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Inflammatory Bowel Disease, Osteoporosis, Exercise, and Bone Mineral Density

Permanent Link: http://ufdc.ufl.edu/UFE0020500/00001

Material Information

Title: Inflammatory Bowel Disease, Osteoporosis, Exercise, and Bone Mineral Density
Physical Description: 1 online resource (56 p.)
Language: english
Creator: Zeilman, Charles J
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: bone, bowel, colitis, crohns, density, disease, efficacy, exercise, inflammatory, mineral, osteoporosis, ulcerative
Nursing -- Dissertations, Academic -- UF
Genre: Nursing Sciences thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Patients with inflammatory bowel disease (IBD) are at increased risk of developing osteopenia and osteoporosis. The purpose of this study was to examine the feasibility of a non-pharmacological nursing intervention designed to prevent bone loss, reduce the risk of fractures, and promote self-efficacy in adults with Inflammatory Bowel Disease (IBD), Crohn's disease and Ulcerative Colitis (UC). The intervention consisted of progressive load-bearing walking utilizing a weighted vest. Sixteen men, age 30 to 75 years, were recruited to participate in the study. Following baseline testing, subjects were randomly assigned to an exercise group (n=7), or to a sedentary control group (n=9). Subjects in the exercise group participated in 32 weeks (three, 50 minute sessions/week) of exercise training. Training consisted of a home based walking while wearing weighted vests. Measurements included (1) dual-energy x-ray absorptiometry (DEXA) scans of the hip and lumbar spine, (2) serum biochemical markers of bone formation, bone-specific alkaline phosphatase, marker of bone anabolism, and pyridinoline cross-links, an indicator of bone catabolism, or resorption, (3) Osteoporosis Self-Efficacy Scale and (4) change in systolic blood pressure. Results showed no significant differences between the groups.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Charles J Zeilman.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Jessup, James V.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0020500:00001

Permanent Link: http://ufdc.ufl.edu/UFE0020500/00001

Material Information

Title: Inflammatory Bowel Disease, Osteoporosis, Exercise, and Bone Mineral Density
Physical Description: 1 online resource (56 p.)
Language: english
Creator: Zeilman, Charles J
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: bone, bowel, colitis, crohns, density, disease, efficacy, exercise, inflammatory, mineral, osteoporosis, ulcerative
Nursing -- Dissertations, Academic -- UF
Genre: Nursing Sciences thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Patients with inflammatory bowel disease (IBD) are at increased risk of developing osteopenia and osteoporosis. The purpose of this study was to examine the feasibility of a non-pharmacological nursing intervention designed to prevent bone loss, reduce the risk of fractures, and promote self-efficacy in adults with Inflammatory Bowel Disease (IBD), Crohn's disease and Ulcerative Colitis (UC). The intervention consisted of progressive load-bearing walking utilizing a weighted vest. Sixteen men, age 30 to 75 years, were recruited to participate in the study. Following baseline testing, subjects were randomly assigned to an exercise group (n=7), or to a sedentary control group (n=9). Subjects in the exercise group participated in 32 weeks (three, 50 minute sessions/week) of exercise training. Training consisted of a home based walking while wearing weighted vests. Measurements included (1) dual-energy x-ray absorptiometry (DEXA) scans of the hip and lumbar spine, (2) serum biochemical markers of bone formation, bone-specific alkaline phosphatase, marker of bone anabolism, and pyridinoline cross-links, an indicator of bone catabolism, or resorption, (3) Osteoporosis Self-Efficacy Scale and (4) change in systolic blood pressure. Results showed no significant differences between the groups.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Charles J Zeilman.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Jessup, James V.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0020500:00001


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3234619a93c16ac8243875182a0dc544fa28742a







INFLAMMATORY BOWEL DISEASE, OSTEOPOROSIS, EXERCISE, AND BONE
MINERAL DENSITY




















By

CHARLES JOSEPH ZEILMAN III


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2007


































2007 Charles Joseph Zeilman III

































To my parents who always stressed the value of education and the belief that anything is
possible.









ACKNOWLEDGMENTS

I would like to thank my supervising committee chair, Dr. James Vernon Jessup, for his

guidance, encouragement and patience. I appreciate his mentorship throughout my education and

career that he has provided since 1994.

I gratefully acknowledge and extend my appreciation to my supervising committee

members (Saunjoo Yoon, PhD, Stephen Dodd, PhD, and John F. Valentine, MD). Each of them

provided areas of specialty knowledge and moral support. I would like to thank Dr. Dodd for his

support in learning effects of exercise on the human body, Dr. Yoon for her support and

application of Nursing theory, and Dr. Valentine for leadership, mentorship and education on

treating patients with IBD.

I also want to thank my best friend Todd Houchin who tolerated many days missed for

events throughout this process. Lastly, I want to give special thanks to children Casey and Joey

for their understanding and especially my wife Pam who tolerated and supported me.









TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ..............................................................................................................4

L IS T O F T A B L E S ................................................................................. 7

LIST OF FIGURES .................................. .. ..... ..... ................. .8

ABSTRAC T ...........................................................................................

CHAPTER

1 INTRODUCTION ............... ................. ........... .............................. 10

B background of the P problem .......................................................................... ......... ........... 10
Purpose of Study ............................................................... ... ........ ............... 11
C conceptual Fram ew ork ........................................... .... ......... ... .. ................11
Significance of this Study ........................................................ ........ .. ............ 12
Research Hypotheses .............. ................. ............ .................. ......... 13

2 L ITE R A TU R E R E V IE W ........................................................................ .. ....................... 14

Pathogenesis of O osteoporosis ........................................................... .. ............... 14
Inflammatory Bowel Disease and Osteoporosis...................... ... ........................ 14
Risk Factors for O steoporosis.................................................... ...... 15
Treatm ent and Prevention of O steoporosis........................................................ ..................15
Nutritional Factors and Osteoporosis: The Role of Calcium and Vitamin D .........................16
Effects of Exercise on Bone Health .................................................................... 17
Biochemical M arkers of Bone M etabolism ................................ ......................... ........ 18
Self-E efficacy and E exercise ........................................................................... ....................19
Literature Review Sum m ary ............................................................................. 20

