‐0278‐8
19. Lucas, R., Fraga, S., Ramos, E., & Barros, H. (2012). Early initiation of smoking and alcohol drinking as a predictor of lower forearm bone mineral density in late adolescence: A cohort study in girls. Plos One, 7(10), 1 – 10.
20. Rudang, R., Darelid, A., Nilsson, M., Nilsson, S., Mellstrom, D., Ohlsson, C., & Lorentazon, M. (2012). Smoking is associated with impaired bone mass development in young adult men: A 5‐year longitudinal study. Journal of Bone and Mineral Research, 27(10). 2189 ‐ 2197. doi: 10.1012/jbmr.1674
21. Alund, A., Mercer, K., Pulliam, C., Suva, L., Chen, J., Badger, R., & Ronis, M. (2017). Partial protection by dietary antioxidants against ethanol‐induced osteopenia and changes in bone morphology in female mice. Alcoholism: Clinical and Experimental Research, 41(1), 46 – 56.
22. Maurel, D., Boisseau, N., Benhamou, C., & Jaffre, C. (2012). Alcohol and bone: Review of dose effects and mechanisms. Osteoporosis International, 23. 1 ‐ 16. doi 10.1007/s00198‐011‐1787‐7
23. Schrader, S., Blue, R., & Horner, A. (2005). Better bones buddies: An osteoporosis prevention program. The Journal of School Nursing, 21(2), 106 – 114.
24. Cheng, F., Monnat, S., & Lohse, B. (2015). Middle school‐aged child enjoyment of food tastings predicted interest in nutrition education on osteoporosis prevention. Journal of School Health, 85(7), 467 – 476.
25. Rosenstock, I. (1974). Historical origins of the health belief model. Health Education Monographs, 2(4), 328 – 335.
26. United States Census Bureau. (n.d.). 2010 Census Summary File 1. Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF
27. Brown, S. & Schoenly, L. (2004). Test of an educational intervention for osteoporosis prevention with U.S. adolescents. Orthopaedic Nursing, 23(4), 245 ‐ 251
28. Harnack, L., Lytle, L., Story, M., Galuska, D., Schmitz, K., Jacobs, D., & Gao, S. (2006). Reliability and validity of a brief questionnaire to assess calcium intake of middle‐school‐aged children. Journal of the American Dietetic Association, 106(11), 1790 – 1795
29. Hightower, L. (2000). Osteoporosis: Pediatric disease with geriatric consequences. Orthopaedic Nursing, 19(5), 59 – 62.
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