Osteoporosis Prevention in

Adolescents
Group 3
Manager: Leila Shinn
Backgrounder: Melissa Raney
Identifier: Nol Konken
Evaluator: Nikki DeAngelis

Osteoporosis Prevention in Adolescents

Osteoporosis Prevention in Adolescents | [Pick the date]

Table of Contents

INTRODUCTION .................................................................................................................................... 3
IDENTIFIER
HOW?..................................................................................................................................................... 3
KEY WORDS & WHY?........................................................................................................................... 3
TOPIC CHOICES EXPLAINED ................................................................................................................ 4
CHOICE 1: CALCIUM INTAKE EDUCATION FOR ADOLESCENTS (AGES 12-18) ............................ 4
CHOICE 2: TYPE II DIABETES PREVENTION IN NATIVE AMERICANS .......................................... 4
CHOICE 3: FIBER INTAKE EDUCATION IN ADULTS ....................................................................... 4
PROGRAM OF CHOICE .......................................................................................................................... 5
RATIONALE ............................................................................................................................................ 5
GOALS AND OBJECTIVES ...................................................................................................................... 5
PROCESS EVALUATION ......................................................................................................................... 6
BACKGROUNDER
BACKGROUND INTRODUCTION .......................................................................................................... 7
PREVIOUS STUDIES ............................................................................................................................... 8
PROGRAM 1........................................................................................................................................ 8
PROGRAM 2........................................................................................................................................ 8
PROGRAM 3........................................................................................................................................ 8
PROGRAM 4........................................................................................................................................ 9
PROGRAM 5........................................................................................................................................ 9
PROGRAM 6...................................................................................................................................... 10
FINANCIAL PLANNING ........................................................................................................................ 10
SUPPLIES NEEDED........................................................................................................................... 10
PROJECTED COST............................................................................................................................ 10
APPLICATION OF STAGES OF CHANGE THEORY.............................................................................. 10
OVERVIEW OF STAGES OF CHANGE .............................................................................................. 11
STAGES OF CHANGE STUDY 1........................................................................................................ 11
STAGES OF CHANGE STUDY 2........................................................................................................ 11
STAGES OF CHANGE STUDY 3........................................................................................................ 11
STAGES OF CHANGE STUDY 4........................................................................................................ 12
EVALUATOR
KEY ISSUES OF IDENTIFIERS WORK ................................................................................................. 12
KEY ISSUES OF BACKGROUNDERS WORK ....................................................................................... 13
CRITIQUE OF BEST POINTS & LIMITATIONS .................................................................................... 13
EVALUATION OF PROJECT ................................................................................................................. 14
CONTENT SURVEY QUESTIONS ..................................................................................................... 14
OBJECTIVES AND EVALUATION OF OBJECTIVES ......................................................................... 15
BEHAVIOR THEORY ............................................................................................................................ 15
STAGES OF CHANGE SPECIFIC SURVEY QUESTIONS.................................................................... 15
RELIABILITY AND VALIDATION PROCESS ........................................................................................ 16

Osteoporosis Prevention in Adolescents | [Pick the date]

FACE AND CONTENT VALIDITY...................................................................................................... 17

CRITERION RELATED VALIDITY ..................................................................................................... 17
CONSTRUCT VALIDITY ................................................................................................................... 17
MANAGER
EXPLANATION OF PROPOSED PROGRAM.......................................................................................... 17
SESSIONS .............................................................................................................................................. 17
SESSION 1 ......................................................................................................................................... 18
SESSION 2 ......................................................................................................................................... 18
SESSION 3 ......................................................................................................................................... 18
SESSION 4 ......................................................................................................................................... 19
PROGRAM IMPLEMENTATION ............................................................................................................ 19
REFERENCES ........................................................................................................................................ 20

Introduction
The purpose of our program is to teach adolescent children (ages 12-18) about the
importance of nutrition and how it can affect their health. Specifically, our program focuses on
the importance of calcium in the prevention of osteoporosis. It will be implemented through
the school system in four 45-60 minute sessions, cover different topics, and implement the
Stages of Change Theory. In order to monitor the success of our program, we will utilize both a
pre-test before program implementation and a post-test three months after the program is
over.

Osteoporosis Prevention in Adolescents | [Pick the date]

How?

By utilizing the internet, I used google as my browser because, as the identifier, I was
looking for more broad-range information on the most publicized nutritional topics of
concern. To create a successful nutritional program, our group believed our topic should be
well-known amongst the general population; thus, I google searched, top nutritional concerns
in America and was given various credible organizations (such as the Center for Disease
Control and Prevention and The Mayo Clinic) top lists of trending nutritional issues in
America. Among many of the websites I was connected to, there was a common trend of type
2 diabetes, osteoporosis, and digestive disorders (such as constipation, diverticular disease,
and celiac disease). After singling out these three nutritional areas of concern, I further refined
my google search by researching the leading cause and influential target audience of type 2
diabetes, osteoporosis, and digestive disorders. I was satisfied by the use of the browser,
google, because other search engines, such as google scholar, tend to give more specific
research data on a targeted demographic or relationship I found this specificity unnecessary
within my role. Utilizing google allowed my research to be consistent with the general
population's accessibility and perception of nutrition. Also, google allowed me to see what our
program should address based on current concerns in the eye of the public.