3 M A TER IA L S A N D M ETH O D S ........................................ .............................................22

R e se a rc h D e sig n ............................................................................................................... 2 2
S am ple an d S getting ..........................................................................2 3
Random Assignment to Treatment Groups ........................................ ........................ 24
M measures and R research V ariables ................................................ .............................. 25
Independent variable ............................................ .. .. ........... ......... 25
Dependent variables .............. ..... ............ .... .......... ........ .. .......... 26
The osteoporosis self-efficacy scale (OSES) ...................................... ............... 27
Exercise m easurem ents .............................. .. ....................... .. ...... ............... 28
Biochem ical variables .................................. .. .. ... ....... .. .............28
P ro cedu res .............................................................................................2 8
E x ercise G group P rotocols ............................................................................. .................... 29
D ata A naly sis ...............................................................................................3 1









Potential Health Risks .................. ............... ........ ........... ...............3 31

4 A N A L Y SIS A N D R E SU L T S........................................................................ ...................34

Descriptive Statistics ................................. .. ... .... ................... 34
Descriptive Variables.......... ........ ............. .. ... .. ....................35

5 DISCUSSION ...................... ................. ................... 38

D discussion of Findings ........................ .. ........................ .. .... ........ ....... .. 38
H ypotheses.......... ...........................................................38
Descriptive Variables ................................ 39
L im itatio n s o f S tu d y ............................................................................................................... 4 0
Statistical A analysis L im stations ........................................... .................. ............... 41
Strengths of Study ......................................................................................................... 4 1
C o n c lu sio n s......................... ...................................................................... ............ 4 1
R ecom m endations for Future R esearch...................................................................... ...... 42
Im plications for Clinical Practice ........................................................................ 42

ABSTRACT

A DEMOGRAPHIC INFORMATION ......................................................... ..............43

B MEDICAL HISTORY QUESTIONNAIRE...................................................... ...............44

C OSTEOPOROSIS SELF-EFFICACY SCALE ........................................... .....................46

D T IM E L IN E ............................................................................... 4 9

E EXERCISE AND CALCIUM AND VITAMIN D SUPPLEMENTS LOG BOOKS ..........50

L IST O F R E F E R E N C E S ......... .. ............... ................. ............................................................52

B IO G R A PH IC A L SK E T C H .............................................................................. .....................56


















6









LIST OF TABLES


Table page

4-1 Baseline data analysis: demographics...................... ..... ............................. 35

4-2 Baseline data analysis: dependent variables ........................................... ............... 36

D-1 Load bearing walking schedule of progression ................ .............. ..................49

D-2 Timeline for individual subjects: Each subject will be required to participate in the
study for approxim ately 45 weeks ............................................................................. 49









LIST OF FIGURES

Figure page

2-1 Corticosteroids and bone m ineral density................................................... ............... 21

4-1 Pre and post D EX A scan results .............................................. .............................. 36

4-2 Effects of exercise on systolic blood pressure ....................................... ............... 37

4-3 Effects of exercise on body mass index (BM I)..................... ........................................ 37











































8









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

INFLAMMATORY BOWEL DISEASE, OSTEOPOROSIS, EXERCISE, AND BONE
MINERAL DENSITY

By

Charles J. Zeilman, III

August 2007

Chair: James Vernon Jessup
Major: Nursing Sciences

Patients with inflammatory bowel disease (IBD) are at increased risk of developing

osteopenia and osteoporosis. The purpose of this study was to examine the feasibility of a non-

pharmacological nursing intervention designed to prevent bone loss, reduce the risk of fractures,

and promote self-efficacy in adults with Inflammatory Bowel Disease (IBD), Crohn's disease

and Ulcerative Colitis (UC). The intervention consisted of progressive load-bearing walking

utilizing a weighted vest. Sixteen men, age 30 to 75 years, were recruited to participate in the

study. Following baseline testing, subjects were randomly assigned to an exercise group (n=7),

or to a sedentary control group (n=9). Subjects in the exercise group participated in 32 weeks

(three, 50 minute sessions/week) of exercise training. Training consisted of a home based

walking while wearing weighted vests. Measurements included (1) dual-energy x-ray

absorptiometry (DEXA) scans of the hip and lumbar spine, (2) serum biochemical markers of

bone formation, bone-specific alkaline phosphatase, marker of bone anabolism, and pyridinoline

cross-links, an indicator of bone catabolism, or resorption, (3) Osteoporosis Self-Efficacy Scale

and (4) change in systolic blood pressure. Results showed no significant differences between the

groups.









CHAPTER 1
INTRODUCTION

Background of the Problem

Epidemiology of osteoporosis-related fractures. In the United States, one in two women

and one in eight men older than 50 years will suffer an osteoporosis-related fracture in their

lifetime (Cooper, 2000). Of the more than 1.5 million fractures that occur each year, over

300,000 are fractures of the hip, 250,000 are fractures of the distal forearm, 700,000 are vertebral

fractures, and 250,000 are fractures at other sites (Riggs & Melton, 1995). A low bone mineral

density (BMD) has been reported in 30-75% of patients with IBD in cross-sectional and

prospective studies (Pollak et al., 1998). Compared to the general population, patients with IBD

have up to 40% more fractures (Frei et al., 2006). Most hip fractures are attributed to falls at

home while the majority of distal forearm (Colles') fractures are caused by extending the arm out

to break a fall. Vertebral fractures have a multiplicity of causes, but rarely result from a single

traumatic event. Of all fractures, those to the hip are the most devastating as they result in the

highest rate of morbidity and mortality (Kelley, 1998).

It is estimated that up to 33% of all hip fractures occur in men. Although women

typically experience hip fractures related to postmenopausal osteoporosis, men of all ages with

IBD experience increases morbidity and mortality due to steroid-related osteoporosis (Lawson,

2001). The incidence of fracture among persons with IBD is 40% greater than that in the general

population (Bernstein, Blanchard, Leslie, Wajda and Yu, 2000). Twenty-four percent of patients

die in the year after a hip fracture, and more than 40% are discharged from a hospital to a nursing

home (National Osteoporosis Foundation [NOF], 1997). By the end of one year, one-third of

those hip fracture patients are still in the nursing home. In addition, approximately 50% of all

people suffering a hip fracture will be unable to walk without assistance. Degenerative fractures









of the osteoporotic spine are subtle, but kyphosis due to vertebral collapse greatly diminishes

quality of life for many older men. The health-care cost of osteoporosis-related fractures is

nearly $14 billion annually in this country (NOF, 1997), but the cost in pain, suffering, lost

personal freedom and independence cannot be measured. Moreover, with the demographic shift

occurring in our population, the problem of osteoporosis-related morbidity and mortality will

likely increase.

