1.

Introduction

1.1 Epidemiology of osteoporosis and fractures

1.1.1 Definition of osteoporosis

“Osteoporosis is a systemic skeletal disease characterized by low bone mass and micro-

architectural deterioration of bone tissue, with a consequent increase in bone fragility and

susceptibility to fracture” (Inderjeeth & Poland, 2009). The condition of osteoporosis, clinically

manifests by fragility fractures, most common at the distal forearm, spine and hip (Shin et al.,

2020).

ETIOLOGY AND PATHOPHYSIOLOGY

Fractures in the elderly occur more frequently following falls or chronic stress instead of a single

traumatic event. Osteoporosis is the most important risk factor contributing to these fractures in

old patents (Rasmussen & Dal, 2019). This is mainly due to senility but can also be attributed to

prolonged corticosteroid use. Medical conditions such as hyperthyroidism and diabetes mellitus

have also been found to be associated with an increased risk of fracture and associated

complications. On the other hand, the risk of fall is increased by physical deconditioning,

malnutrition, impaired vision or balance, neurologic problems, and slower reflexes. Fractures in

children, adolescents and young adults usually result from high-energy trauma associated with

multiple concomitant injuries (Kruppa et al., 2018). Most fractures result from Road Traffic

Accidents (RTA) and a fall with minor trauma (Ghuman et al., 2022)
1.1.3 Fracture rates

The incidence of osteoporosis differs among populations and ethnic groups, and the incidence of

fractures differs between countries. The explanation of the decreasing fracture incidence is

unknown, but is likely to be multi factorial as several determinants have been linked to bone

mass density levels, osteoporosis and fracture risk (Leslie et al., 2020). This may also reflect

cohort effects driven by improved nutritional status during childhood and growth in the present

elderly. As this is merely speculation from ecological studies, we need more knowledge on how

lifestyle affects bone health in younger age groups. The global age-standardized rates of

incidence, prevalence for fractures decreased slightly from 1990 to 2019, but the absolute counts

increased substantially. Older people have a particularly high risk of fractures, and more

widespread injury-prevention efforts and access to screening and treatment of osteoporosis for

older individuals should help to reduce the overall burden (Walker, 2020).

1.3 Peak bone mass and its determinants

1.3.1 Definition of peak bone mass

Bone mass increases as the skeleton grows, reaching a plateau, the peak bone mass (PBM) at the

end of the second or early in the third decade of life. PBM are defined as the amount of bone

tissue present at the end of skeletal maturation. (Porwal et al., 2020)

1.3.2 Weight and nutrition

Body weight that is a compound of hereditary and environmental factors, is the major

determinant of the variability in adult bone mass. Body weight explains roughly half of the bone

mass´ variance at a population level. The best on bone mass is well established in adults as well

as in youths. Maintaining weight has been regarded as protective of future fracture risk.
However, some studies suggest that the positive effect of BMI is limited to a certain threshold. In

addition, non-mechanical factors such as bone active hormones from the adipocyte, muscles and

the gut may have an anabolic impact on bone. (Gregson et al., 2017). Beyond sufficient energy

intake, a broad array of macro- and micronutrients are important for bone health. Some key

nutrients such as calcium, vitamin D and proteins, must be present in adequate levels. For the

collagen synthesis, enough proteins are of importance. Low calcium levels seem to be a limiting

factor for bone accumulation,

1.3.3 Physical activity

High impact sports, participation in recreational play, as well as higher levels of normal physical

activity have a positive effect on bone strength (Mutz & van Munster, 2020). Regular weight

bearing exercises with dynamic activities including high strain rates, such as jumping and

running are widely reported to be osteogenic. Physical activity with rest periods in between, is

regarded to be the most beneficial as the sensitivity of the bone cell to loading stimulus returns

after a period of rest. During growth when the periosteal surfaces have a greater proportion of

active bone cells, the mechanical loading increases the already active modelling process. Skeletal

adaptation to loading implies changes. A recent study concludes that physical activity during

youth should be encouraged for lifelong bone health, due to its effects on bone size and strength

rather than its effect on bone mass.

