VIEWPOINT

Nutrition Education for Osteoporosis Patients: An Innovative Approach to Care of the Chronically III Elderly

CONNIE W. BALES1 AND DEBORAH T. GOLD2

Center for the Study of Aging and Human Development; lSarah W. Stedman Center for Nutritional Studies; and 2Department of Psychiatry, Duke University Medical Center, Durham, North Carolina 27710

INTRODUCTION

Osteoporosis is a painful and debilitating bone condition that annually produces more than one million non-trau­matic fractures in Americans over age 45. As graduaI increases in life expectancy (1) and the movement of the "baby boom" cohort into maturity greatly increase the number and proportion of older adults in the population, the National Osteoporosis Foundation predicts that the incidence of osteoporosis will grow at an alarming rate (2). Currently, more th an 20 million people have osteo­porosis, women being more likely than men to develop the condition. Annual medical costs associated with the treatment of osteoporotic fractures approach $10 billion (3). Although many vertebral fractures go unreported, it is estimated that 40% of all women will have at least one spinal fracture by age 80 years (2). Osteoporosis-related hip fractures (the incidence is 250,000 annually) are ac­companied by high rates of morbidity and mortality. Within the first year after the fracture, elderly individ­uals have a 5 to 20% risk of dying as a result of the injury. Fifteen to 25% of those who were living independently prior to the hip fracture remain institutionalized one year later (2). Unless current trends are altered, the annual hip fracture rate in the United States will be greater than 600,000 by the year 2040.

The overwhelming physical and financial costs in­curred with osteoporosis-related fractures are well doc­umented. However, the social and psychological effects of this disease also exact a great cost. To experience chronic pain and reduced mobility damages self-confi­dence and undermines an individual' s ability to cope with the challenges of everyday life. In addition, kyphosis (known by the deprecating name of "dowager's hump") and the crippling nature of rib and hip fractures may

Address for correspondence: Connie W. BaIes, Center for the Study of Aging and Human Development, Box 3003, Duke University Med­ical Center, Durham, NC 27710; (919) 684-5736. 0022-3182/91/2303-0120$03.00/0 © 1991 SOCIETY FOR NUTRITION EDUCATION

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alter one' s appearance profoundly and have devastating effects on self-esteem (4).

Not all individuals are at equal risk for developing osteoporosis as they age. Established risk factors for the condition include petite build, extreme inactivity, early menopause or premenopausal oophorectomy, corticoste­roid use, being white or of Asian descent, and being female (5). Although heredity is a strong determinant of bone density, environmental factors such as dietary in­take (e.g. protein, energy, vitamin D, and calcium) and physical activity have been shown to have separate and signiflcant modulating effects on bone mass (6).

Primary osteoporosis is, above aB, an age-related dis­order. The heterogeneity of its pattern of occurrence and clinical course has led to the characterization of two rel­atively distinct subtypes (see Table 1). Type 1 osteopo­rosis (sometimes called "post-menopausal") occurs pre­dominantly in women and is characterized by an accelerated and disproportionate loss of trabecular bone. Type II ("age-related") osteoporosis may commonly oc­cur in both men and women and typically has a later age of initial ons et th an Type 1. The diagnosis and detailed characterization of these subtypes have been previously delineated (7-10).

Osteoporosis cannot be reversed by any known drug therapy, exercise regimen, or dietary intervention. How­ever, appropriate medical and nutritional interventions have the potential to slow its progression. Estrogen re­placement therapy for many peri- and post-menopausal women provides the best protection against Type 1 os­teoporosis (11-13). Calcium supplementation cannot fully compensate during the transmenopausal period of ac­celerated bone loss (14), but the concomittant adminis­tration of calcium supplements may augment estrogen therapy, thereby reducing the necessary effective dose of the hormone (15).

Calcium intakes are typically low in adult Americans. It has been estimated that 75% of females over age 35 have calcium intakes below the RDA of 800 mg per day (16). Although the general consensus is that adequate

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Table 1. Characterization of Types 1 and Il osteoporosis.'

