Planning for bone health and fracture prevention

Planning for bone health and fracture prevention A Workbook for Regional Health Boards Prepared by the Bone Health and Fracture Prevention Committee October, 2001 Ministry of Health Services Women s Health Bureau

The Women s Health Bureau would like to thank the following people for their contributions to this workbook: Dr. Penny Ballem, Kate Ballem, Dr. Marcia Hills, Dr. Elizabeth Whynot, Tara Bambrick and the Bone Health and Fracture Prevention Steering Committee. Copies of this document are available from the Women s Health Bureau B.C. Ministry of Health Services 5-2, 1515 Blanshard Street Victoria B.C. V8W 1X4 Telephone: (250) 952-2256 Fax: (250) 952-2205 This document is also available on the Ministry of Health Services web site: http://www.healthservices.gov.bc.ca/whb/ National Library of Canada Cataloguing in Publication Data Main entry under title: Planning for bone health and fracture prevention Available on the Internet. Includes bibliographical references: p. ISBN 0-7726-4644-9 1. Osteoporosis - British Columbia - Prevention. 2. Osteoporosis - Prevention. 3. Fractures - Prevention. 4. Falls (Accidents) Prevention. 5. Bones. I. British Columbia. Bone Health and Fracture Prevention Steering Committee. II. British Columbia. Ministry of Health Services. RA645.O75P62 2001 614.5 9716 C2001-960270-7

Preface This document is a companion document to A Provincial Strategy for Bone Health and Fracture Prevention: Recommendations of the Bone Health and Fracture Prevention Steering Committee (January 2001). Together these documents provide a Provincial Bone Health and Fracture Prevention Strategy as well as some tools for implementing this strategy at the local health authority level. These documents are the result of a multi-sectoral stakeholder committee the Bone Health and Fracture Prevention Steering Committee that was chaired by Dr. Penny Ballem. This committee was an outcome of on-going work by the Women s Health Bureau, Ministry of Health Services, to ensure that women receive appropriate and effective bone health care. The impetus behind the formation of this committee and the work of the Women s Health Bureau was the result of a 1997 research study by the BC Office of Health Technology Assessment which found that bone mineral density testing is not a good predictor of who will go on to fracture the primary complication of osteoporosis. If women could not rely on this test to tell them about their future risk of fracture, it became vitally important to find out what health professionals could do to help women develop optimal bone health, maintain existing bone health, and protect their bones from fracture. It was recognized that healthy bones is vital resource and that preventing diseases such as osteoporosis means taking a big picture view. This means reviewing lifestyle, medications, and one s environment. It is hoped that this workbook, in conjunction with the Provincial Strategy, will enable community planners, health authorities, and concerned health professionals develop community-based programs and educational initiatives to assist women and men of British Columbia achieve the healthiest bones possible.

Table of Contents Introduction............................................................ 1 Getting Your Numbers Straight.............................. 2 Did You Know? Facts About Bone Health Fractures Can Be Prevented Social Determinants of Bone Health...................... 4 Physical Activity...................................................... 5 Fall Prevention........................................................ 6 Medical................................................................... 9 In the Regional Context: Making Sense of the Data................................... 10 Physical Activity Fall and Fracture Prevention Medical Issues In the Regional Context: Mapping Your Strengths...................................... 13 In the Regional Context: Choosing Priority Areas....................................... 20 In the Regional Context: Addressing Priority Areas.................................... 22 End Notes............................................................. 27 Appendices: Tables and Graphs......................... 28

Appendices: Graphs and Tables Graph 1: Hospitalizations Due to Eating Disorders by B.C. Health Region, All Ages, 1998/1999....................................................................... 28 Graph 2: Tobacco Prevalence by B.C. Health Region, Age 12+ Years, 1997....................... 29 Table 1: Tobacco Prevalence by B.C. Health Region and Age Group, 1997...................... 30 Graph 3: Alcohol-Related Death Rate by B.C. Health Region, 2000............................... 31 Table 2: Population by B.C. Health Region and Gender, Age 65+ Years, 2000.................. 32 Table 3: Graph 4: Graph 5: Graph 6: Graph 7: Table 4: Table 5: Hospitalizations Due to Fractures Resulting From Falls by B.C. Health Region and Gender, Age 65+, 1999/2000............................... 33 Hospitalizations Due to Fractures Resulting From Falls by B.C. Health Region and Gender, Age 65+............................................ 34 Percentage of Patients Taking Prescriptions For Tranquillisers and Sleeping Pills by B.C. Health Region and Gender, Age 65+, 2000................. 35 Average Number of Prescriptions per Patient For Tranquillisers and Sleeping Pills by B.C. Health Region and Gender, Age 65+, 2000................. 36 Number of Bone Density Services Per 1,000 Population by B.C. Health Region and Gender, Age 65+, 2000/2001............................... 37 Percent of Women Prescribed Osteoporosis-Related Drugs by B.C. Health Region and Age Group, 2000............................................ 38 Average Number of Prescriptions per Patient for Osteoporosis-Related Drugs by B.C. Health Region and Age Group, 2000..................................... 39

