LIFESTYLE IMPROVEMENT CARE PLAN

Posted: November 8th, 2023

LIFESTYLE IMPROVEMENT CARE PLAN

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Lifestyle Improvement Care Plan

The global ageing population is only growing bigger with time, increasing the strength of osteoporosis as a key public health concern. The World Health Organization (WHO) terms the disorder as a silent disease because it is asymptomatic until a bone fracture occurs. At the end of the last decade, it was estimated that over 3 million adults above 50 in the United Kingdom had osteoporosis, while nearly 7 million individuals had suffered bone mass reduction. The bone health of many adults is in jeopardy, and if left unchecked, society risks having an ageing population with mobility impairments at the least. The proposed lifestyle improvement plan highlights that improving health literacy on osteoporosis will encourage the adoption of preventive behaviours. As per the medical, social and economic costs of osteoporosis, implementing comprehensive lifestyle improvement care plans should be an imperative for all national health policymakers. Enhancing health literacy on osteoporosis using Pender’s health promotion framework can be effective in causing substantial changes in preventive behaviours.

Rationale

            The purpose of the lifestyle improvement plan is to evaluate osteoporosis-related preventive behaviours. The paper adopts Pender’s model as the conceptual framework describing the various health behaviours. The model has its origins in public health, nursing and social cognitive theories (Askarian et al. 2019, p. 325). As in many chronic conditions, the model hypothesizes that people interact with their interpersonal and physical environments to determine their health status. Therefore, the proper way to improve health is via complex processes influenced by various variables. Using Pender’s mode, the lifestyle improvement plan considers three sets of factors:

1. The patient’s personal attributes and previous experiences in relation to the preferred behaviour.
2. Factors influencing particular health behaviours, such as emotions and cognitive dissonance. Past scientific studies confirm that health behaviours are influenced by perceived risks and benefits, perceived self-efficacy and social support, among many others.
3. Substitute activities for the preferred lifestyle behaviours. The care improvement plan acknowledges that there are activities or occurrences of events that people have little control over, such as family obligations and type of job.

Osteoporosis is a potential generational problem, thus the need for early prevention among the youth and adults. According to the Pender model, minimal research has been done on preventive lifestyle behaviours before the onset of menopause (Askarian et al. 2019, p. 325). The proposed care plan focuses on what currently healthy individuals can do to minimize the chances of developing the chronic disorder. Top bone mass is attained at the age of 30, explaining why men and women from the age of 35 must be active in maintaining bone health (Askarian et al. 2019, p. 325). The care plan follows the WHOs definition of health promotion as an activity that enhances wellbeing in every aspect of a person’s life.

Background

            Osteoporosis is a medical condition that wanes the bone, making them more vulnerable and likely to break. The disorder develops over several years and is often discovered after a fall or sudden knock (Varacallo & Fox, 2014, p. 818; Salari et al. 2021). The condition is associated with low bone mass and the gradual deterioration of bone tissue. The clinical significance of osteoporosis lies in the fractures that emerge. In the United Kingdom, it is estimated that 536000 new fractures occur annually (Compston et al. 2017). The number comprises 79000 hip fractures, 66000 clinician diagnoses vertebral breaks and 69000 arm fractures. Women (61%) are more likely to experience osteoporosis than men (39%) by the age of sixty (Compston et al. 2017). More than a third of women will suffer from the condition compared to a fifth of men (Compston et al. 2017). Fractures are associated with severe pain and functional impairment.

Osteoporosis is a significant national health problem with regard to healthcare spending. According to the National Health Service, osteoporosis is responsible for 4.4 billion pounds in annual medical consumption (Compston et al. 2017). First-year fracture prevention expenses amount to 3.2 billion pounds before reducing to 1.1 billion and 84 million pounds for the second and third years. Curtis et al. (2016, p. 19) conducted a meta-analysis of the literature on osteoporosis to identify the incidence rates of different types of fractures. The analysis finds that hip fractures accounted for nearly four thousand in-hospital admissions in North Ireland, England and Wales (Curtis et al. 2016, pp. 21). Hip fractures are the most common type of osteoporosis, accounting for nearly half of the fractures. Unfortunately, nearly 53% of patients with a hip fracture cannot exist or work independently, while 28% die within the first twelve months of the injury (Compston et al. 2017). The average length of hospital stay is 20 days. These numbers outline huge medical costs at the individual, household and national levels.

