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Bone Health and Osteoporosis: A Report of the Surgeon GeneralChapter 13: A Vision for the Future: A Framework for Action To Promote Bone Health
IntroductionThe major messages of this Surgeon General’s report are as follows: 1) that bone health is essential to the general health and well-being of all Americans; 2) that great progress has been made in the last several decades in understanding and promoting bone health and in preventing, diagnosing, and treating bone disease; 3) that most individuals have the opportunity to make lifestyle choices that can result in stronger, healthier bones throughout life; and 4) that health care professionals, health systems, communities, and a variety of other stakeholders have critical roles to play in supporting individuals in making appropriate choices and in promoting timely preventive, diagnostic, and therapeutic interventions in those who have or who are at risk of developing bone disease. However, these messages are not yet widely understood. As a result, the bone health status of Americans remains in jeopardy today, and without concerted action it will get worse in the future. Far too few Americans follow the dietary and physical activity guidelines that can help promote bone (and overall) health. Health care professionals can do a better job in paying attention to the bone health of their patients. Many individuals do not receive timely diagnostic tests and preventive and therapeutic measures that can serve to minimize the impact of bone disease. The net result is unnecessary pain, suffering, and complications that can imperil overall health and well-being, along with financial and social costs that diminish the quality of life for individuals and burden both individuals and society at large. Improving the bone health and well-being of Americans requires actions at all levels of society, including individuals and neighborhoods, local communities, health systems, cities, States, and the Nation as a whole. A coordinated effort can overcome the barriers—be they educational, social, systemic, policy-related, or financial—that have created a population whose bone health status is at risk. A Framework for ActionThis Surgeon General’s report looks upon the Nation’s at-risk bone health status as an opportunity to do better. A national action plan for bone health can benefit all Americans. This plan can be aimed at improving overall health and quality of life by enhancing the underlying bone health of all individuals, including men, racial and ethnic minorities, the uninsured, and the underinsured. Everyone has a role to play in improving and promoting bone health, including families and individuals, health care professionals, hospitals and rehabilitation centers, academic medical centers, the research community, health systems, managed care organizations and insurance companies, public and private purchasers, private industry, community-based organizations, State and local public health departments, voluntary health organizations, professional associations, policymakers, and agencies at all levels of government. These stakeholders can work together to broaden the public’s and providers’ understanding of the importance of bone health and its relevance to general health and well-being and to promote policies and programs to ensure that existing and future preventive, assessment, diagnostic, and treatment measures for bone diseases and disorders are made available on a timely basis to all Americans. This approach can serve as the primary vehicle for improving bone health in this country. Key Action Steps
While much valuable work is already underway, more needs to be done to change the perception that osteoporosis is an inevitable part of aging. On the contrary, like heart disease, it needs to be thought of as a preventable chronic disease, the roots of which begin at a fairly young age even though symptoms may not manifest until later in life. Like heart disease and other chronic conditions, there needs to be a better understanding of how much can be done throughout life to prevent its eventual onset. Fractures, especially in the elderly, need to be thought of by both the public and practitioners as a sentinel event that probably signals the presence of a frail skeleton and an increased risk of future fractures. Much as a first heart attack is thought of as an opportunity to intervene to prevent future heart attacks, an individual’s first fracture must be seized upon as an opportunity to intervene to prevent future fractures. Suffering one fracture is more than enough for any individual, and therefore treating fractures should go beyond the orthopedic aspect of setting and fixing the bone. Rather, fractures should be considered a red flag for the potential for bone disease and therefore should be a catalyst for further assessment, diagnosis, prevention, and treatment of bone disease. Patients who suffer non-spine fractures represent one of the easiest high-risk groups to identify and target for intervention, since most fracture patients seek medical care for their injury. Health care practitioners and the public at large must recognize that fractures caused by weakened bones do not always manifest as broken arms, broken wrists, or other easy-to-recognize problems. Rather, they can occur “silently” in the spine with the collapse of spinal vertebrae. Individual patients may not recognize them as fractures, but rather may come into the office complaining of back pain or discomfort. Today these warning signs are too often dismissed by individuals and health professionals. As a result, too many patients end up suffering multiple fractures before anyone considers the possibility of bone disease. Individuals, especially elderly individuals, must recognize that recurrent back pain could be a signal of a bone-related problem, and practitioners that attend to individuals with back pain must consider the possibility of a spine