Social Work in Public Health, 25:511526, 2010 Copyright Taylor & Francis Group, LLC ISSN: 1937-1918 print/1937-190X

X online DOI: 10.1080/19371910903178946

Osteoporosis: Prevention and Implications for Social Work Practice and Policy
SHAWN A. LAWRENCE and AISHA AZHAR
School of Social Work, University of Central Florida, Orlando, Florida, USA

Osteoporosis is one of the major disorders of our time and is increasing at an alarming rate. It affects over 10 million women in the United States and is expected to affect 14 million by the year 2020. There are a number of risk factors for osteoporosis that are of a modifiable nature; however, many women do not take the necessary precautions to prevent the disease. The reasons that women do not actively engage in preventative and remedial strategies to deal with the potential for osteoporosis are complex. It is clear that women must have adequate knowledge to make informed decisions regarding osteoprotective behaviors. Social workers are in a unique position to provide interventions not only on a micro level (educating individual clients) but also on a macro level in terms of large-scale education campaigns focusing on nutrition and exercise both in children and in adults. This article examines the reasons for the failure of women to engage in osteoprotective behaviors by exploring barriers to prevention and their impact on social work policy, practice, and research. KEYWORDS cial work Osteoporosis, prevention, knowledge, resources, so-

Osteoporosis is a skeletal disease characterized by loss of bone mass, resulting in an increased risk of fractures (Munch & Shapiro, 2006). These fractures often lead to physical impairment and in some cases can lead to death. Osteoporosis is a chronic health problem with over 10 million Americans
Address correspondence to Shawn A. Lawrence, PhD, LCSW, School of Social Work, University of Central Florida, P.O. Box 163358, Orlando, FL 32816-3358, USA. E-mail: slawrenc@mail.ucf.edu 511

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estimated to have the disease and an additional 34 million having osteopenia (low bone mass) (National Osteoporosis Foundation, 2007). Many of the risk factors for osteoporosis are preventable, yet research indicates that many women do not take the necessary precautions to prevent the disease (Kasper, Peterson, Allegrante, Galsworthy, & Gutin, 2001; Ribiero, Blakely, & Laryea, 2000; Weiss & Sankaran, 1998). The purpose of this article is to examine the complex interplay of factors that impede womens participation in osteoprotective behaviors prior to the onset of disease-related symptomology. Given the potential long-term physical consequences and the number of people with the disease, it is clear that osteoporosis is one of the major disorders of our time, and it is increasing at an alarming rate. With the increase of the number of Americans older than 65, the number of cases of osteoporosis is likely to increase as well. In fact, the cases of osteoporosis are expected to increase to 14 million by 2020, with an increase to 47 million cases of osteopenia (National Osteoporosis Foundation, 2002). Associated with this increase in osteoporosis is the consequent increase in medical costs. Each year, there are approximately 1.5 osteoporotic fractures occurring in the United States, costing an estimated $18 billion. The physical ramifications of vertebral fractures often result in a stooped posture, decline in height, and chronic pain. Osteoporosis can also cause compression on the lungs and stomach. As a result of the pain associated with osteoporosis, people tend to restrict their movement and mobility, consequently leading to isolation and deterioration of overall physical and mental health (Munch & Shapiro, 2006). What is particularly alarming is that 24% of individuals who sustain a hip fracture will die within 1 year of the fracture.

RISK FACTORS
There is considerable debate as to the exact etiology of osteoporosis. Some research suggests that it is linked to a combination of the aging process and the decreased production of estrogen (Munch & Shapiro, 2006), while others suggest that osteoporosis results from a lack of bone strength stemming from early child and adolescent behaviors such as diet, physical activity, and calcium intake combined with the current stage of menopause (Heaney et al., 1997). What remains consistent in the literature however are the known risk factors for osteoporosis. The risk factors for osteoporosis are of both an uncontrollable and modifiable nature. The uncontrollable risk factors include low birth weight, ethnicity (particularly European American and Asian/Asian American), sex, genetics, and menopause. The risk factors for osteoporosis that are of a modifiable nature include cigarette smoking, high caffeine intake, alcohol abuse, improper diet (low calcium intake as well as high salt, protein, and phosphate intake), and lack of physical activity

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(National Osteoporosis Foundation, 2007). In addition to the above risk factors, osteoporosis has also been associated with some diseases such as chronic liver disease (Collier, Ninkovic, & Compston, 2002) and Turner Syndrome and with long-term corticosteroid use (Pritchett, 2001).

