Leader’s Guide

Standing Strong:
Preventing and Treating Osteoporosis
 Leader’s Guide

Standing Strong:
Preventing and Treating Osteoporosis

Introduction
Purpose

The purpose of this workshop is to educate women recently

diagnosed with or at risk for osteoporosis, about the disease.
Information provided through this workshop will give participants a
A woman’s greater understanding of osteoporosis, its risk factors, diagnosis, and
risk of hip treatment. It will also help participants understand how to prevent the
disease or, for those already diagnosed, to live with the disease and
fracture maintain a good quality of life. Ultimately, this information will help
women to best manage the prevention and/or treatment of this disease,
from and equip and empower them to communicate with their doctor.

osteoporosis
Audience
is equivalent The primary target audiences for this workshop are women (1) at risk
to her for developing osteoporosis, typically post-menopausal, and (2) who
have recently been diagnosed with osteoporosis. The number of
combined participants in a given workshop will vary by site. Suggestions are
made throughout this guide on how to adapt the curriculum for large
risk of or small groups.

developing
Workshop Goals
breast,
To help women with osteoporosis or at risk to (1) know the risk
uterine, and factors and signs of osteoporosis, and (2) work effectively with
providers to prevent and treat the disease, and remain fracture-free.
ovarian
cancer. Objectives

Each section of this guide contains the learning objectives for

that section of the workshop. The objectives state specifically what
the participants should know or be able to do at the conclusion of
that section.

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Preparing for the Workshop

Before you conduct the workshop, you will need to do the following:

• Choose a date and time. Consider coordinating with other

events that your audience may attend.

• Secure a location. See below for space requirements.

• Promote the workshop. See below for tips on letting people

know about the workshop.

• Make copies of worksheets and evaluation forms. You may

have to wait until you have a head-count for the workshop.

Promoting the Workshop

Getting the Word Out

Consider how you will let your intended audience know
about the workshop. Different promotional techniques
will work in different communities, so use your own
experience or the experience of others in your commu-
nity to determine the available avenues for promotion
and what is most likely to bring people to the workshop.
Below are some ideas to get you started.
• Prepare a flyer. Announce the workshop location,
date and time, and registration information.
• Distribute the flyer. Bring or send the flyer to dif-
ferent organizations that have regular contact with
women at risk for osteoporosis, such as:
– Community centers and YMCAs
www.ymca.net OR (800) 872-9622
– Senior Centers
– Libraries
– Red Hat Societies
www.redhatsociety.com OR (714) 738-0001
– State or local agency for elders and aging
– Women’s groups, such as Junior League (www.ajli.org
OR (212) 951-8300), book groups, and garden clubs
– Assisted living facilities
You may also want to post or send flyers to organizations
in the larger community, such as:
– Faith-based organizations
– Community bulletin boards
(libraries, schools, supermarkets)
– Hospitals
– Medical offices and community health centers
• Advertise. Many newspapers have a section that
lists local seminars. Contact your local newspaper
to submit your workshop information. Local radio
public service announcements provide another way
to promote the workshop.
• Tell people. There is no substitute for personal
contact. Whenever possible, make a personal contact
with those who are most likely to refer participants
to the workshop.

Registering Participants

Decide whether or not you will require registration in advance. Advance registration may help you to better plan
for the workshop. Make sure you provide a registration contact name, telephone number, and email address in all
advertisements.

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Workshop Logistics
Timing
This workshop will last approximately one hour.
Leader Note: This workshop is full of information and
resources. To get through all the material, you will need to
manage the time well. Assure participants that there will
be time to share stories and network after the workshop.
Materials and Equipment List
❍ Leader’s Guide
❍ DVD with video and presentation slides
❍ Brochures for participants
❍ Evaluation forms for participants
(at back of Leader’s Guide)
❍ Risk assessment forms (on DVD) for participants
❍ LCD Projector
After the Workshop
When the workshop is over, please take a few moments to complete and mail the leader survey form. This feedback
will help us to better support you and other workshop leaders in the future. The survey is a postage-paid form—
simply fill it out, fold it, and send it in.
Space Requirements and Room Set-Up
The space requirements vary depending on group size.
Ideally, each participant will have a seat at a table so
that they can take notes and participate in the writing
components of the workshop.
If round tables are used, place the tables so that no
table is immediately in front of another. If rectangular
tables are used, set them up chevron style for a larger
group, or in a “U” shape for a smaller group (fewer
than 15). These two set-ups are illustrated below:
Chevron U Shape
❍ Laptop and/or DVD player
❍ Screen
❍ Table or Podium (for leaders);
tables and chairs for participants
❍ Flipcharts and markers OR blackboard and chalk OR
whiteboard and markers
❍ Pens or pencils
❍ Pointer
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Session Agenda
Learning Objectives Activities and Notes