Purpose of Study

The purpose of this study was to examine the feasibility of a home based non-

pharmacological nursing intervention to prevent bone loss, reduce the risk of fractures, and

promote self-efficacy in adults with Inflammatory Bowel Disease (IBD), Crohn's disease and

Ulcerative Colitis. The goal was to reduce morbidity associated with falls and bone fractures in

this population. The intervention consisted of progressive load-bearing walking and daily

calcium and vitamin D supplementation.

Conceptual Framework

Self-efficacy and exercise. An active lifestyle is particularly important for adults given

the broad constellation of physiological, behavioral, cognitive, and biochemical outcomes that

are influenced by physical activity. However, the majority of adults do not exercise or participate

in sports on a regular basis per a National Health Interview Survey (National Institute of Health,

1991). There are a number of theoretical explanations that provide an understanding of why

individuals choose to participate or not participate in health-related behaviors. Recently, self-

efficacy has received considerable support as a predictor of the initiation and maintenance of an

exercise program for health and fitness. The construct of self-efficacy is derived from Bandura's

social cognitive theory (1986). According to the theory, people are motivated to engage in a

behavior based on the belief that: (a) the behavior will result in a favorable outcome (outcome









expectation), and (b) the individual is capable of executing the behavior (efficacy expectation). A

meta-analysis of studies of health-related behaviors revealed consistent support for the

importance of self-efficacy as a determinant of healthy lifestyles, including regular exercise

(Gillis, 1993). Considerable literature further suggests that participation in exercise training has a

positive influence on self-efficacy. McAuley, Bane, and Mihalko (1995) examined the effects of

both long-term exercise participation and acute bouts of exercise on the physical self-efficacy of

middle-aged men and women. In addition to demonstrating the utility of physical mastery

experiences in influencing efficacy, McAuley Bane, and Mihalko (1995) reported some

interesting patterns with respect to gender responses. Whereas men and women demonstrated

significant gains in perceived capabilities in response to both acute and long-term exercise, men

initially were significantly more efficacious than women. I hypothesize that subjects in the

exercise group would gain both the psychomotor skills and the self-efficacy to continue

exercising as part of a healthy lifestyle.

Significance of this Study

The evidence clearly demonstrates that exercise training can offer a nonpharmacological

alternative for improving bone health in those who do not choose to take osteoporosis

medications (e.g., Biphosphonates). Other benefits associated with regular exercise include a

reduction in risk factors for many diseases, enhancement of overall functional fitness and well

being, and improved self-efficacy. It has not been clearly determined, however, what type,

magnitude, and duration of exercise would be the most efficacious for adults with IBD. The

exercise-training program described in this proposal combines ground-reaction and joint-reaction

forces to repeatedly place moderate, progressive strain on the whole skeleton, but more

specifically on the spine, femoral neck and hip, of men with IBD. Subjects trained for 50

minutes/day, 3 days/week, for 32 weeks. The first exercise session was closely supervised for









the subject's safety, and included warm-up and flexibility exercises, followed by walking while

wearing a weighted vest. Exercise with weighted vests improved dynamic balance, leg strength

and muscle mass in older women (Shaw & Snow, 1998). By walking while wearing vests with a

moderate weight (20% of body weight), adults with IBD were able to safely apply a load-bearing

strain to the bones of the spine and hip without the risk of pylometric (jumping or bouncing) or

high impact maneuvers. It is anticipated that the intervention would improve bone density,

physiologic exercise induced changes in vital signs, biochemical markers for bone resorption and

formation, and self-efficacy in adults with IBD.

Research Hypotheses

* Hypothesis 1: Thirty-two weeks of progressive load-bearing walking exercise by adults
with IBD who are not taking osteoporosis medications would result in increased bone
density of the lumbar spine, hip and femoral neck (measured by dual-energy X-ray
absorptiometry) significantly greater than that of adults with IBD who do not exercise.

* Hypothesis 2: Thirty-two weeks of progressive load-bearing walking exercise by adults
with IBD who are not taking osteoporosis medications would result in increased serum
levels ofBAP and increased ratios between BAP and DPD significantly greater than that
of adults with IBD who do not exercise.

* Hypothesis 3: Completion of a weeks exercise program by adults with IBD who are not
taking osteoporosis medications would result in improved self confidence in managing
their own care (measured by the Osteoporosis Self-Efficacy Scale) that are significantly
higher than those of adults with IBD who do not participate in exercise training.

* Hypothesis 4: Thirty-two weeks of progressive load-bearing walking exercise by adults
with IBD would result in improved systolic blood pressure.









CHAPTER 2
LITERATURE REVIEW

Pathogenesis of Osteoporosis

Osteopenia is defined as failure of the rate of osteoid tissue synthesis to keep up with the

rate of bone loss without respect to cause. It is characterized by abnormally low bone

mass/density and a disruption in the microarchitecture of bone tissue, leading to a reduced

effectiveness of trabecular cross bracing (Sheth, 1999). This loss of bone connectivity results in

bone fragility and fatigue. Once bone fatigue occurs, osteoblastic apoptosis ensues, resulting in

osteoporosis. If there is impact from a mechanical load, the bone may fracture. Osteoporosis is

clinically defined as bone mineral density (BMD), measured by dual energy x-ray

absorptiometry (DEXA) or computed tomography, of more than 2.5 standard deviations below

the reference value for a normal, healthy adult (Black, Palermo, & Bauer, 2000). Osteoporotic

fracture, however, is not a single disease with a single etiologic agent. It has multiple levels of

pathogenesis that involve genetic and cellular factors, developmental processes of bone

remodeling (bone growth in children and bone loss in aging), and environmental factors such as

falls (Cooper, 2000). Although bone loss is a universal concomitant of advanced age affecting

both men and women, it proceeds at a much faster rate in gastrointestinal disorders,

hypogonadism, immobilization, organ transplants or with certain medications.