Introduction Bone health is an important issue for all British Columbians. Osteoporosis has received much attention from the media and from pharmaceutical industry. For this reason, bone health is sometimes regarded as an issue that only concerns post-menopausal women. However, people of any age can be affected by poor bone health. The steps needed to ensure good bone health during much of the lifespan are relatively simple; good nutrition and physical activity help children, adolescents, and adults develop and maintain strong bones. In seniors, bone strength declines as a natural part of ageing, but if proper precautions are not taken, this decline can accelerate, resulting in the condition known as osteoporosis. In the senior population, physical activity and nutrition are also essential to prevent accelerated decline of bone strength. In addition, the prevention of falls in seniors is a critical part of fracture prevention. The purpose of this workbook is to help guide regions and communities through the process of mapping their own bone health initiatives. This process should allow regions/communities to identify areas that need improvement and to develop a bone health strategy by building on the strengths of existing programs. The questions presented in the workbook are designed to target all age groups and place bone health within a regional context. What am I supposed to do with yet another document? You can get the ball rolling on bone health This workbook provides an easy-to-use, step-by-step guide to building a comprehensive, cost-efficient bone health and fracture prevention strategy for your region. It is designed to build on the programs and policies that are already in place and to provide for the needs of future generations while meeting short-term demands. This document should be passed on to the senior administrator or the vice president of programs or community health for your region. This person could then assign someone to collect relevant data which, with the information provided in this workbook, will be presented to the health board of your region. The health board, with the help of community groups that may exist in your region, will identify priority areas for bone health. Your region could then apply for a grant or pass the community planning section of this workbook on to the communities. Communities can then create new programs or modify existing ones to address the priority areas identified by the region. This is not a difficult or costly process, and this workbook makes it even easier! All you need to do is get the ball rolling Planning for Bone Health and Fracture Prevention 1

Getting Your Numbers Straight Did You Know? In 1993, the health care cost of osteoporosis in Canada was over $1.3 billion. Most of your adult bone mass is acquired during childhood and adolescence. This bone mass is maintained throughout adulthood and then naturally diminishes with old age. The bone mass attained during youth is a strong predictor of bone mass during old age. If you acquire more bone when you re young, you ll have more left when you get older. Genetics determine 60% of your bone mass, but the other 40% depends on lifestyle behaviours such as nutrition and physical activity something everyone has the power to change. Calcium is the nutrient most important to the attainment of peak bone mass and prevention of bone loss. American studies estimate that only 25% of boys and 10% of girls receive the appropriate amount of calcium (1). HELPFUL HINTS The disc provided with this workbook has PowerPoint overheads of these facts. Use them to make a presentation on bone health and fracture prevention to your health board! Facts About Bone Health Growing bones need calcium and vitamin D, but as many as 50% of adolescent Canadian girls are on diets of some kind that make it difficult for them to obtain enough calcium (2). Participating in high impact physical activities (like running and weight-lifting) promotes bone growth during youth and bone maintenance during adulthood. Inactivity, alcohol and smoking are all seriously detrimental to bone health and can contribute to accelerated bone loss or osteoporosis. Long-term use of steroids such as corticosteroids can negatively impact the development of bone mass (3). 2 Planning for Bone Health and Fracture Prevention

Fractures Can Be Prevented! Hip fractures are associated with extremely high costs to the health care system and with decreased quality of life and autonomy for seniors. Low bone density is only one of many predictors of future fractures. Most fractures are caused by falls. For example, 97% of hip fractures result from falls! Remember, people with normal bone density account for at least 50% of fractures! Eliminating environmental hazards, using canes/walkers when appropriate, using proper footwear, ensuring adequate lighting, improving strength and agility and limiting the use of mind-altering medications can prevent falls. The use of hip pads among seniors can reduce hip fractures. Several American studies have suggested that the use of hip pads can reduce fractures for a range of 60% to 70% (4) (5). Get Your Numbers Straight! Before your health board can determine what the priority areas for your region should be, you need to collect some data from your region. Don t do all the work yourself! Pass this job on to someone who is good at getting data quickly! Collect the data needed to answer the following questions, which are divided into four themes of bone health: nutrition, physical activity, fall prevention and medical issues. Nutrition Calcium and Vitamin D intake is is not considered to be a problem in our region (conduct a local survey). The following age groups are regularly consuming enough calcium and vitamin D to meet the needs of their bones: Children Adolescents Young Adults Middle Aged Adults Seniors HELPFUL HINTS Don t forget to use your resources! Contact the Women s Health Bureau, local school boards, pharmacies, community centres, and continuing care homes for information. See the Inventory for some contact names and numbers. Planning for Bone Health and Fracture Prevention 3