Key Words & Why?

While utilizing google, the keywords I typed in were osteoporosis and calcium
because the relationship between consuming the recommended daily intake of calcium and
the development of osteoporosis go hand-in-hand as evidenced by University of Californias
research. It is stated calcium consumption throughout the lifespan is critical in optimizing
bone density and preventing osteoporosis. I also utilized the keywords, type 2 diabetes and
Native Americans because according to the American Diabetes Association, American
Indians and Alaskan natives have the highest risk for type 2 diabetes among all racial and
ethnic groups in the United States as evidenced by 16.1% of this targeted population currently
being diagnosed with the disease. Finally, in relevance to digestive disorders, the keywords I

searched were digestion and fiber because fiber benefits digestive health as evidenced by
Cornell Universitys study that fiber affects the rate of digestion of foods, the absorption of
nutrients, and the movement of waste products through the colon. Fiber also provides a
substrate for the beneficial intestinal bacteria.

Topic Choices Explained

Choice 1: Calcium Intake Education for A dolescents (Ages 12 -18)
Building up calcium stores in bones starts at the beginning stages of life; however,
calcium absorption remains at its maximal until the age of 24. As individuals grow older, little
to no calcium stores are created in the bones and may be the underlying cause as to why 1 in 3
postmenopausal women develop osteoporosis. According to NHANES statistical data, 30% of
men and 49% of women aged 50 or older have low femur bone density (osteopenia). WebMD
claims: the thicker your bones are at about the age of 30, the longer it takes to develop
osteopenia and osteoporosis. Because bone density cannot critically improve after age 30, it is
critical to target a younger population to educate them on the importance of calcium
consumption.

Type II diabetes prevalence is at a high for adults in the United States; however, there is
a specific population within our nation at an increased risk for developing the
disease. According to the CDC, American Indian and Alaskan native adults are two times more
likely to have diagnosed type II diabetes than non-Hispanic whites. From 1994-2004, Indian
and Alaskan natives chance of developing diabetes before the age of 35 has more than
doubled. Type II Diabetes is a life-long endocrine disorder with countless complications
associated with the disease: heart disease, blindness, amputations, and chronic kidney
failure. This target population is under represented in society and requires additional resources
to prevent type II diabetes diagnoses from increasing.
Choice 3: Fiber Intake E ducation in Adults
Fiber is an important component of a healthy diet; yet, many Americans are not getting
the recommended daily value. The USDA has set the recommended daily intake of fiber for
adult males and females at 38 g and 25 g respectively. According to NHANES nutritional data,
current fiber intake is considerably lower than the past with a daily consumption of US adults
at approximately 10-15 g per day. The benefits of fiber include increased bowel health, control
of blood sugar and cholesterol levels, and aids in weight management. Foods highest in fiber
include fruit, vegetables, whole grains, legumes, beans, nuts, and seeds. Diets low in fiber can
cause weight gain, constipation, and variable blood glucose levels.

Osteoporosis Prevention in Adolescents | [Pick the date]

Choice 2: Type II Diabetes Prevention in Native Americans

Program of Choice: Calcium intake education in Adolescents

Rationale: We chose to target US adolescents (ages 12-18) on calcium consumption
education based on the need to educate this specific age group. While calcium is a popular
topic for children, very few programs continue to stress the importance of calcium after a child
has stopped growing; however, during adolescence there is a 2-4 % increase in bone mineral
density such that by the end of adolescence bone mineral density should reach 90% of its peak.
Supporting evidence has proven adolescents that do not reach their peak bone mineral density
put themselves at risk of developing bone fractures and osteoporosis early in life. Overall, the
topic of calcium consumption affects every single adolescent in our nation. The American
Academy of Orthopedic Surgeons claims 10 million people have been diagnosed with
osteoporosis, 18 million people are at high risk of developing osteoporosis, and 34 million
Americans are at risk for osteopenia. The money that could be saved in health care with
preventative measures taken on osteoporosis is expansive. According to NBCI, the average
annual cost for an osteoporosis patient with a fracture is $8,600, and $500 for non-fractured
osteoporosis patients. Overall, by improving bone density in adolescence, we can prevent the
prevalence of osteoporosis nation-wide.