Type 1

51-75 6:1

Type 1/

>70 2:1

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Age range (yrs) Predominance (female:male) Boneloss Disproportionately rapid trabecular bone

loss Proportion al loss from cortical and tra­becular bone

Most common fracture locale Vertebra; distal radius Hip, proximal humerus, proximal tibia, pelvis

Etiology Metabolic manifestations

Estrogen deficiency Increased bone resorption

Aging Impaired bone formation; secondary hy­perparathyroidism

'Based upon Riggs and Melton (7), Wardlaw (8) and others (9).

calcium intake helps delay bone loss, a good deal of controversy still exists concerning the value of a high calcium diet as therapy for osteoporosis. Discrepancies between the results of such studies may be explained by variation in research protocols, difficulties in measuring bone density and calcium intake, and the variable ability of specifie individuals to adapt to a low calcium di et (5, 8, 17). The sometimes weak effect of dietary calcium on calcium balance (18, 19) makes it difficult to predict the value of dietary calcium intake for a given individual. Yet there is substantial evidence that calcium supple­mentation reduces postmenopausalloss of cortical bone (20, 21). National consensus development conferences have repeatedly endorsed the benefits (and noted the low risks) of a high calcium diet and have recommended calcium intakes of 1000 and 1500 mg calcium per day for estrogen-replete and estrogen-deprived women, respec­tively (22, 23). Thus, calcium supplementation continues to be endorsed as an adjuvant to therapeutic regimes for osteoporosis (provided urinary calcium excretion does not exceed 250 mg per 24 hours).

Other dietary recommendations in the treatment of osteoporosis may include instructions to moderate the intake of di et constituents that may threaten calcium balance when used to excess, such as alcohol, protein, sodium, caffeine, and dietary fiber (17). Supplementation with vitamin D metabolites or analogues may also be used to improve calcium absorption in osteoporotic pa­tients (24, 25). In addition, experimental drugs, such as calcitonin and etidronate, have proven to be beneficial for sorne patients in clinical trials (26, 27). There is also the potential for improvements in bone mineraI content (28) and functional capacity (29) when physical therapy and exercise are applied in osteoporosis therapy. Thus, although no specifie treatment will cure osteoporosis, the appropriate combination of therapies may produce pos­itive changes in medical and functional outcomes.

The purpose of this paper is to explore challenges involved in the nutritional management of osteoporosis both for the patient, who must adapt to life-Iong changes in di et and lifestyle, and for the nutrition educator, who must plan and recommend these dietary changes. In the

course of this discussion, weaknesses inherent in tradi­tional approaches to nutrition education for the chroni­cali y ill elderly will be identified and alternative ways to meet the changing nutritional needs of the osteoporotic older adult will be explored. Many of the concepts dis­cussed here regarding nutrition education may be ap­plied equally weIl to other situations in which mature adults must modify their dietary patterns because of a chronic health condition.

NUTRITIONAL CARE OF PATIENTS WITH OSTEOPOROSIS

Specific dietary prescriptions for the management of os­teoporosis vary with the patient, the type and extent of bone loss, and the medical history. It is beyond the scope of this paper to delineate a precise course of therapy for various types of osteoporosis. However, as a point of reference, Table 2 presents typical dietary guidelines and components of nutritional evaluation for osteoporosis pa­tients. Many management/treatment protocols for osteo­porosis rely heavily upon lifestyle modification (often in­cluding a high calcium diet) and a reduction ofbehaviors such as excessive alcohol and caffeine consumption likely to jeopardize calcium balance (17). Vitam in D status must be documented and interferingfactors such as megadoses of nutrient supplements eliminated. Nutritional instruc­tions should complement the chosen treatment protocols and be appropriately prescribed according to individu al biochemical profiles. For example, calcium supplemen­tation may enhance the effectiveness of estrogen therapy but may be undesirable for patients with hypercalciuria. The degree of disability and the presence of co-morbid conditions is likely to have an important impact on di­etary needs. Thus, a basic tenet of dietary management must be that no single nutritional therapy is appropriate for aIl patients, or even for the same patient over time.