Social Determinants of Bone Health Compared to other regions, the prevalence of eating disorders in our region is: above the provincial average at the provincial average below the provincial average (see Graph 1: Hospitalizations Due to Eating Disorders by BC Health Region, All Ages, 1998/1999). The rate of eating disorders in our region is: Compared to other regions, the prevalence of tobacco use in our region is above the provincial average at the provincial average below the provincial average (see Graph 2: Tobacco Prevalence by BC Health Region, Age 12+, 1997). The age group with the highest rate of tobacco use is (Table 1: Tobacco Prevalence by BC Health Region and Age Group, 1997): 12-18 years 19-24 years 25-44 years 45-64 years 65+ years Compared to other regions, the prevalence of alcohol-misuse in our region is: above the provincial average at the provincial average below the provincial average (Graph 3: Alcohol-Related Death Rate by BC Health Region, 2000). The age group with the highest rate of alcohol abuse is: Children Adolescents Young Adults Middle Aged Adults Seniors 4 Planning for Bone Health and Fracture Prevention

Physical Activity In our region, the rate of enrolment in physical education after grade 10 is (contact school boards): Girls: Boys: In our region, community centres and other recreation and fitness facilities do do not provide programming specifically designed to interest girls and women. (Contact community centres and Promotion Plus Resources. Website for Promotion Plus: www.promotionplus.org and telephone number 604-737-3075 or toll free (in B.C. only) 1-877-55-PROMO.) Details: Have these programs been successful? Why or why not? If they don t exist, are there reasons? In our region, there are are not fitness programs designed specifically for those with osteoporosis, such as osteofit classes. (contact Osteoporosis Society of Canada, B.C. Division) Planning for Bone Health and Fracture Prevention 5

Fall Prevention What is the population over 65 in your region? (see Table 2: Population by BC Health Region and Gender, Age 65+, 2000). Women: Men: Compared to other regions, the percentage of the population over 65 is: above the provincial average at the provincial average below the provincial average (use percentage column for males and females in Table 2: Population by BC Health Region and Gender, Age 65+, 2000). In our region, the number of days of hospitalization due to fractures resulting from falls is (see Table 3: Hospitalizations Due to Fractures Resulting From Fall by BC Health Region and Gender, Age 65+, 1999/2000): Women: Men: Compared to other regions, the days of hospitalizations due to fractures resulting from falls is: above the provincial average at the provincial average below the provincial average (see Graph 4: Hospitalizations Due to Fractures Resulting from Falls by BC Health Region and Gender, Age 65+, 1999/2000. Please use the columns for #days/1,000 population in the table in Table 3 for this comparison and refer to the accompanying chart). Compared to other regions, the percentage of seniors 65 and over taking prescriptions of tranquillisers and sleeping pills is: above the provincial average at the provincial average below the provincial average (see Graph 5: Percentage of Patients Taking Prescriptions for Tranquillisers and Sleeping Pills by BC Health Region and Gender, Age 65+, 2000). Compared to other regions, the average number of these prescriptions per patient (65 and older) in your region is: above the provincial average at the provincial average below the provincial average (see Graph 6: Average Number of Prescriptions per Patient for Tranquillisers and Sleeping Pills by BC Health Region and Gender, Age 65+, 2000). 6 Planning for Bone Health and Fracture Prevention

Do nursing homes in your region provide vitamin D and/or calcium supplements for residents? (contact nursing homes). Yes No Do nursing homes in your region know about and use hip pads for residents? Yes No Are there sidewalk maintenance bylaws in your region to ensure that snow and ice are cleared, and cracks are repaired? (contact municipalities) Yes No Details: Have they been successful? Why or why not? If they don t exist, are there any reasons? Do building codes in your region ensure that homes are equipped with proper hand railings and/or other fall prevention devices? (contact municipalities) Yes No Details: Have they been successful? Why or why not? If they don t exist, are there any reasons? Planning for Bone Health and Fracture Prevention 7