1.3.4 Tobacco and alcohol

Adolescent tobacco use causes lower BMD-levels. The adverse effects are influenced of dose

and duration, and some studies have observed a reversible effect of cessation (Koregol et al.,

2020). Figures from Nor health indicate increased snuffing habits between 2005 and 2009 among
Norwegians aged 15, while traditional smoking decreases. A small study of elderly women, for

whom smokeless tobacco use from childhood was common, reported that such tobacco use had

negative impact by increasing BMD loss with age (Bajracharya, 2018). Excess alcohol

consumption is associated with low bone density, mainly by suppression on bone formation.

Another review and analysis concluded that most evidence support a beneficial effect of

moderate alcohol consumption on bone density.

1.3.5 Hormonal contraceptives

Estrogens are essential for the pubertal bone changes in boys and girls. Hormonal contraceptives

are commonly used in early life. The most frequently prescribed, combined hormonal

contraceptives (CHC), promote a reduction of estrogen and a suppression of endogenic

progesterone production by the ovaries, so that the circulating levels of sex hormones are dose

dependent of the CHC therapy. Several studies have investigated the effect of CHC, and

evidence suggests that the effect is different in young women who have not yet achieved PBM,

compared to skeletally mature women. Depending on estrogen dose and duration of exposure,

CHC may interfere with the normal acquisition of peak bone mass in adolescents. Progestin-only

methods are available as pills, injections and implants (Casper, 2017). While pills contain a small

dosage of contraceptive agents, an intramuscular or subcutaneous depot injection provides a

higher dose of progestin, which has been linked to BMD loss in adolescents. Thus, the possible

influence of these contraceptives is important to follow when bone health is studied.

2.2 LIFESTYLE FACTORS.

2.21 NUTRITION.

There are potentially numerous nutrients and dietary components that can influence bone health

and these ranges from macronutrients to micronutrients as well as bioactive food ingredients.

These nutrients may influence bone by various alteration of bone structure, the rate of bone

metabolism and homeostasis of calcium.

These dietary factors range from inorganic minerals ( calcium, magnesium, phosphorus sodium

and potassium) and vitamins ( A,D,E,K and C).

Calcium.

It is required for Normal growth and development of the skeleton.

Inadequate calcium intake can lead to weakened bones and increase the risk of conditions like

osteoporosis, where bones become brittle and prone to fractures. Calcium is essential for

maintaining bone density and strength, so it's important to ensure sufficient intake through diet or

supplements.

Vitamin D.

Found naturally in very few foods.

Vitamin D deficiency is characterized by inadequate mineralization or demineralization of the

skeleton.
In children severe vitamin D deficiency results in inadequate mineralization of the skeleton

causing rickets whereas in adults it leads to mineralization defect in the skeleton causing

osteomalacia. In addition the secondary hyperparathyroidism associated with low vitamin D

status enhances mobilization of calcium from the skeleton.

Vitamin D deficiency is a contributor to osteoporosis.

Magnesium.

Magnesium deficiency can also impact bone health. Magnesium is involved in bone formation

and helps regulate calcium levels in the body. A deficiency can lead to decreased bone mineral

density and an increased risk of fractures. It's important to maintain adequate magnesium intake

through diet, including foods like nuts, seeds, whole grains, and leafy green vegetables.

Vitamin K.

Vitamin K plays a crucial role in bone metabolism by facilitating the incorporation of calcium

into bone tissue. A deficiency in vitamin K can lead to impaired bone mineralization and an

increased risk of fractures. Ensuring adequate intake of vitamin K through foods like leafy

greens, broccoli, and cabbage, as well as through supplements if necessary, can help support

bone health.

Phosphorus.
Phosphorus is another component of the bone. It is located in almost all foods and by that a daily

intake of 1000–1200 mg is ensured. Chronic, greater than calcium, phosphorus uptake can lead

to bone loss.

Phosphorus is essential nutrient for bone health, as it works alongside calcium to build and

maintain bone tissue. A deficiency in phosphorus can lead to weakened bones and an increased

risk of fractures.

Sodium.

Sodium is not typically associated with bone health in the same way as calcium, magnesium,

phosphorus, and vitamin K. While sodium is necessary for overall health, excessive intake can

lead to negative effects such as high blood pressure and increased risk of cardiovascular disease.

However, inadequate sodium intake is less likely to directly affect bone health compared to

deficiencies in other nutrients like calcium or vitamin D.

2.22 ALCOHOL CONSUMPTION.

Abuse of alcohol is considered to be an important risk factor for fractures and osteoporosis.