The nutritional management of osteoporosis presents unique challenges for the patient as weIl as the nutri­tionist responsible for her care. The current literature provides little information concerning the specifies of

122 BaIes & Gold/OSTEOPOROSIS PATIENTS

Table 2. Sam pie dietary guidelines for an osteoporosis patient.'

1. Institute high calcium diet, appropriate to need. Ali patients with established osteoporosis should be in­structed to achieve a total calcium intake of 1200-1500 mg calcium per day unless contraindications exist. Highly bioavailable food sources of calcium should be encour­aged but calcium supplements may be necessary to achieve total target intake. Calcium citrate may be better absorbed th an the carbonate form if patient is achlor­hydric.

II. Avoid negative calcium balance. Moderate risk factors such as alcohol, protein, sodium, caffeine, and high dietary fiber in diet. Treat lactose in­tolerance with lactase drops or pills and/or dietary mod­ification.

III. Maintain adequate vitamin 0 status. Blood levels of calcidiol [25(OH)O] should be measured and supplements may be prescribed in cases of defi­ciency. Recommend 10 to 15 minutes in sun, 2 to 3 times/ week.

IV. Establish prudent meal patterns. Oiet plans should be adjusted to include modifications of calorie intake (increased or decreased), saturated fat and cholesterol, carbohydrate or sodium as necessitated by co-morbid conditions. Potentially hazardous vitamin and minerai supplements must be discontinued. Adjust­ments for diet/drug interactions may also be necessary.

'These guidelines are not intended as absolute recommen­dations but will vary according to the prescriptions of the attending physician and dietitian.

nutrition counseling for these patients. However, both their age (50 to 85 + years) and the incurable nature of their condition must be taken into account in the de­velopment of nutritional care plans.

Age-associated nutritional risk factors such as inactiv­ity, poor taste acuity, depression and economic con­straints, along with the demands of chronic disease (in­c\uding drugs and associated side-effects, special di et prescriptions, pain and fatigue), reduce the likelihood that dietary intakes will be adequate in the elderly pop­ulation (30, 31). Calorie needs decrease with age (due to reduced metabolic requirements as weIl as lower phys­ical activity), and thus calorie intake is commonly re­duced as weIl. Although there is remarkable variation in the general health and well-being of elderly individuals, in many cases calorie intakes are sufficiently low to affect the consumption of adequate amounts of one or more essential nutrients. This makes the implementation of a new dietary regimen, particularly one that adds food to the diet (such as a high calcium diet), more difficult. When the patient is not overweight, the best approach is to increase the number of times per day that small meals are consumed. In other cases, the substitution of high calcium foods for high calorie foods of poor nutrient density may be more appropriate.

Unfortunately, the NRC-Recommended Dietary AI­lowances (32) provide limited guidance for the nutritional care of older osteoporosis patients. These allowances are

the same for aIl adults 51 years of age and older and apply only to healthy individuals. In addition, the newest re­vision does not make a specific recommendation for cal­orie consumption in the elderly, although it is accepted that the energy requirement of those over age 75 is prob­ably lower th an for younger individuals (33).

Nutrition education for osteoporosis is made more complex by the chronicity of this condition. TypicaIly, loss of bone density occurs quite slowly (i.e., over a number of years). Thus, attempts to slow the rate ofbone loss may take a long time to make a difference in the clinical outcome for many patients. Coping with this chronic condition is c\early made more difficult by the typically slow response to dietary, medical and exercise therapies. Those whose expectations are based on the traditional medical model of rapid cures for acute iIl­nesses may be frustrated as they wait for signs of prog­ress. In fact, patients with severe osteoporosis may ex­press regrets that the condition is not terminal because of the stressful nature of their depressing and uncertain prognosis (4). Maintaining appropriate dietary intake over the long term will be difficult for these patients, espe­cially when the recommended diet differs substantially from life-Iong food habits (34). In the next section, we will discuss examples of ways in which patients some­times try and fail to accept and/or maintain special dietary instructions.