PREVENTION
While many individuals assume that osteoporosis is a normal part of aging, this assumption is incorrect. While up to 80% of bone mass is determined by genetic factors, there are actions an individual can take to reduce the likelihood of having a diagnosis of osteoporosis (Brown & Shoenly, 2004). These preventive actions include an adequate intake of calcium and vitamin D, regular weight-bearing physical activity, and minimal use of cigarettes and alcohol. With so many of the risk factors for osteoporosis being modifiable in nature, it is understandable that researchers and healthcare providers would wonder why many women do not take preventative measures to avoid the disease. The reasons that individuals do not actively engage in preventative and remedial strategies to deal with the potential for osteoporosis, such as engaging in weight-bearing exercise and/or taking calcium/vitamin D supplements, are complex and appear to involve both knowledge-related factors and the decision making process at both individual and structural levels. There are, however, barriers to the prevention of osteoporosis. These barriers are on individual and structural levels. The Centers for Diseases Control and Prevention (CDC) is geared toward the tracking of disease, injuries, and premature deaths as well as the promotion of quality of life. The CDC has articulated objectives that relate to public health; among them, osteoporosis is a part of a nationwide prevention program to promote womens health. There is an expectation that attention to these issues will help to solve many health problems of the urban population. To that end, research has been developed based on cooperation between federal, state, and local governments (Speers & Lancaster, 1998). Centers for Disease Controls Healthy People 2010 is the articulation of a national prevention program for the United States. It is a statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats (Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, n.d.).One of the two primary goals of Healthy People 2010 is to increase life expectancy and improve quality of life. Included in this plan are provisions to prevent illnesses and disabilities related to osteoporosis. A substantial part of the battle against osteoporosis is preventing its occurrence in the first place. Preventing osteoporosis must begin many decades before menopause when a woman is

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most at risk. It has been determined that one of the key factors in preventing the disease is women knowing what the disease is and what can be done so that overtime they do not lose bone mass. As mentioned earlier, there are a number of modifiable risk factors for osteoporosis. There are three key factors that have been associated with preventing osteoporosis: diet (calcium rich, low salt, and phosphates), exercise, and lifestyle choices (Drugay, 1997). Even with the increase in spending and the creation of CDC specific objectives, the incidence of preventable diseases such as osteoporosis in the United States has been increasing.

Health Belief Model

The health belief model (Figure 1) is one of the most respected and most commonly employed models to explain why individuals do not engage in positive behaviors that promote well-being (Clark, Lovegrove, Williams, & Machperson, 2000). The model grew out of an effort to explain the reasons for the widespread failure of people to participate in prevention programs (Hochbaum, 1958; Rosenstock & Kirscht, 1974). The health belief model states that the likelihood of an individual engaging in preventive healthcare behaviors is largely a function of the degree to which the individual perceives a threat and how vulnerable they are to the threat (perceived vulnerability). According to the model, patients engage in treatments when they believe that the illness will result in serious harm or if the recommended therapy reduces a perceived imminent health problem (Berman, Epstein, & Lydick, 1997). In other words, the expected vulnerability to the disease is recognized by patients who knowledgeably weigh the cost of engaging in the preventive behavior (e.g., dollars, time, discomfort, inconvenience) against the potential cost of continuing to take health risks or because they chose not to be

FIGURE 1 Health belief model.