Goals and Objectives

Osteoporosis Prevention in Adolescents | [Pick the date]

The goals and objectives of our program are to have participants:

1) Identify calcium rich foods that include plant and dairy products
2) Increase the consumption of calcium rich foods in adolescents by aiming for one
serving of calcium rich foods at 2 meals each day (for a total of at least 2 calcium
rich foods)
3) Identify why calcium is an important mineral to consume at a young age

Focusing on these three goals, we hope to see our participants 1) progress through
stages of change with favorable results, 2) gain knowledge and interest in preventative
nutrition, and 3) appreciate the positive effects of physical activity on health and longevity. Our
program will inspire participants to begin consuming adequate amounts of calcium rich foods
to reach the FDAs recommended daily intake for boys and girls in our target age range (1,300
mg of calcium). According to Mediscapes research data, the current average intake of calcium
for adolescents in the United States falls below this recommended amount; thus, our program
intends to utilize the stages of change behavioral theory to adapt our participants attitudes on
calcium intake. We chose to utilize the stages of change model because our participants will be
adapting a new behavior that is related to food intake. The stages of change model is superior
to the Theory of Planned Behavior because, although this theory can be applied to food intake,
it is most successful with a one-food focus. Our program not only aims to increase the
consumption of milk-- but identify and increase the consumption of various calcium-rich
foods. Likewise, we neglected to use the Social Cognitive Theory because we intend to focus
our program more on the behavioral change of consuming more calcium as opposed to the
environmental aspect of the behavior. Milk, and other calcium-rich items, are easily accessible

Utilizing the stages of change model, we can transition adolescence from the precontemplation phase to the action and maintenance stage through educational lessons and
social support. Most adolescents would fall into the pre-contemplation stage because the
perceived severity of developing osteoporosis seems a distant concern to many young
adults. In a 2009 research study through the University of Alabama, college-age study
participants were asked to complete osteoporosis health belief scales, osteoporosis knowledge
tests, and osteoporosis self-efficacy scales. The results of these questionnaires showed
participants did not find themselves susceptible to development of osteoporosis and perceived
minimal barriers to physical activity and calcium intake. If college-age individuals see limited
susceptibility to the development of osteoporosis, it can be inferred even younger individuals
are the same. As a result, the stress of the program will initially be on awareness. To increase
awareness of calcium consumption and osteoporosis susceptibility, the beginning lessons will
include personal surveys where participants will be able to evaluate their current calcium
intake through a food frequency questionnaire, target the severity of osteoporosis utilizing
educational video clips, and reveal low-bone density visual aids. The program will also use
similar tools to describe how calcium absorption is most optimal at the participants current
age. By increasing the awareness of calcium absorption and the importance of reaching
optimal bone density in adolescence, we can prompt our program participants to contemplate
the pros and cons of increasing calcium intake. Our program educators will discuss how the
benefits of adequate calcium consumption outweighs the negatives and provide the needed
tools to prepare individuals to perform the action through interactive learning via games, visual
demonstrations, and peer discussion. To assure our program participants are moving forward
through the stages of change, monitoring measures will be collected upon the ending of each
lesson rating the participants self-efficacy to adapt the behaviors brought before them and
allowing space for comments and concerns. Finally, the program will continue to support its
participants through the action and maintenance stages of change by providing healthy
incentives and supportive messaging to promote the newly adapted lifestyle behavior.

Process Evaluation
Evaluation is an essential component of our program in improving the programs
future, demonstrating its usefulness, and documentation of our impact. We intend to evaluate
our program utilizing process evaluation throughout the program. Through process
evaluation, we can determine whether our program is reaching our target population of
adolescents, and how effectively our plans, activities, and materials are at changing calcium
consumption behavior. By the end, using this method, we should be able to determine if the
overall education program is excelling as we have intended.
Primarily focusing on the programs activities and reach, in monitoring the participants
satisfaction of the activities delivered, the program implementer will document

Osteoporosis Prevention in Adolescents | [Pick the date]

in our target schools and often offered at a low-cost; thus, it is the attitude of the behavior we
intend to focus on.

participation. If participants are actively engaged throughout the activities-- collaborating

with their peers, and sharing insightful thoughts throughout the process, we will consider
satisfaction to be high. If the program facilitator is not receiving feedback from the
participants and the activities drag in silence, satisfaction will be considered low. Additionally,
we can evaluate the reach of the program by stating how many adolescent students we have
educated throughout the program and determine if this classroom age was appropriate with
the programs educational content, materials used, and games or activities
administered. Again, age-appropriateness can be based off the documented participation by
the program facilitator. High participation denotes materials and activities were accurately
reflective to our target audience and age whereas low participation could be a result of too
challenging or easy of program content.

Osteoporosis Prevention in Adolescents | [Pick the date]

To add, utilizing process evaluation, we can assess the delivery methods of education
by surveying participants on their satisfaction on the use of supplemental materials, multimedia resources, and discussion-based learning. Such surveys could be delivered at the
conclusion of each lesson and give a base rating. Utilizing a survey to document our
participants average attitudes on each individual lesson will allow us to make needed changes
to future lessons throughout the program process, and provide us with helpful tools to revise
program implementation after conclusion of the administration. A final survey after the
program completion would be an important process evaluative measure to discover the
receptivity of our audience and their final thoughts on the program as a whole from the
facilities used to the program facilitators effectiveness of communication.

Finally, using process evaluation, we will monitor management of the program by

documenting perceived versus actual costs of the program and whether the budget was
maintained. The program would also appreciate feedback from the program educators on
whether they felt adequate training was delivered, how management was administered, and if
they believed communication to be effective with knowing what was expected, given program
dates well in advance, and reasonable deadlines for projects.
Overall, merely looking at the outcomes of changed knowledge and behavior of calcium is not
enough. By evaluating each aspect of the process to its entirety, we can refine where our
weaknesses lied to reaching our objectives.