PATIENT RESPONSES TO DIETARY INSTRUCTION

Patients receiving nutritional counseling for the man­agement of a chronic illness like osteoporosis may have some difficulty initiating and/or maintaining recom­mended dietary modifications. Although each patient's response to these changes is unique, some patterns of patient behavior are prototypical. These response pat­terns do not distinctly belong to patients with osteopo­rosis; rather, they can be generalized to almost aIl pa­tients with non-terminal, chronic illness. Below, we describe two of the many potential responses to dietary instruction that may be counterproductive. The "DO IT ALL" and the "BUT SHE'S NEVER DONE IT" patients are at opposite ends of the spectrum of possible re­sponses. Again, we do not suggest that aIl osteoporotics fIt into one or the other of these categories. Instead, we offer these descriptions as examples of ways in which we have observed some patients respond to nutrition coun­seling in the clinical setting.

The first type, the "DO IT ALL," leaves the diet coun­seling session with every intention of complying to the letter with aIl nutritional recommendations, as weIl as with exercise, medical, and psychosocial recommenda­tions made by other health care providers. This patient is trying to solve problems and palliate her emotions with

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ideal behaviors, despite the fact that pragmatic and psy­chological issues may make it impossible for her to be a "perfect" patient. She believes sincerely that she can significantly alter the ways in which she eats and lives and is not daunted by the problems associated with eating frequently in restaurants or dealing with the side effects of drugs or calcium supplements. Without question, her actions post-nutritional counseling are totally compliant. During the first few months, this patient may double or triple her calcium consumption.

Unfortunately, at sorne point in the future, many "DO IT ALL" patients experience a change in attitude toward nutritional compliance specifically and toward medical compliance in general. The rigid and unyielding routines of dietary and exercise compliance into which she has plunged have become boring, and she is likely to slip back into old patterns of behavior. Alternatively, sorne critical event may precipitate great feelings of discour­agement. This pattern can happen often to the patient who experiences an osteoporosis-related fracture shortly after treatment has begun. Although she realizes logically that it is too soon to expect any positive results from her treatments, she still may hecome disillusioned by the additional pain and limitations. At this point, the "DO IT ALL" patient may return to her former lifelong pat­terns of eating.

Another common, inappropriate patient response to diet instructions is the "BUT SHE'S NEVER DONE IT" reaction (called denial in behavioral medicine tenns) (35, 36). This patient meets the challenges of chronic illness management by maintaining the status quo. She always has someone-a relative, a friend, a casual acquaint­ance-who has never followed any special diet and ap­pears to be healthy. This model of good health provides the rationale for never making any serious attempt to change dietary habits. Further, this patient may be es­pecially vulnerable to negative folklore about high cal­cium foods, such as the association of milk with indiges­tion or "calcified arteries." These cultural prohibitions provide unassailable reasons for discounting professional dietary recommendations with complete confidence.

The "DO IT ALL" and "BUT SHE'S NEVER DONE IT" patients represent just two specific types of reactions that are diffucult to manage. In the development of a lifetime nutritional care plan, the nutrition educator must identify each patient' s response accurately and try to use that response to advantage.

ALTERNATIVES FOR IMPROVING PATIENT RESPONSIVENESS AND NUTRITIONAL OUTCOMES

Osteoporosis is a debilitating disease that presents major challenges to its victims in most arenas of everyday life. Health care providers, including nutrition educators, must

June 1991 123

help patients meet these challenges by providing indi­vidualized and reasonable interventions that optimize long-term compliance. Sporadic adherence to restricted diets or specialized exercise programs may undermine long-tenn success. Unless patients comply with dietary prescriptions consistently over time, nutritional coun­seling may become a wasted resource as weIl as a po­tential source of discouragement to patients.