Inflammatory Bowel Disease and Osteoporosis

The pathogenesis of bone loss in IBD is multifactorial, consisting of general risk factors

for osteoporosis and disease-specific factors including corticosteroid use, sex hormone

deficiency, lack of physical activity, vitamin D and calcium malabsorption secondary to active

disease and/or intestinal resection, and secondary to osteoclast activation by proinflammatory

cytokines (Southerland & Valentine, 2001). According to a study on young males, mean age 26,









who were steroid naive and a recent diagnosis of IBD, 28% had a decreased bone mineral

density (Sakellariou et al., 2006). Low body mass index was an independent factor for low bone

mineral density (Hela et al., 2005). Corticosteroid usage is the most common cause of secondary

osteoporosis. Chronic or excess corticosteroid has multiple effects on bone metabolism.

Corticosteroids not only decrease bone formation, they also increase bone resorption (Manolagas

& Weinstein, 1999). It has been demonstrated that corticosteroids inhibit osteoblast activity,

which stimulates osteoclast activity thus increasing bone resorption (Lawson, 2000). Due to the

increased rate of bone resorption and inhibition of bone formation, their usage associated with

rapid bone loss. Reid and Heap demonstrated that subjects starting corticosteroid therapy lost a

mean of 27% of the lumbar spine BMD within the first year of therapy.

Risk Factors for Osteoporosis

Risk factor identification for osteoporosis-related fractures is complex and agreement

between leading population-based studies is limited. It is clear that corticosteroid usage is a

major etiologic component and risk factor in bone fragility (Figure 2-1). Regardless of gender,

up to 50% of patients taking corticosteroids on a chronic basis sustain osteoporotic factures

(Lane & Lukert, 1998). Established risk factors for osteoporotic fractures in men include a

family history of osteoporosis, Caucasian, physical inactivity, low calcium and vitamin D intake,

previous history of fracture, mental depression, tobacco smoking, long-term use of steroids,

benzodiazepines, and anticonvulsant medications, gastrointestinal disease and

hyperparathyroidism (Cooper, 2000).

Treatment and Prevention of Osteoporosis

The treatment and prevention of osteoporosis includes both pharmacologic and

nonpharmacologic interventions. There have been great advances in the pharmacologic treatment

of osteoporosis in the past 15 years. The antiresorptive bisphosphonate agents, alendronate









(Fosamax) and risedronate (Actonel ) have been shown in clinical studies to reduce spine

fractures by about 50% when used in combination with estrogen replacement therapy (ERT) in

aestrogenic women (Tonino, Meunier, & Emkey, 2000). The bisphosphonates have serious side

effects, however, including esophageal ulceration, nausea, vomiting, diarrhea, hypocalcemia, and

renal toxicity. Other drugs have been investigated for the treatment of osteoporosis. In the 1980s,

sodium fluoride, an anabolic agent, was widely advocated as a treatment that reduced fractures

by improving BMD. Although BMD in treated subjects increased, they had significantly more

fractures of the lower extremities than the placebo control subjects (Gray, 2000). Unfortunately,

there is low compliance with osteoporosis drug therapy primarily due to cost. For example, daily

alendronate costs approximately $50 monthly. For many patients this cost makes drug therapy an

unrealistic option for the prevention and treatment of osteoporosis.

Nutritional Factors and Osteoporosis: The Role of Calcium and Vitamin D

Nutrition is a modifiable risk factor for osteoporosis. There is substantial evidence that

adequate calcium and vitamin D intake influences all aspects of bone health throughout the life

cycle, from the development of peak bone mass in adolescents, to the maintenance of bone mass

in adults, to the reduction of bone loss and fracture in the elderly (Heaney, 2000). A meta-

analysis of 15 randomized clinical trials found that Calcium supplementation improved BMD at

all skeletal sites in postmenopausal women (O'Shea et al., 2000). Other researchers found that

daily supplementation with 1000 mg calcium plus 400 IU vitamin D ergocalciferoll) for 12

months inhibited bone remodeling and significantly increased BMD in women who were 10

years postmenopause (Huang, Lu, Zhou, Liu, & Wang, 2000). Additionally, individuals with

IBD are at increased risk for vitamin D and calcium malabsorption secondary to active disease

and/or intestinal resections.









Effects of Exercise on Bone Health

Although there is substantial evidence that physical activity stimulates bone formation,

research on the mechanisms by which bone is affected by mechanical stress is in its early stages.

In 1892, Wolff (Smith, 1988, p. 81) hypothesized that weight bearing compresses and bends long

bones, consequently strengthening them and making them less likely to fracture. Weight bearing

(gravity) and muscle contraction are the major mechanical forces on bone. Bone mass increases

with greater weight bearing, muscle contraction or both and decreases with immobilization or

weightlessness. The degree of bone change is proportional to the difference in magnitude and

frequency of the mechanical stimulus from normal. Bassett (1971) indicated that bone functions

as a piezoelectric crystal, generating an electric charge in proportion to the forces applied to the

bone. Bone matrix is removed from areas of positive charge and laid down in areas of negative

charge. Carter (1984) hypothesized that mechanical forces produce microfractures, which

stimulate osteoclastic remodeling coupled with osteoblastic activity. Lanyon (1981)

demonstrated that both the rate and magnitude of strain influenced bone remodeling. He

monitored bone mineral in the radii of sheep under artificial stimulation. No change occurred

with strain magnitude less than that of the animal's normal walking load. With higher strain

magnitude and normal strain rates, periosteal bone deposition increased slightly. When both

magnitude and rate were higher than in normal walking, periosteal bone increased substantially.

Thus bone, like muscle, requires a specific magnitude and rate of stimulus in order to stimulate

hypertrophy. Although the specific level and magnitude of exercise to improve bone density in

humans has not been clearly delineated, most studies indicate 20 to 30 minutes of weight-bearing

exercise, 3 to 4 days per week will maintain skeletal health.