Fracture rates in the United Kingdom vary by age, sex, ethnicity, class and geographical location. Men have become more prone to suffer hip fractures in recent decades, whereas women will experience vertebral fractures (Cauley et al. 2014, p. 341). The ageing population is likely to double the number of fractures in the next five decades if preventive measures are not taken. The lowest incidence rates were in London, East of England and the South East Coast (Curtis et al. 2016, p. 22). The highest was the South West, Scotland and Northern Ireland. Fishing and old industry communities have the highest number of osteoporosis cases. Black individuals had the lowest rate in terms of ethnicity, with White women nearly five times more likely to suffer a fracture than Black women (Clynes et al. 2020, p. 112). Men of mixed ethnicity equally have a low incidence rate. White and South Asian women have the highest osteoporosis incidence rate. With most chronic conditions, the incidence rate increases as a person move from high to low socioeconomic status.

Epidemiology

Etiology

Bone quality and bone density are the two main indicators of bone strength. The WHO has established criteria for evaluating bone health and fracture risk, defined by a T score (standard deviation) (Lane, 2006, p. 54). The T-score expresses bone density, also expressed as grams per square centimetre. Evidence indicates that the risk of fracture increases when bone density reduces. Bone density is also determined by its minerals. A measure of length and width alone is insufficient in estimating fracture risks. The material aspect of bone density covers the mineral to matrix ratio, collagen composition and damage accumulation (Rachner et al. 2019, p. R148). The material aspect is influenced by the bone turnover rate or the degree to which old bone tissue is replaced by new bone tissue. Osteoporosis is popular in women because hormonal changes during and after menopause affect bone turnover rate. An increase in oestrogen levels increases bone reabsorption, meaning oestrogen deficiency during menopause and menstruation decelerates reabsorption.

It is estimated that 2.7 million suffer from hip fractures annually. Three quarters of these injuries occur in women. Over sixty percent of hip fracture patients have a history of hip or vertebral bone issues (Rachner et al. 2019, p. R148). Bone research indicates that a density loss of 10% increases a person’s risk of hip fractures by 2.5 times. One vertebral fracture takes place every 35 seconds globally (International Osteoporosis Foundation, 2014). The problem with vertebral fractures is that they are often undiagnosed. Only a third of the condition receive medical attention. Fewer than 10% of vertebral fractures require hospitalization, implying they are less incidental and severe than hip fractures (International Osteoporosis Foundation, 2014). In North America and Europe, the standardized incidence rate is 11 people per 1000 persons. Forearm fractures are more likely to occur in women abopve 65 years than men. Only 15% of wrist fractures occur in men, a statistic that does not change with age (International Osteoporosis Foundation, 2014). All the numbers combined, osteoporosis is more common than other chronic diseases that catch public attention.  

Pathogenesis

            Healthy bone turnover entails a balance between the rate of bone tissue reabsorption and the rate of bone formation. Osteoclasts remove old bone tissue via acidification and proteolytic digestion while secreting osteoid fluid into the reabsorption cavity (Khadka et al. 2018, p. 755). As aforementioned, numerous factors, ranging from age to menopause, influence bone turnover. In post-menopausal women, the rate of bone turnover increases rapidly and remains so for several years following the end of ovarian function. The immediate result is progressive bone density loss (Khadka et al. 2018, p. 755). The diagram below offers a simplistic view of the interaction between risk factors causing an increased likelihood of fractures.

Pathogenesis of osteoporotic fractures; Retrieved from Lane (2006, p. 55)

Risk Factors

            Clinical Factors

 A major predictor of bone density is peak bone mass. The attainment of peak bone mass occurs in a person’s early 30s and is typically over by age 40 (Lane, 2006, p. 56). A combination of nutrition, exercise and genetics determines an individual’s peak bone mass. In post-menopausal women, there is a rapid reduction in bone mass. Women with low body weight, body mass and body fat are at an increased risk of developing post-menopausal osteoporosis (Varacallo et al. 2013, p. 95). In women above the age of 65, low estradiol concentrations and high globulin levels increase the reduction of hip and vertebral bone density. Prior studies also associate a history of fractures with an increased risk of osteoporosis.

            Behavioural Factors

Certain behaviours increase the risk of developing osteoporosis. Foremost, cigarette smoking is associated with accelerated bone mass loss. Nicotine is known to reduce calcium reabsorption in the intestines (Rachner et al. 2019, p. R149). Secondly, a low level of physical activity is associated with ease of fracturing. Exercise reinforces bones and muscles, improving neuromuscular functions. Thirdly, alcohol consumption of over two drinks per day is known to reduce calcium intake and food digestion, ultimately impacting bone mass (Rachner et al. 2019, p. R149). Lastly, caffeine intake is also associated with an accelerated loss of bone mass, especially in older women with vitamin D receptors.