Osteoporosis cannot be reversed by any known ther­apy, nutritional or otherwise. Most therapeutic measures are directed toward halting the progression of the con­dition and/or ameliorating its symptoms. Thus, dietary counseling for these patients must make specific ad just­ments with these considerations in mind. In this regard, two critical principles of care should be emphasized. First, long-term followup and periodic reevaluation of dietary needs are an essential component of osteoporosis management. This allows nutrition educators to be con­sistently supportive and flexible, as adaptations in dietary management may be necessary. Secondly, this long-term care needs to be provided by a nutritionist who functions as a member of an established osteoporosis care team. An invaluable supportive relationship is established be­tween a health care te am and the patient if contact be­tween the two can he consistently maintained. (Even if one or two members varies at a given follow up, conti­nuit y of care can he maintained if most te am members are unchanged and communication lines are unob­structed.) In this context, the relationship between pa­tient and team memhers can have strongly beneficial therapeutic influences (37).

But it is important to take the clinical approach to nutrition therapy one step further. We propose that the psychosocial needs of the patient and her life situation must be considered and incorporated into on-going treat­ment strategies (see Figure 1). The interaction between psychosocial well-being and manifestation of illness is weIl established (38, 39). In addition, the recognition of psychosocial strengths and weaknesses provides inpor­tant clues for effective structuring of dietary care plans. Thus the development of standard dietary guidelines also must take into account psychological and social concerns, as weIl as mental health status, coping style, and the stress of recent role changes. For example, depression, the prime mental health problem of the elderly (40, 41), may cause patients to overeat or to neglect the need to consume adequate food. If the nutrition educator is aware of the patient's mental health status, specific recom­mendations concerning ways to cope with these prob­lems can be made. Without this information, the poten­tial risk for malnutrition may never be recognized. Considerations of this type should be important modu­lators of the long-term management of these patients. Our experience suggests that the combination of adjust­ments for psychosocial needs with comprehensi"o'e med­ical and dietary therapies produces improvements in di-

124 BaIes & GoldiOSTEOPOROSIS PATIENTS

Medical and Functional Diet History

History • Food records • Current health • Food frequency • Drug history • Supplement use • Activity patterns • Energy requirements

"" Standard Dietary I~ Guidelines ..

Psychological Concerns -Social Concerns

and Mental Health and

Cognitive Status

Coping Style /

Health Care team for Osteoporosis ~---J

Role Changes

Long-term Follow-up and Evaluation

Comprehensive Nutritional Care

for Osteoporosis

Figure 1. Although dietary prescriptions are routinely adjusted for medical and diet histories, this model for the nutritional care of osteoporosis extends traditional considerations to encompass long-term care involving an integrated health care team and an emphasis on psychosocial concerns.

etary compliance (42), general affect, and optimism about the future (43). In the remainder of this paper, we pres­ent our suggestions for inclusion of psychosocial concerns in comprehensive nutritional care for osteoporosis.

Long-term evaluation and follow up. Nutrition edu­cators know that dietary counseling should include reg­ular followups, with periodic reinforcement of basic in­structions. Yet nutrition education in the clinical setting is often compressed into a small number of counseling sessions and sometimes into a single meeting. The rea­sons for these limitations are numerous and include poor planning by health care providers and limited insurance reimbursement for nutritional counseling. From the medical standpoint, current "treatment" regimens for osteoporosis focus on reduction of environmental risk factors and rely upon experimental therapies that may take years to produce measurable changes in the course of the disease. Nutritional recommendations that are not re-adjusted as treatment protocols change over time are not likely to be effective. It follows that clinical strategies with a strong nutrition component (e.g., calcium sup­plementation for estrogen-deprived patients) will be ad­versely affected unless continuity is maintained.