Are there programs in your region that assess the homes of seniors for risk of falling? (contact municipalities) Yes No Details: Have they been successful? Why or why not? If they don t exist, are there any reasons? Are there individuals in your region that conduct building assessment of nursing homes? (contact municipalities) Yes No Details: Have they been successful? Why or why not? If they don t exist, are there any reasons? 8 Planning for Bone Health and Fracture Prevention

Medical Is bone density testing available in your region? (contact Osteoporosis Society of Canada; see Graph 7: Number of Bone Density Services Per 1,000 Population by BC Health Region and Gender, Age 65+, 2000/2001). Yes No Of the women receiving bone density testing, what percentages receive scores in the following ranges: (contact local bone density measurement services) Normal or Above: Osteopenic: Osteoporotic: The percentage of women prescribed osteoporosis-related drug therapies (hormone therapies, bisphosphonates, calcitonin, raloxifene) in your region is (see Table 4: Percent of Women Prescribed Osteoporosis-Related Drugs by BC Health Region and Age Group, 2000): 50-64 years: 65-84 years: 85+ years: Compared to other regions, the average number of osteoporosis-related drug therapy prescriptions per patient in your region is: (see Table 5: Average Number of Prescriptions per Patient for Osteoporosis-Related Drugs by BC Health Region and Age Group, 2000). 50-64 years: above the provincial average at the provincial average below the provincial average 65-84 years: above the provincial average at the provincial average below the provincial average 85+ years: above the provincial average at the provincial average below the provincial average Do family physicians in your region receive continuing education in the area of bone health? Yes No Are there education programs in your region for those who have osteoporosis or are at high risk for the disease? (contact Osteoporosis Society of Canada) Yes No Planning for Bone Health and Fracture Prevention 9

In the Regional Context: Making Sense of the Data The data you collected provides you with information to help define priority areas for bone health and fracture prevention. The following pointers can help you use the data to interpret the needs of your region: Nutrition Did you find that most of the people in your region are not getting enough calcium and vitamin D? These nutrients are essential to bone health, and if large sectors of the population (particularly children and teens) are not receiving appropriate quantities, this is a serious problem. The prevalence of eating disorders is another indicator. If the prevalence is high, so are the deleterious effects on bone health. Is alcohol and tobacco use a major problem in your region? Addressing this issue can have a large impact on bone health as well as other areas of health and even social issues. What existing policies/programs could you adapt to deal with these issues? If these issues are already a focus, are the present strategies proving to be effective? Physical Activity Are girls taking physical education classes in senior high school, or is the enrollment dropping off as soon as it is not mandatory? Being physically active during their teens has many positive effects on girls, including increased bone mass. Are there community programs to get girls and women active? Programs designed for men and boys may not appeal to women and girls. By improving these programs, girls and women become more active, a step with positive effects on bone health regardless of age. 10 Planning for Bone Health and Fracture Prevention

Fitness programs designed for people with osteoporosis have been found to greatly enhance quality of life, and in some cases, to reduce the effects of the disease. By increasing agility, these programs also affect the risk of falling. By building on existing fitness programs, or incorporating a program such as Osteofit, a large impact can be made. What existing policies/programs could you adapt to deal with these issues? If these issues are already a focus, are the present strategies proving to be effective? Fall and Fracture Prevention Is the number of days of hospitalizations due to fractures resulting from falls really high? If you have a relatively small senior population, but a lot of hospitalizations due to fractures resulting from falls, fall prevention is a serious issue for your region. Did you find surprisingly high levels of tranquillizer and sleeping pill prescriptions? These drugs cause drowsiness and absent-mindedness that can lead to falls. Bylaws regarding sidewalk maintenance, adequate street lighting and prevention of home hazards are very important to the prevention of falls and subsequent fractures. Many of the risks for falling (i.e. throw rugs, poor lighting) can be eliminated without much effort. Programs that assess the risk in homes have a huge impact on the risk of falling. Programs designed to educate seniors for self assessment such as safe step/sure step can reduce the risks for falling. What existing policies/programs could you adapt to deal with these issues? If these issues are already a focus, are the present strategies proving to be effective? Planning for Bone Health and Fracture Prevention 11

Medical Issues Do many of the women receiving bone density measurement procedures have normal bone density? If the answer is yes, your region may wish to focus on non-medical areas of bone health such as fall prevention, nutrition and physical activity. The number of women receiving osteoporosis-related drug treatments should reflect the distribution of women in different bone density categories in your region. Preventative measures (nutrition, physical activity and fall prevention) can be the focus for women in the osteopenic range, while a holistic approach for women in the osteoporotic range includes adequate medical treatment, physical activity, fall prevention and education programs. Medical issues related to treatment, prevention, and multiple medication assessment need to be addressed across the continuum from the community to acute care. Nutrition needs and physical activity concerns can be dealt with in the community. If all the factors related to bone health are being dealt with primarily in the hospitals, consider refocusing on an integrated approach. What existing policies/programs could you adapt to deal with these issues? If these issues are already a focus, are the present strategies proving to be effective? 12 Planning for Bone Health and Fracture Prevention