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adherent to medical recommendations. In this model, the probability of an individual following advice both in terms of prevention and treatment of disease is a function of the patients perceptions of his or her susceptibility to the disease, the likelihood of the severity if the disease is contracted, and the benefits and barriers likely to be derived and encountered as a result of the recommended action. Obviously, therefore, women are likely to adhere to medical advice regarding the prevention of osteoporosis when their health belief model includes recognition that failure to do so will cause them harm and that they can do something proactive to prevent it. However, if the rewards are not imminent (that is, benefits associated with calcium intake do not outweigh possible discomforts), if women have a belief about what aging is (all older women will have height loss and have fractures), or if the health threat is not perceived as proximal (there is no one in the family with debilitating osteoporosis), then this model would suggest that prophylaxis treatment is less likely to be followed because the belief in the health threat is likely to be low. This model can also be used to explain why some women with the same conditions described above do, in fact, become rigorously calcium regime adherent. While neither the threat nor the rewards may be immediate, these women may have adopted a belief that all health-preserving efforts should be followed precisely to prevent problems in the future, and preventing bone loss is just one of a host of health-related preventative methods.

Individual Knowledge Barriers

One suggested explanation for the lack of osteoprotective behaviors is that when prevention strategies occur before the disease is present, as is the case with osteoporosis; patients are more likely to dismiss the advice as opposed to when treating a chronic or life-threatening illness, such as heart disease (von Hurst & Wham, 2007). This is part of the decision making process that is informed by the inadequate knowledge of the benefits of prevention and the costs of inaction. Many women may accept bone loss and its consequences as part of the aging process (Drugay, 1997) and therefore feel that prevention is beyond their control. One result of that belief appears to be that many women do not take the necessary precautions to prevent osteoporosis. While diet, exercise, and lifestyle choices thread their way through most healthcare advice, it is clear that many women do not know enough about how these factors can delimit the development of osteoporosis. Studies have indicated that while most women have at least heard of osteoporosis, there is an apparent lack of adequate knowledge surrounding what the disease actually is, how it is acquired, and what the consequences are (Kasper, Peterson & Allegrante, 2001; Ribiero, Blakely, & Laryea, 2000; Weiss & Sankaran, 1998). This lack of understanding may account for the continuous climb in rates of osteoporosis,

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while the lack of knowledge suggests needed strategies to increase womens knowledge and understanding of osteoporosis and its prevention ( Jamal et al., 1999). More than 40% of peak bone mass is acquired during adolescence (Heaney et al., 2000), and lifestyle choices during this period determine bone density later in life. Therefore, it is important that children and teenagers have an adequate calcium vitamin D intake and engage in regular physical activity. Unfortunately, only 19% of teenage girls and 52% of teenage boys have an adequate intake of calcium vitamin D (National Institute of Child Health and Human Development, 2005). In addition, research indicates that 61.5% of children aged 9 to 13 years do not participate in any organized physical activity during their nonschool hours and that 22.6% do not engage in any free-time physical activity (CDC, 2003). These data suggest that a program of osteoprotective behaviors ought to begin early in life. However, the cost-effectiveness of preventive measures for osteoporosis has yet to be established.

Resources
It is axiomatic that preventive approaches are beneficial not only for improved health and quality of life but also because they result in significant reductions in the healthcare costs associated with chronic illnesses. While it is tempting to ascribe the lack of attention and funding to prevention as purely economical, it still remains unclear why so few dollars are spent on health promotion. There are a number of empirically supported interventions that can be initiated before a condition becomes life-threatening. These interventions are known to be effective in promoting and maintaining health (McGinnis, Russon, & Knickman, 2002). For example, it has been shown that physical activity reduces the risk of cardiovascular diseases, diabetes, and osteoporosis in middle-aged adults. There is emerging evidence that community-based campaigns are effective in changing behaviors in large numbers of people in targeted ways. A number of programs aimed at increasing levels of physical activity appear to have short-term benefits. However, in the absence of longitudinal studies, the impact of these prevention activities on longevity or quality of life is uncertain (Andersen, Franckowiak, Snyder, Bartlett, & Fontaine, 1998; Blamey, Mutrie, & Aitchison, 1995). The absence of longitudinal studies illustrating the potential benefits of prevention programs is likely to be part of the problem. In the absence of long-term evaluations of these prevention strategies, it is difficult to determine the cost-effectiveness of various interventions to promote public health. The treatment of existing conditions with new drugs that require clinical drug trials or protocols represents more straightforward research with fewer confounding variables in study conditions than those found in longrange lifestyle-based prevention strategies. Testing new drugs, combinations