The preferable alternative is to provide consistent,

reliable dietary care over time. Followups to the initial assessment and counseling sessions allow the nutrition educator to develop a more comprehensive and individ­ualized set of guidelines for each patient. Integration of information from the medical, social, and psychological history aids in this process. Multiple contacts between nutritionist and patient permit reinforcement of rec­ommendations and modification of dietary goals as sit­uations (clinical and otherwise) change. Furthermore, the scheduling of regular return appointments encour­ages the introduction of increasingly complex nutrition concepts at each visit; it also allows the patient to apply new suggestions in small doses and thus improves dietary compliance (44).

The provision of long-term dietary care for osteopo­rosis patients is neither simple nor inexpensive, but it is crucial for the success of aIl aspects of the therapy for these individuals. Without this dependable cornerstone, other therapies may never be optimally effective.

Continuous care by a health care team. The chronic nature of osteoporosis requires that multiple dimensions of patient status be integrated and analyzed prior to the development of nutrition care plans. The nutrition ed­ucator must receive input from physicians, physical and

J. of Nutr. Educ. Vol. 23, No. 3

occupation al therapists, mental health clinicians, and other professionals in order to develop dietary recom­mendations that are realistic within the patient' s life con­text. Unfortunately, communication between health care providers is often limited and sometimes nonexistent. Time and resource constraints are ever-present, but the greater the number of different health care providers who refer patients to the nutritionist (e.g., 12 physicians versus three), the more difficult it will be for the nu tri­tionist to establish a strong working-relationship with the members of each associated group of health care pro­viders (38). This is one reason we so strongly advocate the establishment of a stable osteoporosis "health care team."

The team approach to health service provision is not new. This approach has been shown to function weIl in acute care settings. It is clearly more difficult to main tain a consistent care te am core over months and years of treatment. Moreover, this kind of te am must continue focusing upon a specialized chronic condition (osteopo­rosiS) as its members maintain long-term responsibility for medical management. This consideration becomes particularly important when co-morbidity complicates treatment regimens. Other chronic conditions common in older adults, including cardiovascular disease, arthri­tis, hypertension, pulmonary disease and diabetes, must be taken into account when prescriptions for diet, med­ications, and exercise therapy are considered. Other­wise, the basic components of osteoporosis therapy may be sacrificed. These problems are more likely to be over­come by an osteoporosis care team that also has expe­rience with other co-morbid conditions commonly as­sociated with aging.

In establishing an "ideal" treatment te am for osteo­porosis, we would suggest the following members: a phy­sician/endocrinologist, physical and occupational the ra­pists, social worker or clinical psychologist, and a nutritionist (Registered Dietitian). Consultants in related specialties such as rheumatology, radiology, gynecology, and geriatrics provide important complements to the core team.

When health care te am members work together on the same cases over time, the quality of care is enhanced by the combined experience of the team. Important de­tails are less likely to be missed, and each caregiver can construct a more detailed picture of the patient as an individual. For example, the physician and physical ther­apist can inform the nutritionist concerning the degree of limitation on functional ability due to in jury , pain, or medications. The development of a nutritional care plan for long-term use is much more likely to succeed when such supporting background information is available at the outset.

Thus, the interaction of health care team members promotes the development of a more informed and com­prehensive plan of treatment. Team members educate

June 1991 125

each other, establishing a more complete knowledge base, and allowing the exploration of new areas of need. In this way, complementary interactions of the care te am may enhance over-all compliance and medical outcomes.

Emphasis on psychosocial concerns. Although the im­portance of social and psychological considerations in the care of chronically ill patients has been weil documented (4, 29, 43, 45-47), the consistent use of a comprehensive psychosocial evaluation in the development of nutritional care plans is not common. This is unfortunate, because mental state can profoundly influence the type and amount of food intake. Those of us in clinical practice can easily recall examples. An elderly patient, once relatively com­pliant with dietary and pharmaceutical prescriptions, be­comes clinically depressed and loses aIl motivation to follow her therapy at home. Married to a man with ad­vanced cardiovascular disease, another patient is so con­cerned about preparing her husband's low cholesterol diet that she neglects her own dietary prescriptions. These problems can often be successfully addressed when ad­equate mental health resources are available.