:00 Welcome and • Meet participants. • Leader introduces the workshop, describes
Introductions what will be covered, and points out
• Understand what will be covered during
(5 minutes) necessary logistical information such as
the workshop.
the location of restrooms.
• Appreciate the impact of osteoporosis on
• If the group is under 12 people,
quality of life.
participants introduce themselves.
• Leader presents information/talking points
on how osteoporosis impacts health.
• Leader states the importance of taking
the initiative in talking with the doctor
about osteoporosis.

:10 Risk Factors and • List the risk factors for osteoporosis. • Leader presents information on risk factors.
Early Warning Signs
• Know what questions to ask your doctor • Participants complete brief risk
(15 minutes)
about your risk for osteoporosis. assessment survey.
• Know when you should request a baseline • Leader presents questions to ask doctors
bone density test. about osteoporosis risk.

:20 Diagnosis • Describe what a bone density test is and • Leader presents information on bone
(10 minutes) how it is done. density tests.
• Understand how frequently a bone • Participants have an opportunity to ask
density test is done. questions about tests.
• Interpret the bone density test results.

:25 Treatment Options • Describe the different types of treatments:
(15 minutes) nutrition, lifestyle modifications,
medications, and alternative therapies.
• Know how to stay abreast of
developments in traditional and
alternative treatments.
• Leader presents information on treatment
options and how to stay abreast of
developments in treatment.
• Possible discussion questions: “What
treatment options seem like they might
work for you? Which ones present
barriers for you, and why?”

:45 Living with Osteoporosis • Know how to communicate with your
(10 minutes) doctor about your questions during
treatment.
• Identify steps you can take to stay with
your treatment and maintain your
independence.
• Identify ways to modify your environment
to minimize trips and falls.
• Leader emphasizes the importance of
continuing with prevention or treatment,
and communicating with the doctor
throughout treatment.
• Watch DVD.
• Participants create an action plan for
taking preventive steps, initiating
treatment, and/or persisting with an
existing treatment plan.
• Participants discuss action plans in pairs or
small groups.

:55 Wrap-Up and Evaluations • Participants and workshop leaders

(5 minutes) complete evaluations.

1:00 Adjourn

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Workshop Script
Welcome and Introductions (5 minutes)
Objectives: • Meet participants.
• Understand what will be covered during the workshop.
• Appreciate the impact of osteoporosis on quality of life.

Leader Note: Arrive at least 30 minutes before the start time to familiarize yourself with
the room and facility, specifically:

• Lighting and light switches/adjustment • Location of leader table or podium

• Temperature controls • Audio-visual equipment
• Arrangement of participant tables & chairs • Location of fire exits and restrooms

WELCOME participants to the workshop. If there are fewer than 12 people you should have them
introduce themselves to the group. Be mindful of the time and limit this to about 7 or 8 minutes.

SAY: • Thank you for joining us today.

• Osteoporosis is a disease that can have a great impact on your quality of life.
• Bone fractures, which can happen as a result of the disease, can limit your
ability to live independently.
• But the disease is preventable and, when you have it, it’s treatable.
• That’s why we’re here today.
• Before we get started, let’s introduce ourselves.

SHOW slide.

POINT OUT logistical information such as the agenda, location of restrooms and fire exits, etc.

Risk Factors and Early Warning Signs (15 minutes)

Objectives: • List the risk factors for osteoporosis.
• Know what questions to ask your doctor about your risk for osteoporosis.
• Know when you should request a baseline bone density test.
Source: National Osteoporosis Foundation

ASK: • Can anyone tell me what osteoporosis is?

SOLICIT responses.

SHOW slide.