compression fracture and hence the need for further assessment of the potential for metabolic bone disease. Further work is needed in the area of basic research, clinical and epidemiological research, health system-based research, and population-based research, including community intervention trials. Specific research questions in each of these areas are discussed in relevant chapters of this report. A broad message of this report is that the Nation is not doing equally well in all areas of research and prevention. While extensive work is being done in the area of basic research, the translation of this research to clinical practice often lags behind. Clinical and epidemiological research and evaluation enjoy significant support as well. More needs to be done, especially with respect to research related to men and racial and ethnic minorities and how best to translate basic and clinical research findings into everyday practice. While much of this basic, clinical, and epidemiological research will be focused on osteoporosis, it is important to remember that research breakthroughs in osteoporosis (e.g., the development of bisphosphonates) are already paying dividends for the treatment of other bone diseases, and these benefits will likely continue in the future. More health system- and population-based research in the area of bone health is needed as well. One of the biggest voids is in the area of population-based research on behavior change, where little is known about how to get people to adopt bone-healthy behaviors. Fortunately, many of the behaviors that promote bone health also promote other aspects of health, including cardiovascular health. The goal going forward should be to integrate bone and musculoskeletal health into larger studies that are evaluating these behavioral issues in other disease areas. Within the area of health systems-based research, much more needs to be known about the most efficient and effective ways to use the various risk assessment, diagnostic, and therapeutic tools available in bone health today. As noted, insights from basic and clinical research need to find their way into everyday practice. There are two components to this issue. First, within a given disease area, many insights from basic and clinical research are never applied in practice. For example, research might show that a particular drug, administered in a particular dose, is effective in treating a specific population. Once these findings are published, practitioners often do not know how to use this population-based information when assessing and treating individual patients. They may not know if a specific patient’s situation applies and, if so, how long to use the drug in question. Second, in some situations insights from research into the prevention of other chronic diseases will have applications in the prevention of bone disease. These insights frequently do not become known to health care professionals responsible for bone health. Much more needs to be done to address both of these problems. Work should focus on stimulating the translation and application of basic research into clinical research and to promote the use of basic and clinical research findings in everyday practice. The research community should be encouraged to play a larger role in translating their findings into usable knowledge that helps a health care professional.
As noted earlier, many of the behaviors that prevent bone disease are also critical for preventing other diseases and chronic conditions, including asthma, diabetes, obesity, heart disease, and stroke. Thus, it is absolutely essential that information directed toward the public and physicians about the behaviors that optimize health be integrated. These integrated educational messages need to promote all aspects of health for individuals in various stages of life, including infancy, childhood, adolescence, young adults, middle-aged adults, and the elderly. For the most part, the critical messages in each of these disease areas will be the same. The key is to maintain a healthy weight and diet, avoid smoking, and engage in regular physical activity. For example, the bone health community could join forces with other organizations promoting healthy lifestyles and the prevention of chronic diseases, such as the National Cancer Institute’s 5 A Day for Better Health campaign to advocate consumption of fruits and vegetables and the American Heart Association’s efforts to promote cardiovascular health through physical activity, diet, and smoking cessation. The goal should be to ensure that their messages emphasize the bone-health benefits of whatever is being promoted, be it following an appropriate diet, exercising on a regular basis, or other bone-healthy behaviors. These integrated messages will help both the public and practitioners to understand that there is not a different “recipe” for keeping different parts of the body healthy, and that therefore it is not an all-consuming task to do what is needed to maintain one’s health. Rather, the message will be a much more positive one—that following healthy behaviors is relatively easy to do and that focusing on a few critical elements such as nutrition and physical activity can go a long way toward achieving overall health and well-being. While there will always be a need for more research and a greater understanding of bone health and bone disease, more than enough is known today to get started on any of a variety of critical actions that are needed to enhance the bone health status of Americans. The Roles of Key StakeholdersMany fruitful activities are already underway in the area of bone health. Advocacy groups, medical and science organizations, and others have been working diligently to promote better bone health for all Americans, including underserved populations. This Surgeon General’s report can be a catalyst to build upon, broaden, and expand these efforts. To that end, this report calls for public and private