            Nutritional Factors

Foods low in calcium, iron and iodine weaken bone density, increasing the chances of fracturing. Vitamin D deficiency is a well-known risk factor in infants and the elderly (Lopez-Olivo et al. 2021, p. 28). Lack of the mineral results in high bone turnover due to reduced calcium reabsorption. Research also informs that certain supplements and medications affect calcium re-intake, including diuretics, anticonvulsants and anti-inflammatory medications. Certain combinations of foods impede calcium intake. People who consume foods rich in amino and fatty acids are less likely to develop osteoporosis.

Assessment/Diagnosis

Bone mass and bone density are the two measures applied to diagnose osteoporosis. Several clinical technologies have been developed to measure the two indicators, including quantitative computer tomography and DXA.

DXA

            The method is considered the primary approach to the diagnosis of osteoporosis. The clinical test can measure bone mineral content from any site of the human body. The lumbar spine and the proximal femur are preferable (Engelke et al. 2015, p. 345). A machine passes two beams of different wavelengths through the patient’s bone. Important to note is the beam does not expose the patient to any radiation-related complications because they are 90% weaker than the standard waves used in a chest radiograph (Engelke et al. 2015, p. 345). Bone mass is reported using t-scores, denoting the risk of developing osteoporosis. A low DXA value is insufficient to make a diagnosis or inform clinical decisions. Only positive values warrant a response in treatment.

Quantitative Computer Tomography (QCT)

            The technique also measures bone density at the lumbar spine. A calibration phantom containing elements of calcium hydroxyapatite is used to predict fractures using the same values as DXA. However, QCT can measure true volumetric density in a 3-dimensional format (Brett & Brown, 2015, p. 182). QCT is more sensitive to changes, enabling it to provide more accurate estimations. The technique can identify differences between trabecular and cortical bone as determined by the turnover rate of the former (Brett & Brown, 2015, p. 182). Therefore, orthopaedics can employ the technique to map skeletal changes over time, helping track the effects of osteoporosis therapy.

Health Promotion Model

            The lifestyle improvement plan borrows from Nola Pender’s health promotion model to significantly impact health-seeking behaviours. According to Khodaveisi et al. (2017, p. 167), the health model is one of the most widespread tools in public health to change unhealthy behaviours in a target populace. The framework is based on the social cognitive theory, which states perceptual factors, such as perceived risks and benefits, influence engagement in health-seeking behaviours (Khodaveisi et al. 2017, p. 167). Modifying factors, including interpersonal influences, culture and demographic variables, are considered how they interplay to influence perceptual factors. The components help provide a comprehensive source of interventional strategies. The resultant behaviours should improve health, quality of life and functional ability. The goal is to negate immediate competing demands that can derail the patient from committing to health promotion.

Pender’s health promotion model makes several assumptions that can enhance or negate its utility. Foremost, the framework alleges that each person opts to actively define and regulate their behaviour (Khodaveisi et al. 2017, p. 167). Secondly, people interact with the environment, gradually changing it while also experiencing transformations themselves. Thirdly, Nola Pender posits that nurses, clinicians, and other health professionals comprise a significant part of the interpersonal environment, influencing an individual’s life (Khodaveisi et al. 2017, p. 168). Lastly, self-initiated changes in the individual-environment dynamic are key to sustainable behavioural modifications.

Health Goals

The proposed lifestyle improvement plan aims to cause substantial positive changes at the individual and community levels. Therefore, health goals vary in terms of scope. Individual-level goals are preventative. At the end of the health literacy campaign, participants should commit to eating 2-3 servings of calcium-rich meals per day. A good source of calcium is dairy. Participants must also commit to getting enough vitamin D. Research indicates that nearly 60% of Americans are Vitamin-D deficient (Reniu et al. 2021, p. 119; Lewiecki, 2019, p. 221)). Preferred is for the patient to improve their calcium reabsorption while undertaking physical activities out in the sun. If such a feat is unlikely, the participant should integrate weight-bearing exercises into their daily routines. The objective is to encourage the patient to consult their doctor to develop simple exercise ideas. Anticipated by the end of the campaign is participants having the ability to calculate fracture risk, bone density, monitor calorie intake and proactively prevent falls. Participants will be able to work together with community specialists and generalists, including patient representatives, to prevent and manage osteoporosis.