SAY: • Osteoporosis is also called “porous bone disease,” because when you have the
disease, your bones are not as solid or dense as they need to be to support you
in every day tasks.

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 • When a person has osteoporosis, a trip or fall that would normally cause no
serious damage can cause a fractured bone because the bones aren’t strong
enough to support the extra stress.
• Bone fractures, which occur commonly in the hips, wrists, and vertebrae
(backbones), are serious because:
– As we age, it takes longer for our bodies to heal a bone fracture.
– Bone fractures limit our ability to walk and our independence.
– They can also worsen any chronic conditions you have, and cause physical
de-conditioning such as shortness of breath or limited movement.
– Hip fractures almost always require hospitalization and major surgery.
– Spine fractures can be a source of chronic pain and disfigurement.
– The fracture, or the surgery done to repair it, can cause life-threatening
complications such as blood clots.
– Finally, all of these physical limitations can lead to depression.

Risk Factors

SAY: • Many people don’t know they have osteoporosis until they fracture a bone.
• But there are ways to find out if you have the disease, or are at risk for it,
before that happens.
ASK: • What factors increase your chance of developing osteoporosis?

SOLICIT responses.

SHOW slide.

SAY: • The risk factors for osteoporosis include:

– Advanced age. Among other things, blood levels of protective hormones
(such as estrogen in women and testosterone in men) decrease as we
age. That’s why postmenopausal women are at greater risk than pre-
menopausal women.
– Personal history of bone fracture, especially after age 50. This can also be
an early warning sign of osteoporosis.
– Family history of osteoporosis.
– Diet low in calcium and/or vitamin D.
– Inactive lifestyle.
– Use of certain medications, such as corticosteroids, chemotherapy, and
anticonvulsants.
– Smoking.
– Heavy alcohol consumption.
– Female gender, although men can also develop the disease.
– Being Caucasian or Asian, although African Americans and Hispanic
Americans are also at risk.

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 – Digestive disorders, such as Crohn’s and celiac diseases, that impair digestion
of calcium and vitamin D. Taking anti-acid medications can also impair digestion
of calcium.
DISTRIBUTE Osteoporosis Risk Assessments.

SAY: • I am handing out a brief risk assessment for osteoporosis.

• Please take a couple of minutes to fill it out.

Leader Note: Give participants two minutes to fill out the risk assessment form.

Asking Your Doctor About Your Risk

SHOW slide.

SAY: • It’s important to talk to your doctor about these risk factors.
• Your doctor may have some insight into which ones may be significant risk factors for you.
• Even if your doctor does not bring up the topic of osteoporosis, you should. Because
osteoporosis is “silent,” both doctors and patients can underestimate how important
this conversation is.
• Here are some questions to ask your doctor:
– Based on my medical history, lifestyle, and family background, am I at risk for
osteoporosis?
– Do any of the medications I take now, or have taken in the past, put me at risk for
low bone density?
– Am I getting enough calcium? Be prepared to describe how much calcium you get
through diet and supplements.
– Am I getting enough vitamin D? Be prepared to describe how much vitamin D you
get through sunlight exposure and supplements.
– How much physical activity should I get?
– What limits should I place on my consumption of alcohol or smoking?

When to Ask for a Bone Density Test

SHOW slide.

SAY: • The more risk factors you have, the more important it is for you to monitor
your bone density.
• If you are a woman over 65, you should probably have the test as a screen for osteoporosis.
• If you are a smoker, physically lean, or have a family history of osteoporosis, consider
bone density testing at age 60.
• Your doctor may not think to recommend a bone density test, but if you believe you are
at risk for developing osteoporosis, you should request one.
• The test will tell you and your doctor what your bone density is, and will give you a base-
line for measuring future bone loss, and how quickly or slowly you are losing bone density.
• Let’s talk about the bone density test now.

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 Diagnosis (10 minutes)
Objectives: • Describe what a bone density test is and how it is done.
• Understand how frequently a bone density test is done.
• Interpret the bone density test results.
Source: Mayo Clinic. See www.mayoclinic.com/health/bone-density-tests/WO00024 or
www.healthatoz.com/healthatoz/Atoz/common/standard/transform.jsp?requestURI=/
healthatoz/Atoz/ency/bone_density_test.jsp

ASK: • How many of you have had a bone density test?