Exercise is considered to be an attractive alternative to pharmacologic interventions for

preventing and treating osteoporosis. Numerous case-control and retrospective and prospective









cohort studies suggest that exercise improves balance, coordination, and bone strength and thus

reduces the incidence and the severity of fall-related fractures (Kannus, 1999). Unfortunately, no

clinical trials have examined the effects of exercise on osteopenia or osteoporosis in men with

IBD. Numerous studies of the effects of exercise on osteoporosis in postmenopausal women

have been conducted, however, but with conflicting results. For example, one study found no

change in femoral neck BMD (Bloomfield, Williams, Lamb, & Jackson, 1993), while a second

study reported no change in BMD at the femoral neck or Ward's triangle, but did find a

significant increase in the trochanteric region (Kronhed & Moller, 1998). A third study reported

significant increases in BMD at the femoral neck, Ward's triangle, and trochanteric region

(Caplan & Ward, 1993), while a fourth study reported that exercise alone had no effect at any of

the hip sites, but that exercise and calcium supplementation had a positive effect on the femoral

neck (Lau, Woo, Leung, Swaminathan, & Leung, 1992). A more recent study from Jessup,

Home, Vishen, and Wheeler (2003) reported significant improvements in bone mineral density

of the femoral neck and lumbar vertebra in postmenopausal women following 8 months of

exercise training and calcium supplementation. The training consisted of 30-60 minutes of

walking, three days/week while wearing weighted vests. Subjects also took 1000 mg calcium

citrate and 400 IU vitamin D daily during the study period (Appendix F). Taken together these

studies show 4 to 12 months of exercise can inhibit bone loss and improve BMD in adults.

Biochemical Markers of Bone Metabolism

Previous studies of the effects of resistance exercise training on BMD have utilized the

analyses of serum chemical markers of bone metabolism. Serum levels of osteocalcin (OC) and

bone-specific alkaline phosphatase (BAP), both markers of bone anabolism, have been shown to

be sensitive to alterations in bone metabolism following disease, menopause, and hormone

replacement therapy. Serum pyridinoline cross-links (PYD) are an indicator of bone catabolism,









or resorption. In theory, an increase in BMD would be reflected by an increase in OC and BAP

as well as in increase in the ratios between OC and BAP and PYD. Vincent and Braith (2002)

analyzed serum levels of OC, BAP, and PYD in a group of men and women before and after 6

months of low-intensity (LEX) or high-intensity (HEX) resistance exercise training. Although

there were no differences in serum levels of the three biochemical markers between the LEX,

HEX and control groups, nor between the male and female subjects at the beginning of the study,

they were significant increases in OC in both the HEX and LEX groups after 6 months of

training. BAP increased significantly for the HEX group but not for the LEX or control groups.

They also found that the ratios of OC and BAP to PYD increased in the exercise groups but not

in the controls after the 6-month period. They concluded that the increases in the biochemical

markers of bone anabolism and the increased ratios of OC and BAP to PYD were consistent with

increases in BMD measured by dual-energy x-ray absorptiometry observed in the exercise

groups. These three biochemical markers may help explain the alterations that occur in bone

turnover as a result of disease, menopause, hormone replacement and other therapies as well as

exercise training. In a multifactorial analysis of risk factors for decreased bone mineral density in

inflammatory bowel disease, the biochemical marker DPD were consistently elevated indicating

an increase in bone resorption (Bartram et al., 2006).

Self-Efficacy and Exercise

An active lifestyle is particularly important for older adults given the broad constellation

of physiological, behavioral, cognitive, and biochemical outcomes that are influenced by

physical activity. The majority of adults, however, do not exercise or participate in sports on a

regular basis according to the National Health Interview Survey (NIH, 1991). There are a

number of theoretical explanations that provide an understanding of why individuals choose to

participate or not participate in health-related behaviors. Recently, self-efficacy has received









considerable support as a predictor of the initiation and maintenance of an exercise program for

health and fitness. The construct of self-efficacy is derived from Bandura's social cognitive

theory (1986). According to the theory, people are motivated to engage in a behavior based on

the belief that: (a) the behavior will result in a favorable outcome (outcome expectation), and (b)

the individual is capable of executing the behavior (efficacy expectation). A meta-analysis of

studies of health-related behaviors revealed consistent support for the importance of self-efficacy

as a determinant of healthy lifestyles, including regular exercise (Gillis, 1993). A considerable

literature further suggests that participation in exercise training has a positive influence on self-

efficacy. McAuley, Bane, and Mihalko (1995) examined the effects of both long-term exercise

participation and acute bouts of exercise on the physical self-efficacy of middle-aged men and

women. In addition to demonstrating the utility of physical mastery experiences in influencing

efficacy, McAuley, Bane and Mihalko (1995) reported some interesting patterns with respect to

gender responses. Whereas men and women demonstrated significant gains in perceived

capabilities in response to both acute and long-term exercise, men initially were significantly

more efficacious than women. We hypothesize that subjects in the exercise group will gain both

the psychomotor skills and the self-efficacy to continue exercising as part of a healthy lifestyle.

Literature Review Summary

The literature has demonstrated that osteoporosis is a significant healthcare concern.

Osteoporosis is associated with a high morbidity and mortality rate and is a risk factor for

fractures. Due to the long-term us of corticosteroid drugs and other factors, patients with

inflammatory bowel disease (IBD) are at increased risk of developing osteopenia and

osteoporosis compared to the general population. There have been multiple interventions that

have demonstrated an improvement in BMD. The literature review has demonstrated exercise as

an effective non-pharmacological intervention for BMD.

