Background Introduction
It is important to identify the strengths and weaknesses of a program based on previous
similar programs. One factor to take into consideration when planning a program is if the
programs benefits are worth the financial costs. It is also important to identify how the
learning theory will affect the implementation of the program. In this section, we will outline
previous studies conducted, elements of financial planning, and how the Stages of Change
affects health-focused learning.

Previous Studies
Program 1
Stear SJ, Prentice A, Jones SC, Cole TJ. Effect of a calcium and exercise intervention on the
bone mineral status of 1618-y-old adolescent girls. The American Journal of Clinical Nutrition.
2003;77(4):985-992.
This study was conducted on high school aged girls and lasted 16 months. The subjects
were given calcium supplements and encouraged to attend a 45 minute exercise class three
times a week. The results improved bone mineral content. Based on the study, this was a short
term improvement, and there is no telling if bone content will improve or be maintained by
these girls in the future.
This form of intervention is not something ideal for our group to do. The pre and post
assessment involved bone density scans, something that requires time, consent, money and
equipment. The study was also very time and labor intensive.
Program 2

Out of 195 women, half of them were selected to be a part of the intervention group,
which watched an educational movie regarding osteoporosis prevention. The other half
functioned as the control group and did not see the educational movie, but proceeded as
normal and visited their physician. Three months later a test was sent to all the participants.
Those in the intervention scored an average of 92%, whereas the control group scored an
average of 80%. The test showed that more women from the intervention group had started to
take calcium vitamins or exercise more. This is a good program, but could be done more in
depth than just using a movie. A more interactive program may engage the women more and
help them learn more, even if it comes at a higher cost.
Our group could recreate this idea by offering a hands-on activity to kids and
determining if the activities and education changes their knowledge and choices regarding
calcium.
Program 3
Sedlak CA, Doheny MO, Jones SL. Osteoporosis education programs: Changing knowledge
and behaviors. Public Health Nursing. 2000;17(5):398-402.
This article review three educational programs regarding osteoporosis prevention
among women. Educational programs were designed around the audiences needs and the

Osteoporosis Prevention in Adolescents | [Pick the date]

Kulp JL, Rane S, Bachmann G. Impact of preventive osteoporosis education on patient

behavior: Immediate and 3-month follow-up. Menopause. 2004;11(1).

Health Belief Model. A survey was collected before the education intervention. Three weeks
after the intervention surveys were sent to the women. All expressed having a greater
knowledge regarding osteoporosis, but very few had made any lifestyle changes to prevent
osteoporosis. This program was not successful in disease prevention, and should be redesigned
so that women feel both educated and the desire to change their lifestyle.
Although this study proves to not be useful, it is important to note that people are not always
interested in osteoporosis education or lifestyle changes. Kids may feel this way, and it will be
very important for us to appeal to kids.
Program 4
Winzenberg TM, Oldenburg B, Frendin S, De Wit L, Jones G. A mother-based intervention trial
for osteoporosis prevention in children. Prev Med. 2006;42(1):21-26.
This study proves that the more mothers know about calcium, the more likely are
mothers to give it to their children. Also, the more mothers know, the more changes they
make to their own lifestyle as well as their children. Mothers reported serving more calcium to
their whole families as well as getting their children involved in exercise with them. Mothers
were received a pre-assessment, education, and then assessments at the one and two year
mark.
This study brings up the point of the gatekeeper. It is important to keep in mind who
will do the grocery shopping and the food prep for kids, and that is often times the mother.
Although we plan on educating kids, it is important to remember to keep the whole family
involved.

Osteoporosis Prevention in Adolescents | [Pick the date]

Program 5

D Damore, L Robbins, T Karl. The Effects of an Educational Program on the Calcium Intake of
Junior High School Students. The Internet Journal of Pediatrics and Neonatology. 2006 Volume
6 Number 2.
A group of 8th grade students participated in an education intervention regarding
calcium intake, while a group of 7th grade students served as a control group. All students were
asked to keep diaries regarding calcium intake, but only the 8th grade class received lessons
calcium during their health class. There were two lessons, each forty minutes long. Very few
students in either group added a significant amount of calcium to their diets, nor did they
continue to increase their calcium intake after the intervention. The research declared that the
program had little impact on the students. The program was limited because it relied on
student kept diaries, which were sometimes not completed. However, student kept diaries
were honest, and the best and most inexpensive way to collect results from this study.
This is very similar to what we will be doing in our program. Considering the age
groups, this is a very reasonable design.