SOLICIT responses.

What a Bone Density Test Is

SHOW slide.

SAY: • A bone density test, or densitometry, tests to see if you have osteoporosis or
are at risk.
• It uses X-rays to measure how much calcium and other bone minerals (bone
mineral content) are in a segment of bone.
• The higher your bone mineral content, the denser your bones are. The denser
your bones, the stronger they are and the less likely they are to break.
• This test is NOT the same as a bone scan, which is a test used to find
abnormalities in the bone, and requires an injection beforehand.

How the Test Is Done

SHOW slide.

SAY: • Bone density tests are easy and painless.

• There is no preparation required.
• The test is done on the bones that are most likely to fracture. Different
machines are used depending on which bones are tested.
• For your back and hips, “central devices” are used. There are two kinds of
central devices:
– DXA scan. This is the preferred test for diagnosing osteoporosis. For this
test, you lie on a padded platform while an “imager”—an arm-like device—
passes over you without touching you. It takes 15 minutes. It is the most
commonly used test for screening and monitoring osteoporosis.
– Quantitative CT scan. This is a type of CT (“cat”) scan. For this test, you lie
on a movable table that is placed into a large tunnel-like area where the
images are taken. It takes approximately 20 minutes. This test exposes
you to more radiation and is more expensive than the DXA.

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SHOW slide.

SAY: • For other parts of your body, “peripheral devices” can be used.
• These are smaller machines that are sometimes found in pharmacies.
• These tests are better than no test at all, but are not as good at assessing bone
fracture risk as central devices.
• This is because there can be earlier bone loss in the spine and hip than in
the extremities.
• Sometimes, if this test shows low bone density results, the doctor will have you
do a DXA scan to confirm the diagnosis.

SHOW slide.

SAY: • Not all health insurance plans cover bone density tests, so ask your insurance
provider about coverage.
• Medicare pays for initial bone density tests if you:
– Are postmenopausal and at risk of osteoporosis;
– Have primary hyperparathyroidism;
– Have certain spinal abnormalities that might indicate a fracture;
– Are on long-term corticosteroid therapy, such as prednisone; or
– Need to assess your response to osteoporosis medications.
• The recommended interval for the test is every two years, except for certain
high-risk medical conditions.

Interpreting Test Results

SHOW slide.

SAY: • Bone density test results are reported in two numbers: T-scores and Z-scores.
• Your T-score is the number of units over or under the bone density of a healthy
young adult of your sex. If you are a white postmenopausal woman, here is
how to interpret your scores:
– If your score is above -1, you have normal bone density. You should repeat
the test in 2–5 years, depending on your risk factors.
– If your score is between -1 and -2.5, you are at risk for osteoporosis and
need to take preventive steps.
– If your score is below -2.5, you have osteoporosis. Discuss treatment
options with your doctor. The goal of treatment is to prevent further loss.
• Doctors use Z-scores to determine if there is something unusual causing your
bone loss. This score is used less frequently in postmenopausal women and older
men but are used in pre-menopausal women and younger men.

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 Treatment Options (15 minutes)
Objectives: • Describe the different types of treatments: nutrition, lifestyle modifications,
medications, and alternative therapies.
• Know how to stay abreast of developments in traditional and alternative
treatments.
Sources: National Osteoporosis Foundation. See www.fda.gov/FDAC/features/796_bone.html

SAY: • There are several choices for prevention and treatment of osteoporosis:
nutrition, lifestyle modifications, medications, and alternative therapies.

• Let’s talk about nutrition first.

Nutrition

ASK: • What’s the major nutritional recommendation for people at risk for, or living
with, osteoporosis?

SOLICIT responses.

SHOW slide.

SAY: • Calcium is the most important thing to add to your diet.

• When your body gets enough calcium, it doesn’t have to take any calcium away
from your bones, and your bones can keep the calcium they need to be strong.
• You can get your calcium through diet, supplements, or calcium fortified foods
(such as orange juice).
• You need about 1200 mg of calcium per day. If you take a calcium supplement,
it’s best to take it with meals, rather than all at once. Your digestive tract can
process the calcium more efficiently when you take it three times a day.