In the Regional Context: Mapping Your Strengths On the following pages is an exercise designed to help you identify existing policies and programs in your region that are beneficial to bone health. When policies are complementary, programs can be designed to address more than one policy. Try to identify existing policies that relate to one another. This leads to a comprehensive approach to program design that is economical and more likely to be successful. How to complete the activity: 1. List policies and programs - fill in the appropriate areas with the policies and programs already existing in your region; include those that directly pertain to bone health as well as any that do not directly pertain to bone health but have a beneficial effect anyway (such as tobacco reduction or heart health programs). 2. Identify the gaps - where are the strengths and weaknesses in your policies and programs as they affect each target population? 3. Brainstorm - what simple modifications or additions to an existing program could help fill a gap? Planning for Bone Health and Fracture Prevention 13

1. List Policies and Programs: Nutrition Children Teens Young Adults Middle-Aged/Seniors 14 Planning for Bone Health and Fracture Prevention

1. List Policies & Programs: Physical Activity Children Teens Young Adults Middle-Aged/Seniors Planning for Bone Health and Fracture Prevention 15

1. List Policies & Programs: Fall Prevention Children Teens Young Adults Middle-Aged/Seniors 16 Planning for Bone Health and Fracture Prevention

1. List Policies & Programs: Medical Children Teens Young Adults Middle-Aged/Seniors Planning for Bone Health and Fracture Prevention 17

2. Identify the Gaps Children Teens Young Adults Middle-Aged/Seniors 18 Planning for Bone Health and Fracture Prevention

3. Brainstorm Planning for Bone Health and Fracture Prevention 19

In the Regional Context: Choosing Priority Areas When you have collected and analyzed the data and mapped your existing policies and programs, it is the right time to make a presentation to the health board of your region. Considering the data collected and the strengths and weaknesses identified in the mapping exercise, the board can choose priority areas. If your region has particular committees or a process for community input, these could also be used for input into the decision making process. While you may have found that there are many areas of bone health and fracture prevention that you could focus on, it is important to choose a small number and concentrate on those for about five years before moving on to others. Evaluation of outcome is critical to tracking your success. Don t forget that you can target age groups (children, teens, young adults, middle adults and seniors) within the four broad areas of bone health and fracture prevention. Remember to build on your strengths. Pick areas where small changes will make large differences. These priority areas are not set in stone and can always be reconsidered. They are simply a starting point. For the next years, our region will be focusing on the following priority areas in bone health and fracture prevention: HELPFUL HINTS Choose priority areas that can be addressed through more than one of the five principles of health promotion: public policy, supportive environment, community action, personal skills and reorienting medical services. 1. 20 Planning for Bone Health and Fracture Prevention

2. 3. 4. HELPFUL HINTS When you have chosen your priority areas, go on to the next section, which will help you decide how to address these areas! Planning for Bone Health and Fracture Prevention 21

In the Regional Context: Addressing Priority Areas Go back to the mapping your strengths exercise and determine where changes and/or additions will need to be made in order to address the new priority areas. The following space can be used to brainstorm these ideas. The Health Board will need to approve these policies and programs. By building on existing programs, the financial burden can be lessened and your board will be more likely to approve the proposals. Remember to create policies and processes that reflect an integrated approach to health. Consider public policy, community action, the creation of supportive environments, improvement of personal skills and reorientation of medical services. 22 Planning for Bone Health and Fracture Prevention

Priority area: Proposed policy change or addition: Proposed modification to existing program: Proposed new program: Planning for Bone Health and Fracture Prevention 23

Priority area: Proposed policy change or addition: Proposed modification to existing program: Proposed new program: 24 Planning for Bone Health and Fracture Prevention

Priority area: Proposed policy change or addition: Proposed modification to existing program: Proposed new program: Planning for Bone Health and Fracture Prevention 25