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of drugs or developing medical interventions require controlled studies to establish the safety and effectiveness of the test conditions. These conditions cannot be duplicated in most prevention studies. Public investments in health promotion seem to require acceptance that future savings in health and other social costs will offset the investment in prevention and that there is a benefit in doing so (McGinnis, Williams-Russo, & Knickman, 2002). Few data exists on patient-oriented studies of the outcome of population-based screening. The same is true of data surrounding interventions aimed at lifestyle modification (e.g., diet, exercise, and smoking cessation) and of reduction of risk that proves that they are less expensive than treatment and medications. Gast and Taylor (2000) established the veracity of this quixotic thinking, specifically regarding the prevention of osteoporosis rather than the treatment of the consequences. In reality, if the measure of costs is solely based on the treatment and medication costs associated with fractures, then the benefits may not be straightforward.

Structural Knowledge Barriers

Diagnosis and assessment of any widespread condition or disease must address treatment efficacy in an environment of cost containment (Scientific Advisory Board, Osteoporosis Society of Canada, 1996). For osteoporosis, establishing the cost-effectiveness of preventative interventions is difficult. This is because data on these costs are limited and are not as straightforward as estimating the costs of diagnosis and management of other chronic diseases, such as heart disease or diabetes. Managed care has traditionally provided little support for disease prevention as evidenced by the fact that many providers continue to resist coverage for bone density scans in asymptomatic perimenopausal women (Raines & Erickson, 1997). The Bone Mass Measurement Act (BMMA) signed by President Clinton set forth guidelines to provide for uniform coverage under Medicare Part B for bone mass measurements for services provided on or after July 1, 1998 (Watts, 1999). The BMMA authorizes Medicare coverage of medically necessary measurements, such as a bone density scanning, performed on a individual who falls into at least one of five diagnostic categories: (1) an estrogen-deficient woman at clinical risk for osteoporosis, (2) an individual with vertebral abnormalities, (3) an individual receiving long-term glucocorticoid therapy, (4) an individual with primary hyperparathyroidism, and (5) an individual being monitored to assess the efficacy of an approved osteoporosis drug therapy (Watts, 1999). There was a dramatic increase in the number of bone density scans filed under Medicare (from 1.25 million in 1994 to 2.5 million in 2004), and approximately 75% of female Medicare beneficiaries remain unscreened (Simonelli, 2007). This year the Medicare reimbursement rate for a bone density scan was cut by 40% to just over $80. The reimbursement rate is expected to drop to $35 per screening in 2010.