The inclusion of a mental health professional in the health care team is thus highly recommended. This professional can provide necessary and appropriate psy­chosocial data to the nutritionist, as weIl as deal more directly with underlying causes of the specific problem. This is particularly effective when long-term followup allows periodic adjustment based upon both nutritional and psychosocial factors. When this opportunity is avail­able, the primary areas of psychosocial concern for the nutritionist should be (a) social factors, (b) role changes, (c) mental health and cognitive status, and (d) coping style. Specifie dimensions of each are discussed below:

a. Social factors. The nutrition educator must account for the age (and therefore the birth cohort) of the patient as dietary plans are prepared. Individuals from older cohorts have a strong sense of autonomy and may be likely to self-medicate or make self-determined ad just­ments in the nutrition protocol (31). Likewise, older women may be unresponsive to suggestions about changes in either cooking or eating habits. Although recommen­dations for nutritional change may improve the quality of dietary intake, the y may at the same time threaten long-established dietary patterns. This problem is fre­quently encountered, especially among older women whose social role is that of meal provider and family caregiver. Careful assessment of the patient' s social role, the size and density of social support networks, and al­ternative roles of the patient may permit the nutrition educator to be better prepared to help the patient reach a meaningful and nutritionally sound compromise. In­formation about social factors, such as concerns for the welfare of other family members, may reveal those sit­uations in which the patient feels that modification of

126 BaIes & Gold/OSTEOPOROSIS PATIENTS

her food intake may adversely affect other areas of her life. Counseling members of older cohorts clearly pro­vides a special challenge to the nutrition educator.

b. Role changes. Although familiarity with social his­tory broadens the nutrition educator's base ofknowledge about the patient, other are as of the patient' s daily life are equally important. The nutritionist should be aware of role changes that the patient is experiencing, such as the shift from employee to retiree or from married to widowed. Each role change can be problematic, espe­cially if it is unexpected. Major role changes can draw psychological attention away from the daily treatment protocol (48). Ali changes can have a profound effect on dietary compliance and general health-related behaviors. A period of noncompliance may be expected while a patient deals with an abrupt role change. Later, after the situation has become more familiar, readjustments in dietary practices can be made. The nutritionist who is aware of important role changes can continue to reinforce patient compliance without overemphasizing its rigidity and can modify future recommendations so that they blend with the patient's new role.

c. Mental health and cognitive status. The manner in which nutrition counseling is accepted and complied with may be influenced dramatically by the mental health and cognitive statuses of the patient. This is especially true for older adults who must cope with multiple physical problems, losses of social roles, and who may have mental health or cognitive deficits. An example noted earlier is depression, which can be transitory and situational or a long-term disorder (40, 41) and can have a potent effect on dietary intake in antithetical ways.

Those patients with cognitive limitations must be treated with special care. In these cases, the caregivers of memory-impaired older adults must assume most or ail of the responsibility for implementation of dietary recommendations. They need to be weil informed of the amounts of various nutrients required by the patient. In no way can the patient be he Id responsible for con­sumption of an adequate diet; thus, communication with responsible others must be frequent and effective (49).

d. Coping style. An addition al issue that must be rec­ognized and accounted for in the nutritional care plan is the coping style of the individual. Each person develops a set of coping mechanisms that are called forth when a stress such as osteoporosis exceeds regular coping abil­ities. Although coping strategies are dynamic rather th an static and may vary with the etiology and kind of stress encountered, it is also possible for patients to utilize similar approaches regardless of the source of the stress (36). Therefore, the nutritionist who recognizes the method of coping employed by a patient is in a much better position to offer relevant dietary counseling th an one who ignores this area. Coping tends to be focused

on two goals: problem solving and emotional palliation. Patients usually approach each of these goals with a dif­ferent style. For example, many chronically ill older adults rely on denial as a primary strategy in the early disease stages. DeniaI may transform into information seeking or direct action as time passes, but its initial presence must be recognized and considered (35). In such a case, the nutritionist may do weil to emphasize the benefit of the diet from the standpoint of general good health, rather th an trying to underscore its importance for osteoporosis management. Subsequently, information seeking and di­rect action must be gently channeled into appropriate directions and tempered by good advice. Sometimes pa­tients may "go overboard" in their attempts to solve their medical problems (as the "DO IT ALL" response, dis­cussed previously). It is the responsibility of the nutrition educator to detect these problems and attempt to re­focus the patient on reasonable dietary and medical reg­imens.