Proposed Interventions

Health literacy on osteoporosis, what it is, its causal and preventative factors is the primary approach to promoting good bone health. The first undertaking is to use wide social media and in-hospital campaigns to inform people about the types of diets, vitamins, and nutrients they should prioritize. Larsen and Schmal (2018, p. 499) recommend meals rich in fatty acids and amino acids. The social media marketing effort will require extensive formative research, providing patients with quantitative and qualitative information throughout the change process. Social media influencers will be integrated into the exercise to provide frequent public reminders on what meals to consume and not consume. The availability of information is meant to enhance patient motivation to commit to lifestyle changes.

Health education on lifestyle modification is also a priority intervention in the lifestyle improvement plan. Nurse-led coalitions will provide education on decreasing the risk of bone mass loss, including changes in alcohol and drug intake, smoking cessation and age-related health changes. Alcohol must be reduced to non-excessive amounts, meaning no more than two drinks a day (Agostini, 2018). The elderly will be educated on the importance of frequent fall-risk assessments. The evaluations consider the patient’s internal environment, including physical strength, stability and mental condition. External assessments cover home safety and screening for visual and hearing capabilities. The goal of educating the elderly is to facilitate the early identification of osteoporosis or individual risk factors.  

Direct to consumer advertising inside community health facilities will also be leveraged to increase patient health literacy. The doctor or nurse will talk to the patient concerning the disorder, informing them of potential implications and best practices. The Pender framework advocates for direct consumer-clinician interactions to demonstrate care and support (Khodaveisi et al. 2017, p. 167). The clinician will use taken body measurements, such as body weight, to create a physical routine for the patient. Physical activity is key to reducing a sedentary lifestyle and increasing bone mass. Each exercise program contains specific exercises targeting different skeletal-muscular functions. Resistance training is found to be the most effective in preventing osteoporosis (Agostini, 2018; Fares, 2018; Van Pelt, 2018). There is insufficient scientific data to validate the use of mind-body therapies, such as yoga, in the prevention of osteoporosis.

Evaluation

            The focus of the evaluation process is to monitor and track process measures that gauge the extent to which people have committed to lifestyle modifications. Participants of the program will be requested to provide three or six-month follow-ups for clinical assessments. The medical evaluation will prioritize calcium intake improvements. The mean calcium intake for women should be above 450mg, as the mean low intake is 391mg per day (International Osteoporosis Foundation, 2014). The study should realize almost double the number of female participants committing to the new calcium intake requirements. Health literacy has demonstrated a relatively high potential to decrease the risk of osteoporosis in women (International Osteoporosis Foundation, 2014). Positively impacting the female population will result in substantial gains in public health.

The lifestyle improvement plan targets a particular measure of physical activity per participant of the program. Participants should demonstrate engagement with moderate to vigorous physical activity as per individual body needs. Healthy adults with minimal risk of load-bearing should report at least 45-60 minutes of vigorous exercise per day (Panahi et al. 2021). On the other hand, people at risk of load-bearing should report at least 25-40 minutes of moderate to vigorous exercising. The intervention will depend on past studies to determine what comprises methodological rigour when assessing load-bearing in physical activity. A gap in this approach might be a significant number of participants will opt for none-load bearing exercises.

The proposed intervention must demonstrate positive financial implications at the household and community levels. The lifestyle care plan will integrate WHO’s FRAX (Fracture Risk Assessment Tool) to estimate incremental cost-effectiveness, expressed in medical costs per adjusted (3-month) life span. FRAX pre-screening is done before the patient undergoes bone densitometry (International Osteoporosis Foundation, 2014). The same activity is repeated throughout the campaign, linking changes in bone structure with medical expenses. According to International Osteoporosis Foundation (2014), fully committed individuals above the age of 60 should record nearly 34000 in euro savings per year. Positive FRAX scores should align with positive bone mass and density diagnosis.    

Conclusion

            Osteoporosis is gradually becoming an influential public health concern across the United Kingdom. The resultant fragility fractures have a significant effect in terms of population mortality and morbidity, increasing the overall healthcare burden. The lifestyle improvement plan highlights the need for frequent osteoporosis risk assessments, especially in post-menopausal women. The point of focus for the reviews should be on hip and vertebral fractures. In terms of preventative measures, people should be educated on the recommended daily calcium intake (700-1200mg). Older men and women above the age of 60 should increase their calcium and folic acids intake to enhance bone tissue reabsorption. Weight-bearing physical activities should be advised and designed to suit individual body needs. Osteoporosis is a preventable condition, mandating the need to enhance population awareness, transform attitudes and enhance health-seeking behaviours. The proposed intervention is in line with best practices and models used in chronic conditions, such as cholesterol.

References

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