SHOW slide.

SAY: • There is something else you can do to help your body use the calcium you give
it—get enough vitamin D, either through sunlight or supplements.
• Vitamin D is the “key” that opens the “door” to allow calcium to leave your
intestines and go to your bloodstream.
• You can get vitamin D from 15 minutes of sun exposure without sunscreen on
your hands, arms, and face, three or four times a week. However, this is not
possible in northern climates in the winter. And sun exposure is a risk for skin
cancer, so weigh the benefits and risks.
• When you can’t get sun, you can get vitamin D through supplements. It can
also be found in vitamin D fortified milk, egg yolks, liver, and saltwater fish.
• Older adults need 800 units per day.
• You don’t need to consume more than this unless a medical condition, such as
Crohn’s or celiac disease, requires it. In such cases, you may need more.

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Lifestyle

SHOW slide.

SAY: • In addition to dietary changes, there are other lifestyle changes you can make.
• First, if you smoke, quit now. It’s the single best thing you can do for your
health. Smoking increases your risk for osteoporosis and makes it hard for
your body to absorb calcium.
• Second, cut back on your alcohol consumption. Excessive alcohol consumption
makes it hard for your body to absorb calcium and make use of vitamin D. Talk
with your doctor about how much is too much.
• Third, be active. Weight-bearing exercise (such as weight-lifting, aerobics,
dancing, and stair-climbing) strengthens bones.
– ALL exercise strengthens your muscles, and when your body is strong,
you are more stable and less likely to fall and fracture a bone.
– If you exercise outside, you can be getting vitamin D while you get stronger!
– Even those with osteoporosis can exercise. Programs such as the National
Osteoporosis Foundation’s “Bone Up” are helpful. Whether you have
osteoporosis or not, talk to your doctor before starting a new exercise routine.

Medications

SHOW slide.

SAY: • There are several medications that help prevent and treat osteoporosis.
• One type of medicine, bisphosphonates, can be used for both prevention
and treatment.
• Two of these, alendronate (brand name Fosamax®) and risedronate (brand name
Actonel®), are taken in pill form once a week.
• The other, ibandronate (brand name Boniva®), is taken in pill form once a month.
• All bisphosphonates have been shown to slow down bone loss and
reduce fractures.
• Bisphosphonates are usually well tolerated when taken properly.
• If you don’t take it with the right amount of water, or if you don’t remain upright
for the right amount of time, the medication can cause nausea, heartburn, or
esophageal or stomach irritation.
• Taking the medication in weekly or monthly dosages reduces the chances of
having problems, simply because you are taking the medication less frequently.
• For those who cannot tolerate oral bisphosphonates, injectable therapies are
available.
• Ibandronate (Fosamax®) is available as an intravenous therapy, injected every
3 months.
• Zoledronic acid (Reclast®) is infused once a year.
SHOW slide.

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 SAY: • Hormone therapy can be used for prevention of osteoporosis.
• It is, however, associated with a modest increase in the risk of breast cancer,
strokes, and heart attacks, and the Food and Drug Administration recommends
considering other osteoporosis treatments first.
• Another type of medication, raloxifene (brand name Evista®), has some of the
benefits of estrogen without the potential risks, though it does carry the risk of
deep vein thrombosis and has been only effective in reducing spine fractures.
It is taken once a day in pill form.
• Side effects are relatively rare, but may include hot flashes, leg cramps, and
blood clots.
• The long-term effects on the cardiovascular system are being studied but are
not currently known.

SHOW slide.

SAY: • Another medication used to treat osteoporosis is calcitonin, (brand name

Miacalcin®), which is a naturally occurring hormone.
• It is taken daily by injection or in a nasal spray.
• It may cause an allergic reaction and unpleasant side effects including
flushing of the face and hands, urinary frequency, nausea, and a skin rash.
• So far, this medication has no proven benefit to preventing hip fracture.
It is less effective than other medications.

SHOW slide.

SAY: • The last type of medication is called parathyroid hormone derivatives.