CONCLUSIONS

The nutritional needs of osteoporosis patients are deter­mined by the type of osteoporosis, the degree of asso­ciated pain and disability, co-morbid conditions, psy­chosocial factors and-to a lesser extent-the age of the incliviclual. As medical and technological management of chronic disease in the elderly becomes more sophisti­cated, the nutrition educator can capitalize on benefits from innovations in patient care. The ability to provide long-term followup allows the nutritionist to approach diet management in a step-wise manner and improve patient outcomes through increased compliance. Osteo­porosis care provided via a team approach offers a broad picture of the whole patient upon which nutrition coun­seling can be based. The recognition of the complex mental health and social factors that come into play in progressive chronic disease will enable the nutrition ed­ucator and other te am members to tailor successive rec­ommendations to the current needs and abilities of each patient. The net result will be improved patient satis­faction and compliance-and, ultimately, a significant improvement in the effectiveness of nutrition interven­tion for the chronically ill elderly. 0

ACKNOWLEDGMENTS

Partial support for this work was provided by grants from the National Institute on Aging (AG00420 and AG05462) and the American Federation for Aging Research. The authors express appreciation to Dr. Marc Drezner and to the Duke Preventive and Therapeutic Program for Osteoporosis.

NOTES AND REFERENCES

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DHHS Pub. No. (PHS) 88-1232. Hyattsville, MD: U.S. Depart­ment of Health and Human Services, Centers for Disease Control, 1988.

2 National Osteoporosis Foundation. Osteoporosis fact sheet, 1989. 3 Culliton, B.J. Osteoporosis reexamined: Complexity of bone biol­

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ment of osteoporosis: The psychological impact of a medical edu­cation program on older patients. Journal of the American Geri­atries Society 37:417-422, 1989.

5 Canary, J.J. Osteoporosis. In: Nutrition in the eider/y, D. M. Prins­ley and H.H. Sandstead, eds. New York: Alan R. Liss, Inc., 1989, pp. 167-193.

6 Pollitzer, W.S. andJ.J.B. Anderson. Ethnicandgeneticdiflerences in bone mass: A review with a hereditary vs environ mental per­spective. AmericanJournal ofClinical Nutrition 50:1244-1259, 1989.

7 Riggs, B. L. and L.J. Melton, III. Heterogeneity of involutional osteoporosis: Evidence for two distinct osteoporotic syndromes. American Journal of Medicine 75:899-901, 1983.

8 Wardlaw, G. The elIects of diet and life-stvle on bone mass in women. Journal of the American Dietetic Àssociation 88:17-25, 1988.

9 Johnston, C.C., Jr. Diagnosis and follow-up of patients with os­teoporosis. In: Current concepts of bone fragility, H.K. UhtholI, ed. Berlin: Springer-Verlag. 1985, pp. 61--66.

10 Riggs, M.L. and L.J. Melton, III, eds. Osteoporosis: Etiology, diagnosis, and management. New York: Raven Press, 1988.

11 Lindsay, R The role of estrogen in the development of osteopo­rosis. In: Osteoporosis: Program and abstracts, consensus deuel­opment conference. Bethesda: National Institutes of Health, pp. 59--61, 1984.

12 Hutchinson, T.A. and S. M. Polansky. Post-menopausaloestrogens protect against fractures ofhip and distal radius. Lancet 3:70~708, 1979.

13 Barzel, U. S. Estrogens in the prevention and treatment of osteo­porosis: A review. American Journal of Medicine 85:847-850, 1988.

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