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The effects of this cost cutting will carry over to private insurers, as they base their reimbursements on those paid by Medicare. No provisions have been made by the BMMA for asymptomatic perimenopausal women or women with perceived minimal risks for osteoporosis. Provisions are not likely due to the decrease in reimbursement rates. Consistent with the BMMA, the National Osteoporosis Foundation 1998 practice guidelines (revised in 1999), the World Health Organization Task force for Osteoporosis, and the Scientific Advisory Board for the Osteoporosis Society of Canada (1996) recommended bone mineral density testing in women who are 65 years or older, women who have had loss of height, prolonged corticosteroid use, previous low trauma fracture, and younger postmenopausal women with one or more risk factors for osteoporotic fractures (Cadarette et al., 2001). Despite the high prevalence of osteoporosis and the availability of sensitive diagnostic means to detect osteopenia as well as osteoporosis, there has been little progress in the detection efforts or treatment of early signs of the condition (Stock et al., 1998). This low rate of evaluation testing is ascribed to the high cost of the diagnostic test (i.e., the cost-benefit analysis engaged in by insurers). In addition, there is some confusion about which risk factors warrant the recommendation for bone density tests in perimenopausal women. This is not because there has been an abundance of contradictory data, but rather precisely because there have been so few epidemiological studies done on this population. There are clearly emerging concerns that lack of knowledge exists in large part because there has been an insufficient number of studies addressing womens health issues. Part of the reason that conditions such as osteoporosis have been inadequately studied for so long is the fact that women were rarely a part of clinical trials or epidemiological studies. In fact, for many years women were intentionally excluded from or underrepresented in clinical research studies. Despite the National Institutes of Health (NIH) Revitalization Act and the Womens Health Initiative, women continue to be underrepresented in most research. Some of these exclusions are intentional, spurred by both a reasonable fear of causing harm to women during reproductive periods and the avoidance of the rigid federal guidelines that have been created around inclusion of younger women in federally funded studies. Vidaver, Lafleur, Tong, Bradshaw, and Marts (2000) examined how widespread the problem of excluding women in research is by reviewing published research articles in major medical journals since 1993. They found that in NIH-funded nonsex-specific studies, one-fifth of those studies each year failed to include women, despite clear federal mandates to include them. Additionally, one-quarter to one-third of the studies that included women did not analyze data by sex. They concluded, as have others, that there is a need to articulate clearly a national agenda that will raise awareness about womens health needs in research, reduce the incidents of studies that

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unnecessarily exclude women, and monitor the appropriate recruitment and inclusion of women in clinical research trials (Mosca et al., 2001; Vidaver et al., 2000, Simonelli, 2007).

IMPLICATIONS FOR SOCIAL WORK PRACTICE AND EDUCATION

According to the health belief model, a woman will make the choice as to whether she will engage in health-protective behaviors based on what she feels to be her perceived susceptibility to the condition or disease and her perceived severity of the disease. Health-protective behaviors differ from health-restorative behaviors in terms of adherence in that in health-protective behaviors there is no imminent danger. In terms of osteoporosis, health protection needs to begin early in life. However, the symptoms (pain, loss of height, fractures) associated with osteoporosis do not typically manifest until after menopause. This is likely to affect womens perceived susceptibility and severity while introducing the modifying factor of low motivation. An understanding by social workers that adherence is a function of many psychosocial factors that either alone or in concert with each other affect an individuals ability or motivation to engage in health-protective activities will allow for the implementation of interventions (on both a micro and macro level) that provide realistic goals for the client, thereby increasing the possibility of a successful outcome. This is particularly important given the number of medications consumed by older Americans. Social workers should be educated on health promotion activities through the use of in-services in community agencies and the incorporation of information surrounding health promotion in class curricula for social work students. In order for social workers to help in the prevention of osteoporosis, they need to possess a suitable framework and knowledge of the factors that are associated with osteoporosis. Information surrounding the prevention of osteoporosis can easily be disseminated by social work educators in Human Behavior in the Social Environment (HBSE) and practice courses. This information should also include other social workrelevant dimensions such as policy, implications for research, the systems perspective, and person in environment. By incorporating disease prevention into the social work curriculum, not only in terms of diversity and cultural competence but also in terms of understanding the psychosocial issues of chronic disease, social workers can join in the systemic approach to the prevention of osteoporosis. As mentioned earlier, osteoporosis has numerous physical ramifications such as a decrease in height, stooped posture, broken bones, chronic pain, and in some cases even death. Osteoporosis also has psychological implications such as a decreased quality of life (Bayles, Cochran, & Anderson, 2000) and depression (Palinkas, Wingard, & Connor, 1990). A diagnosis