Figure 2-1. Corticosteroids and bone mineral density









CHAPTER 3
MATERIALS AND METHODS

Research Design

This study was a randomized parallel design to examine the effects of progressive load-

bearing walking exercise in adults with IBD and a prior history of steroid usage but not within

the last 12 months and who have chosen not to take osteoporosis medications. Following initial

screening and testing procedures, subjects were randomly assigned to an exercise group or a

sedentary control group. The principal investigator (PI) supervised the testing of all subjects and

the initial exercise training session of subjects randomized to the exercise group. The co-

investigator assisted with the testing and training. The control group did not participate in regular

exercise during the study period. Sixteen adults, age 21 to 75 years, were recruited to participate

in the study. Following baseline testing, subjects were randomly assigned to an exercise group

(n=7), or to a sedentary control group (n=9). Subjects in the exercise group were issued a

weighted vest, a pedometer/step counter, an exercise log-book, Calcium/Vitamin D log-book and

instructed in their use. Training consisted of stretching and flexibility calisthenics and walking

while wearing weighted vests. Subjects completed three, 50 minute exercise sessions/week for

32 weeks at home. Measurements for all subjects included: (1) dual-energy x-ray absorptiometry

(DEXA) scans of the hip and lumbar spine, (2) biochemical markers of bone metabolism: serum

bone specific alkaline phosphatase (BAP) and urinary deoxypridinoline (DPD), (3) Osteoporosis

Self-Efficacy Scale (OSES) and (4) systolic blood pressure. All variables were measured at

baseline and after 32 weeks. Statistical analyses compared changes in Systolic Blood Pressure,

bone density of the femoral neck, hip and lumbar spine, serum levels of BAP and DPD and the

ratios between the BAP and DPD, and scores on the OSES within and between the two groups.









This research project was approved by the University of Florida, Institutional Review

Board and North Florida/South Georgia Veterans Health Care System Subcommittee for

Investigation.

Sample and Setting

Eighteen men, aged 21 to 75 years, were recruited from the Gastroenterology clinics at the

North Florida/South Georgia Veterans Health Care Center. Sample size calculations revealed

that a sample size of 18 subjects (n=9 in each group) would give a statistical power of 0.80.

However, due to recruitment difficulties that will be discussed later, the study was halted with a

final sample size of 16 subjects, 9 in control and 7 in exercise groups. To estimate the effect size,

the investigators assumed there would be no changes in variables in the control group, and a

standard deviation for the changes from baseline scores in the experimental group. The standard

deviation estimates are based on the results from previous studies conducted by the investigators

and from the literature review (Jessup, Home, Vishen, & Wheeler, 2003; Vincent & Braith,

2002).

Inclusion criteria. Subjects selected were adults with IBD, who were not currently taking

hormones (e.g., testosterone), osteoporosis medications, or steroids, and have not done so for the

prior 12 months. Subjects agreed to undergo two DEXA scans of their lumbar spine, femoral

neck and dominant hip, to take 1200mg of calcium and 400 IU vitamin D daily, and to

participate in either an exercise group or a non-exercise group for 32 weeks. In addition, all

subjects selected were sedentary (i.e., not currently participating in regular exercises such as

walking, jogging, cycling, dance aerobics, strength training, etc., and have not done so for the

previous 12 months). There was no exclusion of subjects from the study based on race or ethnic

origin. Subject attrition was minimized by weekly phone calls by the investigator to subjects in

both groups. During these phone calls the investigator will answer questions and offer









encouragement to follow study protocols. Each subject was also paid a $100.00 honorarium

(prorated) for participating in the study.

Exclusion criteria. Subjects were excluded from the study if their medical history or

physical examination demonstrates evidence of significant cardiovascular disease or other

disorders that would prevent safe participation in the study. The following conditions were

considered exclusionary:

Hospitalizations within the past 12 months for angina pectoris, myocardial infarction,

coronary artery revascularization procedures (angioplasty and/or coronary artery bypass-graft

surgery), or any other cardiac surgeries.

* Congestive heart failure, cardiac pacemakers, heart rate >100 or <50 at rest.

* Blood pressure (uncontrolled or controlled by medications): Resting systolic blood
pressure> 160 mmHg and/or resting diastolic blood pressure >100 mmHg.

* Duel-energy x-ray absorptiometry (DEXA) scan revealing bone mineral density of lumbar
vertebra 2, 3, and 4 or femoral neck of the dominant hip greater than 3.5 standard
deviations below that of a normal, healthy adult.

* Diabetes mellitus or other metabolic or endocrine disorders requiring hospitalization
within the past 12 months.

* Neuromuscular or orthopedic limitations to normal, unassisted ambulation.

* Known or suspected sensitivity to calcium or vitamin D supplements.

* Any other medical, cognitive impairment, or psychiatric conditions, which, based on the
clinical expertise of the investigators or the subject's personal health-care provider would
make participation in the study not in the subject's best interest.

Random Assignment to Treatment Groups

Following the baseline screening and testing procedures, subjects were randomly assigned

to either the exercise or control groups using a computerized random number generator. All

subjects were asked to not change their usual daily eating habits during the study, and subjects

assigned to the control group were asked to continue their usual activities of daily living but to









not begin an exercise program during the 32-week study period. To minimize individual

variations in the dietary intake of calcium and vitamin D, subjects in both groups were asked to

discontinue taking any over-the-counter calcium or vitamin D supplements or any

multivitamin/mineral supplements containing calcium or vitamin D during the study period as it

was provided by the study. Subjects in both groups were issued a 90-day supply (180 doses) of

medication bottles containing 600-mg calcium citrate and 200 IU vitamin D as cholecalciferol.

After contacting the subjects on their adherence to the medications the PI then refilled the

subjects 90 day supply (180 doses) of medications. Subjects were instructed to take one capsule

every morning and one capsule every evening at least 1 hour before or after eating a meal and

record in a daily log book (total daily dose of 1200 mg calcium and 400 IU vitamin D). Subjects

were instructed that if they should miss taking a scheduled capsule, to not "double-up" by taking

2 capsules, but rather to continue taking the capsules with the next scheduled dose. Subjects

were also instructed to immediately notify the investigators) if they experience any type of

adverse reaction that could be associated with the calcium or vitamin D such as nausea,

vomiting, constipation, dry mouth, metallic taste, or skin rashes. Subjects were asked to bring

their log usage of calcium/vitamin D and bring their medication bottles to the investigators at the

Malcolm Randall Veteran's Medical Center, Gainesville Florida at the end of the study

(Appendix E). They were also asked to notify the investigators if there are any changes in their

health status or prescription medications during the study period.

Measures and Research Variables

Independent variable

The independent variables in this study is progressive load-bearing walking exercise. The

exercise-training program described in this proposal combines ground-reaction and joint-reaction

forces to repeatedly place moderate, progressive strain on the whole skeleton, but more









specifically on the spine, femoral neck and hip, of men with IBD. Subjects trained for 50

minutes a day, 3 days a week, for 32 weeks.

