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Office of the Surgeon General (US). Report of the Surgeon General's Workshop on Osteoporosis and Bone Health: December 12 – 13, 2002, Washington, DC. Rockville (MD): Office of the Surgeon General (US); 2003.

Cover of Report of the Surgeon General's Workshop on Osteoporosis and Bone Health

Report of the Surgeon General's Workshop on Osteoporosis and Bone Health: December 12 – 13, 2002, Washington, DC.

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Visions for the Future

The final panel, chaired by Dr. McGowan and Dr. Raisz, offered visions for the future of bone health and osteoporosis.

Achieving Healthy People 2010 Goals for Osteoporosis

Anne Looker, Ph.D.

National Center for Health Statistics

Released every 10 years since 1980, the Healthy People reports lay out the nation’s prevention agenda for the coming decade. To that end, Healthy People 2010 (HP2010) defines 467 objectives in 28 areas, including osteoporosis. Federal, state, and local governments, along with community-based organizations, use these objectives to set up prevention initiatives. Each objective is not only prevention-oriented, but also measurable; 190 different data sources are used to track the nation’s progress toward these goals. More information on the program is available at www.healthypeople.gov.

The HP2010 objectives that directly relate to osteoporosis include the following: reducing cases of osteoporosis, reducing hospitalizations for spine fractures, reducing hip fractures, increasing calcium intake, and increasing physical activity. Other objectives that have relevance to osteoporosis include reducing tobacco use and substance use and abuse, increasing intake of fruits and vegetables, decreasing sodium intake, improving access to quality health services, and increasing education and community-based programs.

Dr. Looker called on audience members to think about ways for using the upcoming Surgeon General’s Report to overcome the barriers to increasing the use of the current Healthy People objectives, to identify relevant data for tracking progress toward these objectives (e.g., surveys), and to promote the adoption and/or revision of osteoporosis-related objectives in Healthy People 2020 (the next version of the report, to be released in 2010).

Beyond 2010: Changing the Paradigm for an Aging Population

David Buchner, M.D., M.P.H.

Centers for Disease Control and Prevention

Dr. Buchner emphasized the importance of changing the paradigm for how the nation thinks about public health in an era of an aging population. Noting that behavior choices are among the leading determinants of health (responsible for 40% of early death), he called for development of evidence-based, community-level interventions to promote physical activity. The key is to emphasize interventions that are easy to focus on by individuals, such as prompts to take the stairs, physical education classes in schools, and enhanced access to recreational facilities. Community-level initiatives can also help, including providing greater social support for individually-adapted behavior changes. As evidence of the potential power of this paradigm shift, Dr. Buchner shared the results of studies conducted in New Zealand which found that exercise programs delivered in a variety of settings helped to reduce falls and injuries by 35%, generating a per-fall savings of roughly $NZ426 (or $210 U.S.).

Dr. Buchner also believes that society needs to further debate and clarify the role of public health in chronic disease and injury prevention. This role may include surveillance, state-level plans and programs (especially those oriented at environment and policy), guidelines and best practices, partnerships, and evaluation. In this context, it is especially important that initiatives oriented at bone health be well-coordinated with those oriented at other public health problems, since many of the desired behavior changes (more exercise, better diets) cut across diseases.

Finally, Dr. Buchner highlighted the need for policy analysis and further research. As illustrated in Figure 14, relatively little is known about how policy and other influences affect the ability and willingness of individuals and communities to put interventions related to bone health in place. While more is known about how these interventions affect risk factors, and about how the risk factors affect bone health, additional research into some aspects of these causal relationships is needed as well. Finally, Dr. Buchner emphasized the importance of programs to translate research findings into practice, holding out The Robert Wood Johnson Foundation’s $10 million investment in this area as an important initiative.

Figure 14. Need for Policy Analysis and Research.

Figure 14

Need for Policy Analysis and Research. Source: David Buchner, Centers for Disease Control and Prevention.

Policies to Promote Bone Health

Wojtek Chodzko-Zajko, Ph.D.

University of Illinois-Champaign

Dr. Chodzko-Zajko reviewed a collaborative program to increase physical activity among adults aged 50 and older. This initiative, known as the Blueprint Partners Project and launched after the release of the Surgeon General’s Report on physical activity, may serve as a useful guide for the nation on how to effectively address osteoporosis and bone health in the future, after the Surgeon General’s Report is released.