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of osteoporosis often results in admonitions to adjust lifestyle that include dietary and activity level changes. Because of the decreased mobility, people with osteoporosis often become isolated. Social workers are in a unique position to help people with a diagnosis of osteoporosis and their families with any biopsychosocial issues that may arise. Physician-based interventions have been shown to be effective in smoking cessation (Ockene & Zapka, 1997; Wilson, Franks, Kendall, & Foreyt, 1998). Despite the positive results of these interventions, many primary physicians do not address smoking cessation and possible interventions (Richmond, Mendelsohn, & Kehoe, 1998; Thomas, Yaphe, & Matalon, 2007). The primary reason for the failure to address the issue is simply that physicians have little time to incorporate the information into a visit (Richmond et al., 1998). The same has been found with osteoporosis. Recent evidence suggests that many pediatricians do not discuss the risk factors of osteoporosis with their patients. This is likely due to a lack of knowledge on the part of the doctor or the doctor not considering osteoporosis to be an important pediatric issue (Fleming & Patrick, 2002). Incorporating a social worker into an office visit with a primary care physician is one example of how to address the risk factors and prevention of osteoporosis while at the same time keeping to physicians free to see other patients. Many individuals are anxious about seeing physicians. Meeting with a social worker before their visit will not only help to raise awareness and develop specific treatment plans to reduce their risk of osteoporosis but also reduce the anxiety about their visit by focusing on the strengths perspective, therefore empowering the woman to make the choice to engage in preventive health strategies. This intervention will also allow for the assessment of psychosocial factors that may be a barrier to engaging in osteoprotective behaviors such as depression, eating disorders, financial problems, abuse, and other stressors, allowing for the best possible intervention. These interventions, however, need to be implemented for women of all ages so that prevention can begin as early as possible.

IMPLICATIONS FOR SOCIAL WORK POLICY

As mentioned earlier, The BMMA outlines Medicare guidelines for utilization of bone density scans. While the number of bone density scans did increase after the inception of the guidelines, 75% of Medicare beneficiaries remain unscreened for osteoporosis (Simonelli, 2007). In addition, the reimbursement rates for bone density tests are decreasing. This decrease will significantly impact the availability of the scans, particularly for women who are asymptomatic for osteoporosis. Social workers who focus in gerontology should advocate not only for adequate reimbursement for the bone density scans but also for screening of women who are asymptomatic. Screening

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those who are asymptomatic but are still at risk due to advanced age will allow for early detection of osteopenia, thereby decreasing the probability of osteoporosis developing. The study of environmental and policy influences on nutrition and eating behaviors is a new and growing science. There are few theoretical models with related data to test the interactions among personal, social, and environmental factors (Ball, Timperio, & Crawford, 2006; Lawrence & Yeatman, 2008). Furthermore, little research has been conducted on which food environments are most influential or the most feasible in which to implement interventions and policies to improve food environments in various populations. As mentioned above, the majority of risk factors for osteoporosis are of a predetermined nature; however, improving peak bone mass has been shown to decrease the risk of osteoporosis. Available research states that prepubescent and pubescent years are the most opportune time for interventions aimed at increasing peak bone mass (Kun, Greenfield, Xueqin, & Fraser, 2001). The majority of policies surrounding physical activity are implemented at the school or afterschool care level.

Schools
Because students spend the majority of their days in school, the school is the most logical place to implement healthy nutrition and exercise policies. Unfortunately, schools have become a reflection of the broader society with foods high in fat and sugar being readily available (Longley & Sneed, 2009). The Child Nutrition and WIC Reauthorization Act of 2004 required local education agencies that sponsor meal programs to establish wellness programs that address nutrition and physical activity beginning in the 2006 2007 school year. Historically, federal regulations have limited jurisdiction of the food provided to students in schools outside the parameter of the federal meal programs. The wellness mandate is the first legislative effort to address the food provided in schools. Schools not complying with the mandates will be cited and will be at risk of losing their federal funding (Longley & Sneed, 2009). While this mandate was developed to reduce and prevent obesity, it has the added benefit of addressing two of the key modifiable elements in osteoporosis prevention: proper nutrition and physical activity. The mandate presents some significant challenges for the schools. Some researchers suggest that the school district health councils provide the best avenue for school-level health promotion policy development. The School Health Polices and Program study found that two-thirds of schools have health councils that develop polices on health issues (Wechsler, Brener, Kuester, & Miler, 2000). However, other researchers paint a less optimistic view of the capabilities of school administration (Kubik, Lytle, & Story, 2001). They state that establishing a nutrition program at the local school level is complex and time-consuming and school administrators do not have the