Priority area: Proposed policy change or addition: Proposed modification to existing program: Proposed new program: 26 Planning for Bone Health and Fracture Prevention

end notes 1. Osteoporosis partnership program: A healthcare professional based. (1999) Szajcz, M. (Ed), Olszynksi, W., Frketic, J., Braithwaite, K., Page. & Davis, G. educational program. M. Szajcz Publications, Saskatoon, Saskatchewan. 2. Osteoporosis Prevention, Diagnosis, and Therapy. NIH Consensus Statement Online 2000 March 27-29; [2000, May 15]; 17 (1): 1-36. 3. Edin, Karcic, MD, Karcic, Arsad A. (2001). Osteoporosis and Fracture Risk Prevention in Long-term Glucocorticoid Therapy. Archives of International Medicine, 161 July 23, 2001: 1780-1781. 4. Kannus P, Pakkari J, Niemi S, Pasanen M, Palvanen M, Jarvien M, Vuori I. (2001). Do hip pads help prevent hip fractures? Canadian Family Physician, 47 May 2001: 965-966. 5. B.C. Office of Health Technology Assessment (1997). Bone Mineral Density Testing: Does the Evidence Support its Selective Use In Well Women? University of British Columbia. Planning for Bone Health and Fracture Prevention 27

Appendices: Graphs and Tables Graph 1: Hospitalizations Due to Eating Disorders by B.C. Health Region, All Ages, 1998/1999 Health Region East Kootenay Northern Interior North West Richmond Simon Fraser South Fraser Valley Cariboo Coast Garibaldi Burnaby Central Vancouver Island Capital North Okanagan Upper Island/Central Coast Vancouver Thompson Fraser Valley Peace Liard Kootenay Boundary Okanagan Similkameen North Shore 0.00 0.02 0.04 0.06 0.08 0.10 0.12 0.14 B.C. Average 0.08 Number of Cases per 1,000 Population Source: Hospitalization: Morbidity Database, B.C. Ministry of Health Services Population: 2000, PEOPLE26, B.C. STATS, Ministry of Management Services; Data obtained from the Ministry of Health Services Health Data Warehouse 28 Planning for Bone Health and Fracture Prevention

Graph 2: Tobacco Prevalence by B.C. Health Region, Age 12+ Years, 1997 B.C. Average: Current Users 23%, 2nd Hand 14% Current Users 2nd Hand North Shore South Fraser Valley Capital Vancouver/Richmond Fraser Valley Kootenay Boundary North Okanagan Health Regions Simon Fraser Central Vancouver Island Okanagan Similkameen Coast Garibaldi Upper Island/Central Coast East Kootenay North West Thompson Northern Interior Cariboo Peace Liard 0% 10% 20% 30% 40% 50% 60% Percent Source: Tobacco Use in B.C., 1997, Heart and Stroke Foundation of B.C. & Yukon and the Ministry of Health Services http://www.health.gov.bc.ca/tobacrs/regcomp.html Planning for Bone Health and Fracture Prevention 29

Table 1: Tobacco Prevalence by B.C. Health Region and Age Group, 1997 Health Region Age 12-18 Age 19-24 Age 25-44 Age 45-64 Age 65+ East Kootenay 16% 37% 33% 26% 10% Kootenay Boundary 10% 46% 28% 18% 13% North Okanagan 13% 34% 29% 21% 7% Okanagan Similkameen 26% 44% 33% 18% 13% Thompson 20% 41% 32% 26% 14% Fraser Valley 20% 25% 25% 25% 10% South Fraser Valley 11% 22% 25% 19% 9% Simon Fraser 16% 26% 28% 24% 13% Coast Garibaldi 14% 43% 33% 22% 9% Central Vancouver Island 21% 34% 29% 21% 14% Upper Island/Central Coast 24% 44% 31% 21% 11% Cariboo 18% 47% 30% 28% 16% North West 18% 41% 30% 30% 18% Peace Liard 21% 37% 34% 29% 14% Northern Interior 22% 28% 32% 28% 15% Vancouver/Richmond 22% 27% 25% 19% 11% North Shore 15% 34% 20% 14% 10% Capital 15% 32% 26% 19% 8% British Columbia ** 31% 27% 21% 11% Source: Tobacco Use in B.C., 1997, Heart and Stroke Foundation of B.C. & Yukon and the Ministry of Health Services http://www.health.gov.bc.ca/tobacrs/regcomp.html ** Age 12-14 is 6% and Age 15-18 is 25% 30 Planning for Bone Health and Fracture Prevention

Graph 3: Alcohol-Related Death Rate by B.C. Health Region, 2000 Health Region Richmond South Fraser North Shore Burnaby Fraser Valley Simon Fraser Northern Interior Vancouver Peace Liard Capital Coast Garibaldi Cariboo North Okanagan North West Central Vancouver Island Okanagan Similkameen Thompson East Kootenay Upper Island/Central Coast Kootenay Boundary 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 B.C. Average 0.42 Rate per 1,000 Population Source: Alcohol-Related Deaths: Table 7B, Quarterly Digest - Fourth Quarter of 2000, B.C. Vital Statistics Agency Population: 2000, PEOPLE26, B.C. STATS, Ministry of Management Services; Data obtained from Ministry of Health Services Health Data Warehouse Planning for Bone Health and Fracture Prevention 31