stakeholders in the area of bone health to join forces in the development of a national action plan. The goal of this effort would be to forge consensus on the different action steps that are needed and to determine which stakeholders are best equipped to take responsibility for their execution. Because every stakeholder has an important role to play, this comprehensive effort should include a wide variety of organizations, including those representing families and individuals, health care professionals, hospitals and rehabilitation centers, skilled nursing facilities, academic medical centers, the research community, health systems, managed care organizations and insurance companies, public and private purchasers, private industry, community-based organizations, State and local public health departments, voluntary health organizations, professional associations, policymakers, and agencies at all levels of government. Some of the most important action steps for the key stakeholders are highlighted below: Individuals and FamiliesBecause many individuals may not realize that they are at risk of bone disease and may not take action (e.g., begin engaging in physical activity) until they are motivated to do so, individuals and families need to:
Health Care ProfessionalsAll health care professionals, including physicians, nurses, nurse practitioners, physician assistants, dietitians/nutritionists, physical and occupational therapists, social workers, dentists, optometrists, and pharmacists can play a critical role in promoting the bone health of their patients. They need to recognize the potential for bone disease in men and racial and ethnic minorities. While the underlying risk in these population groups may be lower than for White women, the potential for bone disease is still real, particularly in the elderly and the poor. Primary care providers have an especially critical role to play. They need to:
Health care professionals working in emergency departments and orthopedic practices also have an important role. They must:
Finally, regardless of the setting, consideration should be given to increasing the role of mid-level providers as a way of promoting bone health and minimizing the impact of bone diseases. Health SystemsHealth systems, including hospitals, organized delivery systems, and health plans and insurers, can do much to promote bone health in the populations they serve, including:
Health Care PurchasersHealth care purchasers, including public and private employers that buy health coverage on behalf of their employees, can use their power both individually and collectively to influence bone health. More specifically, they can do the following:
Communities and Community-Based OrganizationsCommunities consist of multiple components, including individuals, faith-based and other community organizations, employers, and government agencies. Working together these organizations can:
GovernmentGovernments at every level—local, State, and Federal—have a vital leadership role to play in promoting bone health. To play this role effectively, elected policymakers and other government leaders need to recognize the long-term financial and social costs of the status quo (less-than-optimal bone health status), and appreciate the potential to reduce these costs and improve quality of life through prevention, early detection, and early treatment. Local public health departments and government agencies—especially those serving the elderly—have an especially important role to play in developing and implementing a public health approach to bone health promotion at the community level. Specific roles that government can play include:
Voluntary Health OrganizationsVoluntary health organizations play important roles in promoting bone health. They are often able to reach the public and providers with critical information quickly and with fewer constraints than can government organizations. More specifically, they can:
Professional AssociationsProfessional associations play a critical role in promoting bone health. They can:
Academic InstitutionsAcademic institutions can be critical facilitators through their two core missions of education and research. With respect to osteoporosis and bone health, they can:
IndustryIndustry also has an important role to play in promoting bone health. They can:
The Importance of Partnerships Among StakeholdersWhile the roles and contributions of the individual stakeholders cited above are undoubtedly important, public-private partnerships will also be critical to the successful development and execution of a national action plan for bone health. These partnerships can build and strengthen cross-disciplinary, culturally competent, community-based efforts to promote bone-healthy behaviors and support the early identification and treatment of bone disease. There is no question that the collective and complementary talents of both public and private stakeholders will be vital to achieving the goal of improving the bone health status of all Americans. Conclusion Significant strides have been made in understanding bone health and bone disease over the past few decades. Much is known about how to keep bones healthy throughout life and how to prevent and treat bone disease and fractures in those whose bone health deteriorates. Yet too few people—individuals and health professionals alike—make use of this information. As a result, too many people have or are at risk of getting bone disease. The time has come to address this problem, to “get the word out” about the importance of bone health and the serious consequences and significant costs of bone disease and fractures. The time has come for everyone—including individual citizens, solo practitioners, the heads of major public and private sector organizations, and the leaders of governmental agencies—to do his or her part in promoting the bone health of all Americans.
Published: October 14, 2004 |
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