Dependent variables

The dependent or outcome variables measured in this study included bone density of the

lumber spine, hip and femoral neck of the dominant leg, Osteoporosis Self-Efficacy Scale,

exercise measurements and biochemical variables.

Bone density of the lumbar spine (L-2, 3, and 4), hip and the femoral neck of the dominant

leg measured by a Lunar ProdigyTM Bone Densitometer at the Nuclear Medicine Department,

Malcolm Randall Veterans Medical Center, Gainesville, Florida. The Lunar instrument uses a

technique known as dual-energy x-ray absorptiometry (DEXA) to perform non-invasive

estimates of BMD in specific regions of the body (Lunar ProdigyTM). DEXA utilizes a pencil-

beam x-ray filtered to provide the two distinct energy peaks necessary to distinguish bone from

soft tissue. Dual Nal scintillation crystals are used to separately detect the two x-ray energies.

The technique for separating x-ray output into two distinct energy levels is known as K-edge

filtration. In K-edge filtering, a rare earth element is placed in the beam path and x-rays are

sharply attenuated at energy levels particular to that element. Lunar uses samarium as the filter

material because it produces energy peaks at 46.8keV and 80keV, which have proven to be most

effective at differentiating between soft tissue and bone tissue. The DEXA scans were conducted

by a radiology technician especially trained to operate the Lunar DEXA equipment. The subjects

were asked to lie on the table where padding and adjustable straps were placed to prevent

movement. The scan took approximately 15 minutes for each subject. Once the scan was

completed, the Lunar equipment produces a printout indicating the BMD in g/cm2 and the BMD

percentage compared with young healthy normal controls (the T score with standard deviations









above or below normal). The density in g/cm2 and the T scores were used in the data analyses of

this study. Subjects with bone mineral densities of the femoral neck or lumbar spine greater than

3.5 SD below young healthy normal controls were excluded from the study.

The osteoporosis self-efficacy scale (OSES)

The OSES instrument, developed and evaluated by Horan and colleagues (1998), is a self-

administered instrument, worded at a sixth grade readability level that consists of 21 items in a

visual analog format. The lower anchor of a 10-cm line is labeled "not at all confident" and the

upper end is labeled "very confident". The phase "If it were recommended that you do any of the

follow this week, how confident would you be that you could" is used as the stem for the items.

Items include such statements as "begin a new or different exercise program", "exercise for the

appropriate length of time", and "do exercises even if they are tiring". Subjects were asked to

indicate the degree of confidence they feel in their ability to do the activity by placing an X on

the line that is calibrated from 0 to 100mm, on each of the 21 items. Horan and colleagues

evaluated the criterion-related validity of the OSES by comparing responses on the instrument

from 201 women, ages 35 to 95, with responses on the Atherosclerosis Risk in Communities

(ARIC)/Baecke Habitual Physical Activity (ABHPAQ; Baecke, Burema, & Frijiters, 1982)

instrument. The ABHPAQ measures self-efficacy on a sport/leisure scale and on a general

exercise scale. Controlling for biographic (age, height, and weight) variables and experiential

(years of education, friends, family, or both with osteoporosis) variables, the OSES had a

correlation of 0.52 (p< 0.01) with the sport/leisure scores and a correlation of 0.65 (p<0.01) with

the general exercise scores of the ABHPAQ instrument. The internal consistency estimates of the

OSES were also strong (0.94) (Horan, Kim, Gendler, Froman, & Patel, 1998).









Exercise measurements

A pedometer was used to measure the time, distance and adherence to the exercise

protocol. Each subject was provided a pedometer/step counter (Fitness Pedometer 360TM,

Sportline Inc., Campbell, CA) and instructed in its use. The pedometer will record up to 100,000

steps. The pedometer also measured time the subject has walked. After their walks, subjects

were asked to log the time, mileage, and steps in a logbook provided.

Biochemical variables

Non-fasting blood and urine samples were collected from each subject at baseline and at 32

weeks. Bone-specific alkaline phosphatase (BAP) was measured in serum using an Alkphase-

B enzymatic immunoassay kit (EIA) (Metra Biosystems, Mountain View, CA). The assay is

highly specific for BAP, cross-reacting < 8% with liver alkaline phosphatase and not

significantly with other alkaline phosphatase isoenzymes. Urinary deoxypyridinoline (DPD) was

measured from Quest Diagnostics Nichols Institute utilizing luminescent immunoassay To

explore the possible influence of load-bearing exercise on the state of bone metabolism, ratios of

BAP (anabolic indicator) to DPD (catabolic indicator) were calculated.

Procedures

A timeline for individual subjects can be found in Appendix D Table 2. Below is a

description of Visit 1 Part a, Visit 1 Part b, and Visit 2.

Visit 1 Part a. Potential subjects were invited to an orientation session at the Malcolm

Randall Veteran's Medical Center, Gainesville Florida. The investigators explained the

purposes, procedures, potential risks and benefits, and general conditions for the study.

Questions were encouraged and time was allowed for subjects' inquiries prior to agreeing to

participate in the study. Subjects who agreed to participate were asked to sign an informed









consent document and to complete demographic and health-history questionnaires. Subjects

were then asked to complete the Osteoporosis Self-Efficacy Scale (OSES, Appendix C).

Visit 1 Part b. Subjects who have completed Visit l(a) underwent a physical examination

conducted by the PI, including resting heart rate and blood pressure measurements. Subjects who

met the preliminary inclusion criteria were given an appointment to visit the Nuclear Medicine

Department, Malcolm Randall Veterans Medical Center, Gainesville, Florida for DEXA scans of

their spine, femoral neck and hip. Subjects were informed by telephone of the results of their

DEXA scans and whether they met the inclusion criteria for the study. Subjects who met the

inclusion criteria were scheduled to attend Visit 2. They were asked to wear comfortable, loose-

fitting clothing and rubber soled walking shoes suitable for exercising when they attend Visit 2.