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capabilities to establish and implement wellness policies. The challenge is the development of micro, mezzo, and macro policies to address food environments. Sweetened drinks such as soft drinks and fruit juices constitute the primary sources of added sugar in childrens diets. High fructose corn syrup, the main sweetening component in soft drinks, is not unhealthy in small amounts (Committee on School Health, 2004). The amount of high fructose corn syrup in a 12-ounce soft drink is the equivalent of 10 teaspoons of sugar. Soft drink consumption has increased 300% in the past 20 years. Between 56% and 84% of children consume at least one soft drink per day. Not only can soft drinks lead to an increase in obesity, they can also increase the risk of fracture due to the displacement of milk consumption. As soft drink consumption increases, milk consumption decreases. Milk is the primary source of calcium for the majority of Americans. Intake of many nutrients is decreased when milk consumption decreases, which in turn jeopardizes the accrual of maximum peak bone mass at a critical time in life, adolescence (Committee on School Health, 2004). The American Academy of Pediatrics, Committee on School Health, provides recommendations to pediatricians regarding soft drinks in schools. These recommendations encourage advocating for the elimination of soft drinks in school altogether. This would involve the education of school administrators, teachers, parents, and students about the ramification of soft drink consumption. Pediatricians are also encouraged to advocate for the creation of school advisory councils comprising doctors, nurses, dieticians, parents, and other community members. While social workers are not specifically mentioned by the committee, they provide an avenue for advocacy on the micro, mezzo, and macro levels.

Center-Based Care
The Child and Adult Care Food Program (CACFP) sponsored by the United States Department of Agriculture provides meals and snacks for nearly 2.1 million children in center-based care. Interestingly, the CACFP has no requirements in term of the nutritional value of the meals and snacks, nor do they prohibit unhealthy foods (Story, Kaphingst, Robinson-OBrien, & Glanz, 2008). Social workers need to advocate for more federal funding for community-based services and education. On a more macro level, interventions targeting education to increase awareness of the risk factors and prevention activities of osteoporosis should be lobbied for. As mentioned earlier, physical activity is one way to help prevent osteoporosis. Policy interventions such as zoning ordinances, capital improvement programs, and master plans for recreational parks hold particular promise in increasing physical activity within local communities. However, despite the recent attention to the relationship between environmental characteristics and physical activity, there is little research on the extent to which the policies

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impact physical activity levels (Salvesen, Evenson, Rodriguez, & Brown, 2008). In addition, state and local governments across the country have adopted policies to promote greater physical activity. Adopting these policies is only the first step; these polices need to be implemented. Successful implementation depends on a number of factors, such as skillful leadership, appropriate financial resources, and coordination among agencies (Salvesen et al., 2008). In terms of school districts, a school health advisory committee may encompass all of these areas to improve nutrition and increase physical activities not only within the schools but also within surrounding communities.

CONCLUSIONS
Osteoporosis is one of the major disorders of our time and is increasing at an alarming rate. With the increase of the number of Americans older than 65, the number of cases of osteoporosis is likely to increase as well. Associated with this increase in osteoporosis are the consequent increases in both the psychosocial issues of the affected individuals and their families as well as medical costs. There are a number of risk factors for osteoporosis that are of a modifiable nature; however, many women do not take the necessary precautions to prevent the disease. The reasons that women do not actively engage in preventative and remedial strategies to deal with the potential for osteoporosis are complex and suggest intervention strategies aimed at education, knowledge dissemination, and the generation of new knowledge. Social workers are in a unique position to provide interventions not only on a micro level (educating individual clients) but also on a macro level in terms of large-scale education campaigns and knowledge dissemination efforts focusing on nutrition and exercise both in children and in adults. Social workers can also evaluate the efficacy of such programs, adding to the knowledge base. Individuals can significantly decrease the likelihood of osteoporosis with the appropriate knowledge and motivation to do so, particularly as research is conducted on preventive interventions.

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