The project began with release of a national blueprint that laid out goals and objectives for the program, along with 68 strategies for increasing physical activity among older Americans. The strategies cut across five dimensions, including marketing, public policy, medical systems, home/community, and research. (Strategies that cut across these areas comprise a sixth dimension.) Perhaps the most innovative aspect of the program is that it establishes priorities for what is feasible and important to bone health. Within each of the six areas, three high-priority strategies have been identified, with a lead agency designated for leading a coalition to implement the strategy. These organizations are being held accountable for reporting back on their progress in 12 months. For example, within the area of research, the American Geriatrics Society is taking the lead on the development of evidence-based guidelines on the types and amounts of physical activity needed to enhance health and functional outcomes with a special emphasis on chronic illness and disability. The National Council on Aging is leading an effort to conduct research to understand what motivates individuals to participate in community, home-based, and work-site programs. Within the area of home and community, the American College of Sports Medicine has been charged with identifying professionals in the community who can serve as resources for information and assistance, while the National Council on Aging is leading an effort to develop a template for good physical activity programs.

Laura Tosi, M.D.

American Academy of Orthopaedic Surgeons

Dr. Tosi highlighted the need for another major paradigm shift with respect to treating osteoporosis–that is, the need for orthopaedic surgeons to re-evaluate how they traditionally take care of patients with fractures. Orthopaedic surgeons tend to focus on “fixing things” rather than on prevention. And because the bulk of fractures occurs in individuals who do not have osteoporosis, screening and treating the disease is not on most surgeons’ minds on a daily basis.

Dr. Tosi, however, believes that there are compelling arguments for changing this paradigm, arguments that surgeons can relate to. For example, the high risk of re-fracture in patients with metabolic bone disease is something that surgeons should understand and may believe they can “fix.” In addition, compelling evidence that treatment for osteoporosis works should also be a motivating factor for change. To that end, Dr. Tosi called on orthopedic surgeons to do the following: consider the possibility of metabolic bone disorder and/or osteoporosis in every fracture patient; inform the patient or patient’s family of any concerns; ensure that an evaluation is performed and/or partner with other health professionals to do so; participate in establishing clinical pathways for hospitalized patients; and document the evaluation and intervention on the patient’s chart.

“Today is a great day to convince orthopods to change”– Laura Tosi, M.D.

To help promote this major change in behavior among orthopedic surgeons, the Academy is expanding continuing medical education opportunities and publications (e.g., a brochure for orthopedic surgeons on what to do when a fractured patient comes to the office), changing the in-training exam to include questions about osteoporosis, developing a public relation campaign (known as “Breaking Tradition”) for physicians and the public, partnering in the establishment of cost-effective, evidence-based clinical pathways (especially in the area of refracture), and encouraging payers to recognize “fragility fractures” as “pathologic fractures.” Dr. Tosi would also like to see Medicare change its DRG for hip and other types of fracture to cover the costs of BMD testing in the hospital.

Judith Cranford

National Osteoporosis Foundation

NOF is an advocacy organization that works on behalf of the public. The organization operates on three fundamental principles: that advocacy drives policy (and vice versa), that advocacy based on strong scientific evidence is the key to sound, long-lasting policy, and that collaboration can help drive success. As an example of this latter point, Ms. Cranford noted that the National Bone Coalition led the effort to lobby Congress to authorize funding for the Surgeon General’s Workshop and the Surgeon General’s Report on Osteoporosis and Bone Health.

Looking to the future, NOF sees two key imperatives–reducing the prevalence of bone disease across gender and ethnicity, and improving the quality of care and the quality of life for all Americans. Reaching the first objective requires a multifaceted, multigenerational effort that must go beyond a focus on postmenopausal women. Meeting the second goal requires a myriad of activities targeted at promoting access to prevention, screening, diagnosis, treatment, and rehabilitative services. To that end, NOF is proposing a National Framework for Action, a multiyear action plan that represents the organization’s hope and vision for the future. NOF plans to implement this vision in collaboration with lead Federal and state agencies, advocacy organizations, professional health provider organizations and societies, and other key stakeholders. The specific elements of the plan are as follows:

  • ▪ Establish guidelines of care accepted nationally by agencies, insurers, facilities, providers, and other organizations that can be used to evaluate the quality of care.
  • ▪ Shape education messages that resonate with consumers, providers, legislators, insurers, and other key stakeholders. Only through education can the goals be realized.
  • ▪ Further improve osteoporosis prevention, diagnosis, and treatment.
  • ▪ Nurture grassroots and state advocacy efforts.
  • ▪ Increase research funding and encourage/retain scientists.
  • ▪ Maximize use of databases to track progress. Databases must be able to interact with each other, so that best practices and new learning can quickly be shared.
  • ▪ Evaluate cost-effectiveness.

In closing, Ms. Cranford urged all stakeholders to use the Surgeon General’s Workshop and subsequent Surgeon General’s Report as a landmark opportunity to come together to develop and implement a national plan of action for osteoporosis and bone health. The opportunity to have a huge influence on millions of Americans has never been greater.

“Osteoporosis may be considered silent, but as advocates, we cannot be silent.” – Judith Cranford

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