Alcohol abuse is associated with deleterious changes in bone structure detected by

histomorphometry, and with a decrease in bone mineral density. These changes may also be

produced by factors commonly associated with alcohol abuse, e.g., nutritional deficiencies, liver

damage, and hypogonadism. Thus the etiology of alcohol-associated bone disease is

multifactorial. Alcohol has, however, clear-cut direct effects on bone and mineral metabolism.

Acute alcohol intoxication causes transitory hypoparathyroidism with resultant hypocalcemia

and hypercalciuria. Prolonged moderate drinking elevates serum parathyroid hormone (PTH)
levels, whereas chronic alcoholics are characterized by low serum levels of vitamin D

metabolites with resultant malabsorption of calcium, hypocalcemia, and hypocalciuria.

Independently of whether alcohol consumption is of short duration, social, or heavy and chronic,

it seems to suppress the function of osteoblasts, as evidenced by low serum levels of osteocalcin.

It has recently been reported, however, that alcohol can also have a beneficial effect on bone.

Among postmenopausal women, moderate alcohol consumption correlates positively with

central and peripheral bone mineral density, and with serum estradiol levels.

2.22 SMOKING.

Osteoporosis is a common, morbid and costly disorder characterized by deterioration in bone

strength. Cigarette smoking is associated with reduced bone mineral density (BMD) and

increased fracture risk. There are basic, clinical, and observational studies that define several of

the underlying pathophysiologic mechanisms that predispose smokers to bone loss. Such

mechanisms include alterations in calciotropic hormone metabolism and intestinal calcium

absorption

Cigarette smoking is a reversible risk factor for osteoporosis and osteoporotic fractures through

diverse pathophysiologic mechanisms.

2.3 PREVENTIVE MEASURES.

Bone health is a lifelong concern. We build bone to our adult maximum called peak bone mass

and begin losing bone thereafter. Two strategies to reduce the risk of fracture are to maximize

peak bone mass within our genetic potential and to slow the rate of bone loss with age. Bone

mass has been conveniently measured through imaging by dual energy X-ray absorptiometry

ADEQUATE DIET AND NUTRITION.

Calcium and vitamin D are the two nutrients important to bone health most likely to be deficient

in the diet and deficiencies can be easily corrected with supplements. However, the whole diet

merits attention because we do not know all of the nutrients and food constituents that may

benefit bone. Whole foods, especially dairy, provide an entire package of nutrients structurally

important to bone. Hydroxyapatite, the mineral complex providing bone structure, is very similar

to the mineral composition of dairy products. Calcium absorption is similar from milk, yogurt,

cheese, and calcium carbonate supplements (Nickel et al, 1996). Milk is fortified with vitamin D

and provides most of the vitamin D in the American diet. Consequently, bone mineral density is

higher in milk drinkers than non-drinkers (Looker et al, 2008). Milk also is the most important

dietary source of calcium and provides a substantial amount of magnesium, potassium,

phosphorus, B vitamins, and protein.

Whole foods contain many constituents that may have health benefits. For example, flavonoid-

rich plant foods are associated with bone benefits (Weaver et al, 2012). These include plums and

berries.

Vitamin D, also known as calciferol, comprises a group of fat-soluble secosterols and has two

major forms: and Vitamin (ergocalciferol) is largely human-made and added to foods whereas
vitamin (cholecalciferol) is synthesized in the skin, from 7-dehydrocholesterol, and it can be

also taken dietarily via animal-based foods. They are both synthesized commercially and found

in dietary supplements or fortified foods.

Optimal bioavailability of calcium is achieved through concomitant intake of vitamin D . The

administration of calcium and vitamin D supplements in later life helps reduce fractures . Foods

that can contain high amounts of vitamin D are eggs, liver, fish, and breakfast cereals.

The relationship between sodium intake and bone health cannot be studied easily alone, as

sodium interacts with other nutrients (such as potassium) and processes, such as urinary calcium

excretion. Excessive sodium intake, as translated by salt consumption, is a known risk factor for

osteoporosis. However, a study demonstrated urinary sodium excretion and bone health are

negatively correlated.

CESSATION OF SMOKING AND ALCOHOL.

Smoking and excessive alcohol consumption can adversely affect bone health. So cessation of

smoking is recommended, which contributes to the overall health of the person. Regarding

alcohol restriction, less than two servings of alcohol per day for men and one for women may

enhance bone health .