Program 6
Larson NI, Neumark-Sztainer D, Harnack L, Wall M, Story M, Eisenberg ME. Calcium and dairy
intake: Longitudinal trends during the transition to young adulthood and correlates of calcium
intake. Journal of Nutrition Education and Behavior. ;41(4):254-260.
This final program was designed to determine if educational intervention is beneficial
for young adults. A group of high school freshmen were selected to keep a food diary for 5
years to determine how much calcium they consumed. Both males and females drank less milk
and consumed less calcium as the study went on. The results show that calcium education
should be implemented into more health programs as they encourage young adults to increase
their intake, as well as reduce their risk for osteoporosis. This study was very long and labor
intensive, both for the researchers and the students.
The study is far too long for us to reasonably conduct, but the idea behind it is good. Even
following the students for a year would be a good time span.

Financial Planning
Supplies Needed
Handouts for education
Other materials for education (books, movies)
Diaries for the students records
Pre and post exams
Samples of different sources of calcium

Projected Cost
Assuming we are educating the students as volunteers and are not requiring
compensation, this program will be relatively inexpensive and only cost approximately $150 for
educational material and handouts.

Application of Stages of Change Theory

In order to effectively implement this intervention and yield positive and successful
results, the program must be designed in the guidelines of a certain learning behavior. Most
appropriate for this age group and also for our goals and general program design is the
learning theory known as Stages of Change. See the segment of this paper labeled Behavior
Theory for a further explanation regarding details about the Stages of Change learning
theory.

Osteoporosis Prevention in Adolescents | [Pick the date]

10

Overview of Stages of Change

Research shows that the Stages of Change theory is effective in producing positive
changes. Stages of Change often results in a change of behavior and habit, which is what our
intervention aims to do. The Stages of Change include pre-contemplation, contemplation,
preparation, action, maintenance and relapse, which we hope to avoid. Through education, we
hope to assist students through their Stages of Change and help them achieve a healthier level
of calcium intake to prevent osteoporosis.
Stages of Change Study 1
Whitelaw S, Baldwin S, Bunton R, Flynn D. The status of evidence and outcomes in stages of
change research. Health Education Research. 2000;15(6):707-718.
It is important to remember that not every participant and every educator will respond
to the Stages of Change in the same way. Although the Stages of Change theory has been
proven to overall be successful in health, it is important to consider each audience on a unique
and personal level. If the Stages of Change do not seem to be working for a participant, or even
the educators themselves, it is important to change to a different learning theory so that both
parties can benefit and make improvements.
Stages of Change Study 2

Osteoporosis Prevention in Adolescents | [Pick the date]

Zimmerman GL, Olsen CG, Bosworth MF. A stages of change approach to helping patients
change behavior. Am Fam Physician. 2000 Mar 1;61(5):1409-16.

11

Identified in this study is the importance of understanding the persons readiness to

change. Important tools to use include a Readiness Ruler and an Agenda Setting Chart. It is
also crucial for the educator to accept the fact that barriers exist, and know that relapses may
happen. The educator needs to slow to meet the persons readiness to change and help them
move forward.
Stages of Change Study 3
Hampton B, Brinberg D, Peter P, Corus C. Integrating the Unified Theory and Stages of Change
to Create Targeted Health Messages. Journal Of Applied Social Psychology. February
2009;39(2):449-471.
This study was designed to change the way that people approach dietary choices,
specifically fat consumption, by helping to move them through the Stages of Change. The
most influential stage that provided that greatest amount of activity and interest was the pre-

contemplative stage. Interest in making changes peaked, but then tapered back down as they
moved through the remaining stages.
Stages of Change Study 4
Molaison E, Ldn. Stages of Change in Clinical Nutrition Practice. Nutrition In Clinical Care.
September 2002;5(5):251-257.
The Stages of Change were directly applied to nutrition choices in this study. This
theory was the most successful when each stage of change was separated and had a welldefined objective. It was also very important for stages to be personalized for the audience, or
even each individual if possible.

Key Issues of Identifiers Work

The reasoning as to why this program would be beneficial for adolescents/teens/young

adults as opposed to adults was made very clear. Since calcium is maximally absorbed only
until early adulthood, educating this younger demographic would be more appropriate to
prevent bone density complications in the future. The Identifier stated that 1 in 3
postmenopausal women develop osteoporosis, so appropriate calcium intake in adolescents is
definitely a prevalent issue. NHANES data was referenced for men and women aged 50 and
over, but we still need to include both national and community data for calcium intake in our
target audience. Since we are focusing on ages 12-18 for our program, we should reference the
data for this age range.
The rationale as to why calcium education was given priority among other topics is
thorough and backed up by data. We prioritized by considering the prevalence of diabetes
prevention programs and resources already available to the public. Most people are aware of
the growing prevalence of obesity and T2DM, but low bone density and its correlation to
fractures and long term hospitalization is overlooked. Osteoporosis is a prevalent and chronic
condition. It is an expensive condition to have since it often leads to more health complications
(hip fractures surgeries infections). Once bone density is low, there are limited options as
to the type of treatments or therapies to undergo. Adequate calcium intake during
adolescence and young adulthood is key for prevention of osteoporosis.