Table 2: Population by B.C. Health Region and Gender, Age 65+ Years, 2000 Health Region # Female % Female # Male % Male Total East Kootenay 5,619 53% 5,013 47% 10,632 Kootenay Boundary 6,883 55% 5,743 45% 12,626 North Okanagan 10,706 54% 9,180 46% 19,886 Okanagan Similkameen 25,525 55% 21,199 45% 46,724 Thompson 8,653 53% 7,806 47% 16,459 Fraser Valley 18,842 55% 15,306 45% 34,148 South Fraser Valley 40,057 56% 31,760 44% 71,817 Simon Fraser 18,318 59% 12,983 41% 31,301 Coast Garibaldi 5,227 53% 4,641 47% 9,868 Central Vancouver Island 21,726 53% 18,960 47% 40,686 Upper Island/Central Coast 7,271 52% 6,630 48% 13,901 Cariboo 3,544 49% 3,630 51% 7,174 North West 3,113 50% 3,073 50% 6,186 Peace Liard 2,337 52% 2,172 48% 4,509 Northern Interior 4,666 51% 4,506 49% 9,172 Vancouver 38,372 58% 28,190 42% 66,562 Burnaby 14,029 58% 10,212 42% 24,241 North Shore 14,786 58% 10,815 42% 25,601 Richmond 9,396 59% 6,608 41% 16,004 Capital 35,189 59% 24,864 41% 60,053 British Columbia 294,259 56% 233,291 44% 527,550 Source: PEOPLE26, B.C. STATS, Ministry of Management Services; Data obtained from Ministry of Health Services Health Data Warehouse 32 Planning for Bone Health and Fracture Prevention

Table 3: Hospitalizations Due to Fractures Resulting From Falls by B.C. Health Region and Gender, Age 65+, 1999/2000 Health Region Males Females Males Females Age 65 + Age 65 + Age 65 + Age 65 + # Days # Days # Days/1,000 # Days/1,000 North West 275 1,227 92 405 Vancouver/Richmond 4,777 18,677 138 394 Thompson 672 3,127 89 374 Simon Fraser 2,871 10,498 126 328 South Fraser Valley 3,211 11,717 106 304 Peace Liard 72 573 33 252 Capital 2,507 8,766 101 248 North Shore 867 3,499 81 240 Okanagan Similkameen 1,239 5,697 59 226 Northern Interior 216 1,023 50 225 Kootenay Boundary 615 1,530 108 224 Fraser Valley 1,488 4,138 99 223 North Okanagan 1,123 2,345 124 223 Central Vancouver Island 1,042 4,700 56 220 Coast Garibaldi 308 1,020 67 198 East Kootenay 365 941 73 169 Cariboo 151 571 43 165 Upper Island/Central Coast 644 1,031 101 147 British Columbia 22,443 81,080 98 280 Source: Hospitalizations: Morbidity Database, Ministry of Health Services; Data obtained from Ministry of Health Services Health Data Warehouse Population: 1999, PEOPLE26, B.C. STATS, Ministry of Management Services Planning for Bone Health and Fracture Prevention 33

Graph 4: Hospitalizations Due to Fractures Resulting From Falls by B.C. Health Region and Gender, Age 65+, 1999/2000 B.C. Average: Female 280, Male 98 Male Female Health Region Cariboo East Kootenay Coast Garibaldi Central Vancouver Island North Okanagan Fraser Valley Kootenay Boundary Northern Interior Okanagan Similkameen North Shore Capital Peace Liard South Fraser Valley Simon Fraser Thompson Vancouver/Richmond North West 0 50 100 150 200 250 300 350 400 450 Number of Days per 1,000 Population Source: Hospitalizations: Morbidity Database, Ministry of Health Services; Data obtained from Ministry of Health Services Health Data Warehouse Population: 1999, PEOPLE26, B.C. STATS, Ministry of Management Services 34 Planning for Bone Health and Fracture Prevention