• Teriparatide (Forteo®) falls in this category; it treats osteoporosis by
stimulating new bone formation.
• It is taken as a self-administered daily injection for up to 24 months.
• Possible side effects include nausea, leg cramps, and dizziness.
• This medication is expensive, requires self-injection, and has a warning label
with risks of more serious side effects. For these reasons, it is not the first
therapy choice of most doctors.
• It’s good to have options for prevention and treatment, but it can be
overwhelming to sift through the options.
• Talk with your doctor about which medication, if any, would work best for you.

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Alternative Therapies

SHOW slide.

SAY: • People use herbs and other alternative therapies to treat their osteoporosis.
• It’s important to be aware that these herbs are not approved or regulated by the
FDA, and there is not yet conclusive evidence that shows whether they work.
• Some herbs that are used are black cohosh, chaste tree, horsetail, and oat straw.
• Most medical experts exercise caution with unproven therapies like these.
None have proven benefits and some may be harmful.
• Remember that herbs are medications, and are not always benign. They can
interact with other medications you are taking. ALWAYS tell your doctor which
supplements and herbs you are taking.
SHOW slide.

SAY: • Traditional Chinese Medicine (TCM) is sometimes used to prevent osteoporosis.

• Acupuncture can be part of this routine.
• Chinese medicine doctors also use many of the herbs we just talked about, plus
some others.
• An important part of TCM that can help everyone is an exercise routine (such
as Tai Chi) that increases strength, balance, and flexibility. This helps to
prevent falls and the fractures that can result.

Living With Osteoporosis (10 minutes)

Objectives: • Know how to communicate with your doctor about your questions during
treatment.
• Identify steps you can take to stay with your treatment and maintain your
independence.
• Identify ways to modify your environment to minimize trips and falls.

SAY: • Because osteoporosis is a silent disease, it is easy to forget about your

treatment plan and stop taking your medication.
• This is especially true if you experience side effects from the medicine, or you
have other conditions you are managing. Many patients fail to keep up treatment
after a year, yet it takes several years to get the full benefit of treatment, in
terms of reducing fractures.
• However, it is very important to stay with your treatment plan so that you can
continue to live without bone fractures, which could limit your independence
and pose a significant risk to your life.
• If you have concerns during treatment, or are experiencing side effects from
the medication, talk to your doctor about it before you decide to stop your
medication. Have your doctor check your medications and status every year
and your bone density every two years.

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 SHOW slide.

SAY: • If you have osteoporosis, one important thing you can do is reduce your chance
of falling.
• There are a few important ways you can do this:
– Make your home as “trip-proof” as possible. This may seem obvious, but
it’s important to reduce your chances of falling. If you don’t fall you won’t
put undue pressure on your bones.
– Make sure there are hand rails where they are needed.
– Make sure there is enough light in all rooms, especially at night.
– Have a friend help you identify possible trip hazards in your home, and
take care of them.

SHOW slide.

SAY: • You can also reduce your risk of falling by taking care of yourself.
– Stay strong and flexible.
– Wear shoes that are supportive and easy to walk in.
– Get eye exams and keep your eyeglass prescription up to date. Wear
sunglasses when you need them.
– Ask your doctor if any of the medications you are currently taking can
cause dizziness.

SAY: • We will now watch a video that will give you some insight into how a person
with osteoporosis can manage the condition and live a full and healthy life.

VIEW video.

If time permits, ASK:

• What surprised or struck you as you were watching the video?

Wrap-Up and Evaluations (5 minutes)

SAY: • Please take a few minutes to fill out a brief evaluation form.
• Your feedback will help ensure that this workshop is helpful to other women
like you.
• You can leave the completed evaluation on your chair (or the table).
• Thank you for your participation.

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Standing Strong: Preventing And Treating Osteoporosis

Workshop Evaluation
Please rate each of today’s activities in terms of how likely you are to use what you learned.
Please use the following 1-5 scale:

1 = not at all 2 = somewhat 3 = moderately 4 = very 5 = extremely

1. Risk factors and early warning signs 1 2 3 4 5

2. Diagnosis/bone density test 1 2 3 4 5

3. Treatment options 1 2 3 4 5

4. Living with osteoporosis 1 2 3 4 5

5. How effective was today’s workshop overall? 1 2 3 4 5

6. What suggestions do you have for improvement?

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7. What comments or suggestions do you have for the workshop leader?

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Thank you for your feedback.

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