Osteoporosis Prevention in Adolescents | [Pick the date]

I think the Identifiers search covered some of the key issues for adolescents, but
focused mostly on calcium. I think that as a group we immediately focused in on calcium so this
might have put us at a disadvantage when considering other key nutrition issues for
adolescents. Additionally, our initial desire to develop a program for adolescents also held us
back from really digging into nutrition topics for everyone. However, I do believe our specific
topic is a strength of the identifiers work because she knew exactly which type of data to pull
up. We have an in depth report of statistics relating to bone health, osteoporosis, and expenses
of osteoporosis. A limitation of the identifiers work was the lack of data specific to adolescents.

12

After evaluating this needs assessment, I believe that it would be worth it for children
to attend this educational program. Calcium education is the appropriate choice over Type II
Diabetes prevention and Increased Fiber Intake Education. While the latter two topics are
important, calcium is often an overlooked nutrient that needs to be emphasized more in a
childs diet.
As we continue to develop this program, we need to establish the goals and objectives
of what we want the target audience to learn.

Key Issues of Backgrounders Work

There is not much published research or many established programs that target
adolescents/young adults. I recommend that the backgrounder utilizes additional resources to
find studies pertinent to adolescents. Many of the studies evaluated the impact of osteoporosis
prevention programs on post-menopausal women. Most of the studies included pre and post
program surveys or tests to assess their attitude and knowledge about the importance of
adequate calcium intake. The Health Belief Model is a common theory used in these education
programs, so we will consider this model as we contemplate a theory to use in our program.

Osteoporosis Prevention in Adolescents | [Pick the date]

The Backgrounder did find one program titled, The Effects of an Educational Program
on the Calcium Intake of Junior High Students. This is a great article to reference because the
results did not consistently show a significantly increase in calcium intake before and after the
program. We can evaluate their methods to determine what did and did not work for their
specific program. This evaluation will establish areas of concern and improvement in educating
junior high students, and we can specifically focus on these past limitations.

13

Some of the key issues that we can learn from this past study is that they did not
emphasize the future consequences of not building up a strong bone density at a young age.
The other program highlighted health benefits of calcium that kids mostly know, like strong
bones and teeth and that dairy is a good sources of calcium. We want to make the kids aware
(but not scare them) that calcium is a mineral that can affect your long term well-being. We
also want to emphasize plant sources of calcium so the adolescents are more educated and
inclined to eat vegetables and legumes.

Critique of Best Points & Limitations

The purpose of our project is to provide nutrition education to adolescents. The
nutrition education will focus on consuming adequate calcium to maximize bone density since
they are in the age range when calcium absorption is maximized. We also want to include the
consequences of inadequate bone density as you age (i.e. fractures, osteopenia, and
osteoporosis). The education will be delivered in schools.

There are several strengths, or best points, that our program includes. First, calcium is a
nutrient that can easily be included 2-3 times a day in an adolescents diet. We want to
emphasize that dairy is not the only source of calcium, and can be obtained through plant
sources as well. Another strength is that we can use schools as our education medium, so we
have a very controlled age groups that we can take note of in our program data. However,
teaching in schools may also be a limitation because the adolescents do not voluntarily elect to
attend our program. If it were held at a community center, for example, the adolescents who
attended would have elected to attend by their free will. Because of this, the students may not
take our program as seriously. Another limitation is that many adolescents are not concerned
about bone density because 1) its not a tangible health benefit and 2) low bone density will not
affect them in their near future. We will do our best to address this limitation by emphasizing
that fractures can even happen to young adults with low bone density and very active. Another
limitation is that it will be difficult to monitor behavior changes via our Stages of Change
model because the program is only 4 sessions long.

Evaluation of Project

Content Survey Questions

We plan on enacting several measures to evaluate the effectiveness of our program. First,
we will administer both a pre and post test to determine if our audience retained the
information and to see if they changed their eating and exercise habits as a result of the
education (summative evaluation). The questions will have a ranking-style answering system.
For example a question could be, circle a number based on your likeliness to drink milk 2
meals of the day and then have numbers 1-5 available to circle. A style like this is easy for
students to answer and does not require them to write long responses, which is likely
something they are not interested in doing. Some additional survey questions we want to
include in both the pre and post survey are:
1. How many servings of dairy do you eat daily?
2. How many times a week do you eat broccoli, spinach, or collard greens?
3. Do you drink milk with lunch?
4. Do you consume yogurt or cheese on a regular basis?

Osteoporosis Prevention in Adolescents | [Pick the date]

The evaluation of our program will be conducted through participant surveys. Before
we begin our program, we want to use both quantitative and qualitative means of formative
evaluation. The quantitative evaluation comes from the data collected by the Identifier in
relation to the prevalence of osteoporosis and health care costs associated with it. We can also
administer food frequency questionnaires to a focus group to obtain preliminary data
regarding adolescents calcium consumption. We will qualitatively conduct personal interviews
and focus groups in order to gather our own information about the attitudes of adolescents
toward calcium foods and current eating habits. Understanding adolescents thought process
toward consuming certain foods can help us tailor our program to be more effective.