Quitting smoking can have positive effects on bone health. Smoking has been linked to

decreased bone density and an increased risk of fractures. When you quit smoking, your body

can begin to repair some of the damage caused by smoking, including improvements in bone

density. However, it's essential to combine smoking cessation with other healthy lifestyle choices

like regular exercise and a balanced diet to maximize the benefits for bone health.

Regular exercise can play a crucial role in the recovery from bone fractures. While it's essential

to follow medical advice and allow fractures to heal properly, once cleared by a healthcare

professional, gentle exercises can help improve strength, flexibility, and mobility around the

fracture site. These exercises can include low-impact activities like walking, swimming, or

cycling, as well as specific rehabilitation exercises prescribed by a physiotherapist. Exercise

stimulates blood flow to the area, which can aid in healing and prevent muscle atrophy.

However, it's important to avoid activities that could reinjure the bone until it has fully healed.

Always consult with a healthcare provider before starting any exercise regimen after a bone

fracture.

Quitting alcohol consumption can also have positive effects on bone healing and fracture

recovery. Excessive alcohol consumption can interfere with bone formation and remodeling,

leading to decreased bone density and an increased risk of fractures. Additionally, alcohol abuse

can impair the body's ability to absorb essential nutrients like calcium and vitamin D, which are

crucial for bone health.

By ceasing alcohol consumption, individuals can help promote better bone healing and overall

bone health. It's important to combine alcohol cessation with other healthy lifestyle choices like

maintaining a balanced diet rich in calcium and vitamin D, engaging in regular exercise, and
following medical advice for proper fracture care. This comprehensive approach can optimize

the healing process and reduce the risk of complications associated with bone fractures.

CHAPTER 3: RESEARCH METHODOLOGY.

INTRODUCTION

This chapter will discuss the various methods and procedures we will use to conduct the

research.

It is organized as follows: research design, location of the study, study population, inclusion and

exclusion criteria, sample size determination, sampling technique, instruments, pretesting of

research, reliability, data collection techniques, data management and ethical considerations.
3.1 STUDY DESIGN.

The study will use descriptive cross-sectional study to determine the lifestyle factors in bone

fractures susceptibility in kapkatet level 4 hospital. The study design's purpose is to observe,

describe and explore the aspect of the situation.

3.3 Location of the study

The study will be conducted in orthopedic ward in kericho referral hospital, kericho county.

The hospital is located in kericho town.

3.4 Study population

The targeted population are the males and females who had been exposed to fractures in kericho

referral hospital within a period of 18 months. The respondents will involve both the in patient

and outpatient residents attending kericho referral hospital.

3.5.1 Sample procedure

Random sampling will be used.

The study will involve sampling and interviewing the participants attending kericho referral

hospital with orthopedic cases and also utilizes records of orthopedic cases for the last 18 months

in orthopedic department.
3.5.2 Sample size determination.

The sample size will be obtained using Fischer’s formula:

N= [z2×pq]/d2

Where:l

N=DesiredlLsamplesize

Z=Standardnormaldeviation,thestandardnormaldeviationsetis1.96foramaximumsizeat95%

P=percentageofthosewhohadbeenexposedtofracturesinkerichoreferralhospital(80%inthisstudy)

Q=1-p=(1-0.8)=0.2

D=Thelevelofstatisticalsignificancesetat8%

N=z2pq/d2

N=[1.96×1.96×0.2×0.8]/(0.08×0.08)=96.04

N=96
3.6Selectioncriteria

3.6.1Inclusivecriteria

Femalsandmaleswhohadbeenexposedtofracturesinkerichoreferralhospital,boththeinpatientandout

patientcomingformedicalcheckupatorthopedicdepartmentwillparticipate.

3.6.2Exclusivecriteria

Thosewhoareunwillingtorespondandmentallyillresidentwillnotbeinvolvedinthestudyduringpartici

pation.

Sampling technique

In our research, we will utilize simple random sampling technique where we select the

participants from the hospital and in the community. The basic criterion for section is having

been involved in any fracture of the body from all categories of ages and even the progress of the

fracture whether resolved or not.

Study variables

Dependent variables: - bone fracture susceptibility- incidence, severity, and location of fracture.
Independent variables:

 Diet variables- nutrient intake, calcium consumption, vitamin D levels.