Graph 5: Percentage of Patients Taking Prescriptions For Tranquillisers and Sleeping Pills by B.C. Health Region and Gender, Age 65+, 2000 Health Region Cariboo North West Peace Liard East Kootenay Northern Interior Coast Garibaldi Kootenay Boundary Thompson North Okanagan Central Vancouver Island Upper Island/Central Coast Fraser Valley South Fraser Okanagan Similkameen Vancouver/Richmond North Shore Capital Simon Fraser B.C. Average: Female 27%, Male 17% Female Male 0% 5% 10% 15% 20% 25% 30% 35% Percent Source: Pharmacare Claims: Phoenix database, Pharmacare, Ministry of Health Services Population: 2000, PEOPLE26, B.C. STATS, Ministry of Management Services; Data obtained from the Ministry of Health Services Health Data Warehouse Note: Unknown health region and unknown gender not included Planning for Bone Health and Fracture Prevention 35

Graph 6: Average Number of Prescriptions per Patient For Tranquillisers and Sleeping Pills by B.C. Health Region and Gender, Age 65+, 2000 B.C. Average: Female 5.9, Male 5.1 Female Male Health Region Northern Interior Kootenay Boundary North Shore North West South Fraser Peace Liard Vancouver/Richmond Simon Fraser East Kootenay Cariboo North Okanagan Thompson Fraser Valley Coast Garibaldi Central Vancouver Island Capital Upper Island/Central Coast Okanagan Similkameen 0.0 2.0 4.0 6.0 8.0 Average Number Source: Pharmacare Claims: Phoenix database, Pharmacare, Ministry of Health Services Population: 2000, PEOPLE26, B.C. STATS, Ministry of Management Services; Data obtained from the Ministry of Health Services Health Data Warehouse Note: Unknown health region and unknown gender not included 36 Planning for Bone Health and Fracture Prevention

Graph 7: Number of Bone Density Services Per 1,000 Population by B.C. Health Region and Gender, Age 65+, 2000/2001 B.C. Average: Female 84.0, Male 11.4 Female Male Peace Liard Health Region East Kootenay North West Fraser Valley North Okanagan Thompson Kootenay Boundary Cariboo Northern Interior Okanagan Similkameen Upper Island/Central Coast Coast Garibaldi South Fraser Vancouver/Richmond Central Vancouver Island Simon Fraser Capital North Shore 0 20 40 60 80 100 120 140 160 180 Services Per 1,000 Population Source: Bone Density Services Rate: Medical Services Plan, Ministry of Health Services Planning for Bone Health and Fracture Prevention 37

Table 4: Percent of Women Prescribed Osteoporosis-Related Drugs by B.C. Health Region and Age Group, 2000 Health Region Female Male North Shore 170.4 25.0 Capital 118.8 19.3 Simon Fraser 115.4 15.5 Central Vancouver Island 94.1 9.9 Vancouver/Richmond 85.3 10.8 South Fraser 83.3 11.1 Coast Garibaldi 66.7 9.0 Upper Island/Central Coast 59.0 7.8 Okanagan Similkameen 55.3 8.6 Northern Interior 55.2 7.2 Cariboo 53.7 6.1 Kootenay Boundary 48.2 8.7 Thompson 46.1 6.0 North Okanagan 45.9 6.0 Fraser Valley 41.6 8.3 North West 18.0 3.3 East Kootenay 6.9 0.0 Peace Liard 5.2 0.0 British Columbia 84.0 11.4 Source: Bone Density Services Rate: Medical Services Plan, Ministry of Health Services 38 Planning for Bone Health and Fracture Prevention

Table 5: Average Number of Prescriptions per Patient for Osteoporosis-Related Drugs by B.C. Health Region and Age Group, 2000 Health Region Age 50-64 Age 65-85 Age 86+ East Kootenay 3.6 3.1 3.3 Kootenay Boundary 3.8 3.1 3.3 North Okanagan 3.7 3.2 4.3 Okanagan Similkameen 3.8 3.5 5.0 Thompson 3.8 3.2 3.5 Fraser Valley 3.6 3.2 3.4 South Fraser 3.5 3.1 3.0 Simon Fraser 3.4 3.0 3.1 Coast Garibaldi 3.7 3.6 4.2 Central Vancouver Island 3.5 3.2 3.6 Upper Island/Central Coast 3.8 3.3 3.3 Cariboo 4.6 3.6 3.1 North West 3.8 3.1 3.8 Peace Liard 4.0 3.1 3.5 Northern Interior 4.0 3.0 2.2 Vancouver/Richmond 3.4 3.1 3.5 North Shore 3.4 3.3 3.4 Capital 3.7 3.4 3.7 Unknown HR 3.2 2.7 3.5 British Columbia 3.7 3.2 3.5 Source: Phoenix database, Pharmacare, Ministry of Health Services Planning for Bone Health and Fracture Prevention 39

012.SI.WH.081.0313 2001/10