14

These questions will give us a better idea of current eating habits (pre-survey) and then
how they have changed after the program (seen in post-survey responses). Changes in
behavior will be seen by evaluating the responses the Stages of Change specific questions (as
shown below).A food frequency questionnaire will also be helpful in gathering data about how
many times per week specific foods are consumed by our target population.
Objectives and Evaluation of Objectives

Osteoporosis Prevention in Adolescents | [Pick the date]

We set 3 objectives for our program:

1) Identify calcium rich foods that include plant products as well as dairy products
o Evaluation of objective: This is a good objective because the first step to
consuming more calcium in the diet is being able to identify which foods have it.
2) Aim for a serving of a calcium rich foods at 2 meals each day.
o Evaluation of objective: This is a realistic objective to set for our target audience.
At almost every school, milk is offered as a drink option at lunch. Yogurt is a very
commonly eaten food. The difficulty is getting the adolescents to incorporate
calcium in the form of vegetables, but I believe our program can provide tips and
guidelines to make this goal attainable. In addition, many foods or beverages,
like orange juice, are fortified with calcium. This makes finding a commonly
consumed source of calcium a little easier.
3) Identify why calcium is an important mineral to consume at a young age.
o Evaluation of objective: This is a very broad objective. It can be made more
specific by saying, Identify why calcium is important for preventing fractures
damage to bone in the later years of life.

15

Behavior Theory
The behavior theory that we chose to use for our program is the Stages of Change
theory. This is a good model to use because it describes how people acquire a positive
behavior, in our case regularly consuming calcium rich foods. We have to make our audience
be concerned about the need for change and convince them that the change is in their best
interest. After we do this, we will deliver the plan of action to them through our series of
education classes. We plan on developing education handouts that will help our participants
maintain their action phase and prevent falling into relapse. These handouts will include a
calcium-rich shopping list for their parent (or whoever does the shopping in the house) as
well as a list of calcium-rich snacks for the adolescent to become familiar with. Developing a
newsletter or handout for the parent as well is a good idea because the adolescent is mostly
likely not the one going to the store and buying groceries. We can also use this program as an
opportunity to encourage the adolescents to accompany their parent to the store to become
more involved in the food-to-table process.
Stages of Change Specific Survey Questions

These questions will allow us to track their progress through SOC. In the pre-test survey, we
can probably expect low scoring as to the perceived importance of calcium or knowledge of
calcium rich foods. Many of the participants will be in the pre-contemplation stage because
they many either think they get enough calcium or it is not a nutrient of concern to them. Our
early lessons will push them into the contemplation stage when we raise awareness of the
importance of calcium in the diet and the future, severe consequences of inadequate intake.
The subsequent class will focus on the preparation stage. We will educate them on how to
include more calcium in their diet and which foods are calcium rich. Once they realized what
foods are rich in calcium, they may feel more empowered and able to regularly include them in
their diets. The post-test survey will be administered when the participants are in the action
and maintenance stage (third or fourth session). At this point, we hope to see survey responses
with higher ratings pertaining to the confidence to include more calcium foods in their diet.
This is a shorter program (only 4 sessions), so we will be limited in observing their maintenance
for an extended period of time to prevent relapse and offer support.
In addition to these questions to track progress through SOC, we will use a food diary to
track the maintenance stage of adequate calcium intake. We can observe participants
adherence to the objectives we set forth (defined above).

Reliability and Validation Process

Osteoporosis Prevention in Adolescents | [Pick the date]

The questions that we will use to evaluate our participants progress through SOC need to ask
about their attitude and opinion of changing their behavior. We need to be able to track their
progress through the pre-contemplation, contemplation, preparation, action, and
maintenance stages. The following questions will be included on the pre and post-test to
monitor their movement through the stages (answer options will be horizontal semantic scale
with 2 anchors):
1. How likely are you to exercise 5 or more days per week?
2. Do you believe you consume enough calcium on a daily basis?
3. How serious do you believe the health consequences of inadequate calcium
consumption to be?
4. How confident are you that you can include a serving of dairy at breakfast?
5. How confident are you that you can include 2-3 servings of calcium rich foods per day in
your diet?
6. How likely are you to be involved in preparing your own meal or snack?
7. Are you willing to drink low or fat-free white milk in place of chocolate milk once per
week?
8. Do you believe that low bone density is a factor of health to be aware of at this point in
your life?

16

Face and content validity will be evaluated by presenting a draft of the program outline
to university professors who study behavior theory and nutrition. We will also run it by the
grade school teachers who interact with adolescents on a daily basis and are familiar with
different learning styles. We will also submit our pre and post surveys to these reviewers to get
feedback and take into consideration their suggestions for change.

Osteoporosis Prevention in Adolescents | [Pick the date]

Criterion related validity will examine whether survey responses reflect a certain set of
abilities. In our case, these abilities are the knowledge gained and behavior changes in regard
to calcium consumption. We dont have a standard to compare the pre and post survey
responses to. We could do a pilot study using adolescents who have received the educational
program and plot their survey responses versus a group that has not gone through our
program. We would expect the survey scores of the educated group to indicate behavior
change and knowledge gained about calcium. We would expect the group that only received
the surveys to not have scores that indicate change. Having a standard to compare pre and
post survey data to ensures that our surveys are actually measuring change related to going
through our program.