 Physical activity- exercise frequency, type of exercise, and sedentary behavior.

 Smoking and alcohol consumption- quantity and frequency.

 Occupation- type of work, physical demands.

 Environmental factors- exposure to sunlight, living conditions, and weather.

 Participant characteristics- age, sex, morbidity status.

Research instruments

Instruments and equipment necessary for the research study include the following:

a. Questionnaire. This is a well-designed and pretested set of questions used to obtain data

from the participants of the study. The team shall design it and administer it to the

sample.

b. Dietary assessment tools such as dietary recall and food frequency questionnaire to

assess participants’ nutrient intake, including calcium and vitamin D.

c. Anthropometric measurement instruments such as MUAC tape, tape measure for height

or length, weighing machine.

 d. Computer software for data analysis. These include software packages such as

Microsoft excel, SPSS. They will be used to analyze the collected data and identify the

relationship between lifestyle factors and bone fracture susceptibility.

e. Laboratory equipment for blood sample analysis. This may include centrifuges,

spectrophotometers, and immunoassay analyzers to measure levels of vitamin D,

calcium and other relevant markers.

Pretesting of research tool

The prepared questionnaire and the instruments such as the dietary assessment tools, aboratory

equipment will be pretested among a few of the target population in Kericho county referral

hospital and in the community.

This is done to maintain and check the clarity of the tools and the accuracy. It also helps confirm

the consistency in interpretation of questions by the respondents and to identify ambiguous

items.

After pretesting, all the ambiguous, misleading, and wrongly interpreted questions will be

omitted and questionnaire will be revised in accordance with the findings of pretesting. In

addition, the equipment that might bring about wrong and misleading data will either removed or

revised.

Validity and reliability

Validity is the extent to which a measure adequately represents the underlying construct that it is

supposed to measure. (Drost, 2011)

The instruments will be validated at University of Kabianga, Kapkatet Campus, department of

nursing to ensure its ability to adequately measure the intended construct. The expected

assessments will also be drawn from the literature reviews available to us.

Pretesting the research tools will also enable us check on the validity of the tools.

Reliability is the extent to which measurements are repeatable when different people perform the

measurement on different occasions, under different conditions. (Drost, 2011)

Reliability will be enhanced by frequent consultation with the thesis supervisors and also

frequent visits by them. The equipment and instruments shall also be checked on a daily basis for

consistency, completeness, and clarity.

Data collection techniques

Data will be collected using different techniques:

Interviews shall be conducted to allow filling in of the questionnaire and also to obtain the

clinical history from the participants.

We will also utilize the anthropometric measurements, laboratory studies results.

Secondary data will be obtained from the records in the hospital such as the prevalence, some of

the clinical notes and the imaging results.

Every participant will be interviewed by a trained interviewer and provide the required data.

Data management
After the data collection, we will store some of the data electronically that is in flash disks, while

the questionnaires will be kept in the save box in one of our rooms.

Afterwards, the data will undergo refining where we will check them for completeness and

consistency. Then it will be entered into the computer and analyzed using SPSS software and

Microsoft excel. Qualitative data will also be assigned labels to various categories. Verified test

parameters will be used to establish the relationship between the variables and the fracture

susceptibility.

Ethical issues

Given the nature of this project, there are certain ethical considerations that need to be taken into

consideration.

In the first instance, all participants will be treated with respect and courtesy.

A strategy of ‘informed consent’ will be adopted, with the aim and methods of the research

being made clear to all participants.

The confidentiality and anonymity of individual respondents will be assured, and consent will be

sought for the interviews to be included in the research report.

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STUDY LIMITATIONS

• The study may have limited follow-up period which may not be long enough to identify further

morbidity and survival.

• Concomitant academic interests which may lead to constraints on the investigation in patient

follow-up since we are post graduate students with other academic engagements.
• The practice of discharging patients to the nearest health facilities may make it difficult to

follow-up some patients.

Incidence and prevalence

It is known that fracture incidence has elevated rates among children and adolescent, which

declines and raises later with advanced age. Some types of fractures for example hands and feet

typically occur early in life more often in men. They are linked to recreational and occupational

injuries. Other types are seen mostly in elderly such as hip fractures. They are more often in

women and are associated with bone loss and frailty related falls. The rate and prevalence of

fractures in children vary due to geographical area, age, and sex, and it ranges between 12-36

fractures per 100 children.