17

Construct validity refers to the degree to which a test or other measure assesses the
underlying theoretical construct it is supposed to measure. In other words, we have to
determine if our surveys are actually measuring behavior change in regards to calcium
consumption. In order to ensure construct validity and apply it to our program, we have to
make sure the readability and literacy of the surveys is at an appropriate level for our
adolescent target audience. They have to be able to comprehend the questions being asked in
order to reply with honest and valid data. It is important to note that construct validity is a
continuous process of evaluation, reevaluation, refinement, and development. If we are not
getting the data from our pre and post surveys indicating favorable behavioral change after our
program, we need to take a step back and reassess both our teaching methods and survey
design.

Explanation of Proposed Program

We looked at 6 programs covering our topic in populations of all ages and genders. In
reviewing these programs, we have determined that in order to make an impact, our program
will require both a pre- and post-test, nutrition education, audience interaction, and need to be
long enough to provide detailed education (or at least be time-intensive), but not so long that
the program becomes a chore.

Sessions

After looking at the two programs done with our age group of interest, we believe that
students need an incentive in order to care about making lifestyle changes. Therefore, our
program will be 1 month long with a total of four 45-60 minute sessions to accommodate class
time. The sessions will proceed as followed:

Session 2
Lecture: Movie on Osteoporosis
Activity: Handout: Informative Fact Sheet on Osteoporosis
Component of Stages of Change Theory: The movie and information sheet on
osteoporosis will move the participants into the contemplation stage, if the previous
session hadnt already. The information provided on osteoporosis will allow participants
to perform a risk/reward analysis and contemplate the pros and cons of changing their
current lifestyle in order to prevent osteoporosis and other diseases in the future.
Hopefully, they will realize that the pros outweigh the cons and begin to prepare to
take action against developing osteoporosis.
Session

3
Lecture: The Importance of Calcium in the Diet
Activity: Identifying Calcium Rich Foods
Handout: Examples of Calcium Rich Foods
Component of Stages of Change Theory: The lecture, activity, and handout in this
session will encourage participants to move into the preparation stage. By being
made aware of calcium rich foods and how easily they can be implemented into
ones diet, they will be comfortable and willing to commit to taking action. By being
able to identify calcium rich foods, participants will be able to create a plan of how
to implement these foods into their diets by realizing that these foods are easily

Osteoporosis Prevention in Adolescents | [Pick the date]

Session 1
Lecture: Reading Food Labels
Activity: Pre-test and Food Frequency Questionnaire
Handout: Food Logs
Component of Stages of Change Theory: At this point, participants will be in the precontemplation stage of SOC. However, the lecture, pre-test, and process of filling out
food logs should cause them to become more aware of the importance of nutrition and
how they may potentially need to change their behaviors. By learning how to properly
read a nutrition label, having their current knowledge assessed and reflecting back on
their food log, they will hopefully begin to seriously consider ways that they can
improve their lifestyle through nutrition.

18

accessible and may already be part of their diet. This stage will give them the
information they need to create an action plan by the next session.
Session

4
Lecture: The Importance of Physical Activity
Activity: Exercise Stations
Handout: Exercise Examples
Component of Stages of Change Theory: At this point, participants will already be
implementing calcium rich foods into their diet based on the education they
received from past sessions and recording their intake in a food log. Along with
that, they will literally be entering the action stage as they partake in physical
activity. By seeing the variety of exercises they can participate in, they will realize
how fun and easy it is to implement physical activity into their lives and make both
physical activity and a healthy diet part of their lifestyle, if they havent already
done so.

Program Implementation

Osteoporosis Prevention in Adolescents | [Pick the date]

A post-test will be distributed through the school 3 months after the last session to
determine how effective the program was and to test if participants have entered the
maintenance stage or relapsed. We determined the length of our program and sessions to be
appropriate as programs done within this age group were not effective in a 5 year time span or
in a 2 session time span and in order to accommodate schools willingness to take part in our
program it needs to be short enough to not interfere too much with teachers lesson plans as
we would expect teachers to give up class time in order to implement our program.

19

It is crucial that the students schools are willing to implement this program as we will
need them to provide incentive for the students (grades based on participation) and space use
(Session 1 after school at the prospective school, Session 2 and 3 during health class, Session 4
during gym class ). Sessions will be held during class as the topic is applicable to subjects like
health and physical education. Teachers will be responsible for leading the sessions, therefore,
appropriate training will be required. During our program, students will be responsible for
keeping food logs and receive credit in their prospective health/gym class for doing so.
Sessions will be taught by a variety of educators (Session 1 and 3 by a dietitian, Session 2 held
during health class led by health teacher, Session 4 by gym teacher).
Our program will utilize the Stages of Change Theory and importance will be expressed
to students and prospective schools by informing them of the costs that come along with the
development of osteoporosis and statistics (30% of men and 49% of women 50 and older
develop osteopenia).

References

Osteoporosis Prevention in Adolescents | [Pick the date]

References in backgrounders section (pages 7-11)

20