Visit 2. Blood drawing: Visit 2 was conducted at the Malcolm Randall Veteran's Medical

Center, Gainesville Florida. The lab collected a 30-mL blood sample from each subject via

venipuncture and obtained urine sample. During this visit, the subjects in the experimental group

were instructed in proper stretching and warm up exercises prior to exercise. Subjects were

instructed regarding proper footwear, clothing, and hydration for exercising. The control group

was instructed to not engage in any new exercise programs.

Exercise Group Protocols

The investigators monitored all exercise training progress either by weekly telephone or

email correspondence with each subject in the exercise group. All exercise training was

conducted according to the guidelines published by the American College of Sports Medicine

(ACSM, 2000). Subjects in the exercise group completed 32 weeks (three, 50 minute

bouts/week) of walking at a normal pace while wearing weighted vests. Subjects were instructed

regarding proper footwear, clothing, and hydration for exercising. Each exercise session will









begin with 10 minutes of stretching and warm-up calisthenics, and end with 10 minutes of cool

down walking and stretching.

Load-bearing walking. Subjects were issued and fitted with an adjustable lightweight

nylon vest (All Pro Weight Adjustable Exercise VestTM, Fit-1, Inc., Salisbury, Ma). The vest has

foam cushioning for the shoulders, chest, and back, and has twenty pockets with VelcroTM

closures on the front and back that will each accommodate a 0.48 kg (1 lb) weight. The pockets

can accommodate a total of 18.2 kg (40 lbs). For the first week, the subjects walked wearing only

the vest (without weights). Weights were added gradually for all subjects to increase load

bearing up to max of 20 pounds of weight during weeks 9-12 (Appendix D Table 1: Load

bearing walking schedule of progression). Each subject was provided a pedometer/step counter

(Fitness Pedometer 360TM, Sportline Inc., Campbell, CA) and instructed in its use. The

pedometer will record up to 100,000 steps. The pedometer also measured time the subject has

walked. After their walks, subjects were asked to log the time, mileage, and steps in a logbook

provided. The PI either contacted by telephone or email each subject weekly to inquire about

progress and to discuss any concerns or problems the subject may be experiencing. The exercise

log-book information was collected every 7 days when the subjects were contacted by the

investigator as described above.

End-point testing. End-point testing was conducted no longer than 5 days after the end of

the training/control periods.

Visit 3. Visit 3 was conducted at the Malcolm Randall Veteran's Medical Center,

Gainesville Florida at the end of the 32-week study period for the experimental and the control

group. Repeat resting heart rate and blood pressure measurements were obtained. Urine sample

and 30 mL of blood sample were collected in the laboratory at the Malcolm Randall Veteran's









Medical Center, Gainesville Florida.subjects were then be asked to complete the OSES

instrument and DEXA scans of the lumbar spine, femoral neck and dominant hip were repeated

exactly as in Visit 1, Part b.

Data Analysis

The data analysis for this study was conducted using the Statistical Package for the Social

Sciences (SPSS) program, version 15.0 (SPSS Inc., Chicago, IL). Descriptive statistics were

first obtained to provide summary measures for both exercise and control groups. Descriptive

characteristics were compared between groups using analysis of variance (ANOVA). All

statistical analyses were performed using the SPSS statistical software program. An alpha level

of p<0.05 was required for statistical significance.

As previously discussed, subjects were recruited from the North Florida/ South Georgia

Veterans Healthcare System. Over 300 participants were initially assessed for the study,

however only 18 actually began the program with 16 completing the study. The two participants

did not complete the study, one control subject was not able to arrange travel for the post test

evaluation and one experimental subject moved and was not able to make the trip for post test

evaluation. Thus the data analysis was performed on the 9 participants who comprised the

control group and 7 participants who comprised the treatment group.

Potential Health Risks

The risks associated with this study protocol include the risks associated with DEXA

scans, venipuncture, exercise training, and the oral administration of calcium and vitamin D.

There were no potential psychological, social, legal, or other risks to subjects participating in this

project. Risks are discussed in the paragraphs below.

Dual-energy x-ray absorptiometry (DEXA) scans. The radiation exposure from a Lunar

ProdigyTM bone density scan of the spine and hip ranges from 1-3 millirems (mREMs),









depending on the body size (thickness and density) of the individual subject. Compared with 70

mREMs from a typical two-view chest x-ray, or up to 100 mREMs from some dental x-rays,

radiation exposure from the DEXA scan is minimal. In fact, the radiation dose is so low that no

external shielding is required for either the subject or the technologist performing the test (Lunar

ProdigyTM, 2000). In this project, each subject had two DEXA scans approximately 8 months

apart.

The risks of the exercise training, walking, was minimized in this project by the study

design: (1) the rigid exclusion criteria eliminated subjects with unstable cardiovascular or other

diseases, (2) all subjects underwent a physical examination prior to exercise testing, (3) the

principal investigator, a registered nurse and an Advance Nurse Practitioner experienced in

exercise testing and training of older adults, conducted all exercise tests, (4) subjects were

instructed in proper stretching and warm-up techniques prior to testing, (5) subjects were

instructed to stop and notify the investigator if they notice any type of pain or discomfort during

the testing, and (6) following testing, subjects were instructed on proper stretching and "cool-

down" calisthenics to minimize muscle/joint soreness. Walking for exercise is associated with

very little cardiovascular risk. Only one fatal event has occurred over the past 15 years of

exercise training at the Aerobics Activity Center in Dallas; an event rate of less than one in over

one-million miles of walking and running (Pollock & Wilmore, 1995). A five-year follow-up

study of the risks of strenuous exercise in 2,935 men women, 17 to 76 years of age, reported two

fatal cardiovascular events in over 370,000 person-hours of exercise which represented over

1,600,000 miles of walking and running (Hagberg et al., 1989). The risks associated with

training in this project also included the potential for minor musculoskeletal injuries from the

weighted-vest walking exercises.









The risks of musculoskeletal injuries and falling during the weighted-vest walking were

minimized in this project. Subjects were fitted with an adjustable lightweight nylon vest that has

foam cushioning for the shoulders, chest, and back, and has ten pockets with VelcroTM closures

on the front and back that will each accommodate a 0.48kg (llb) weight. During the first week of

training, subjects walked wearing the vest without weights; weight was added gradually to

increase load bearing to 20% of the subject's body weight during the 40-week study period.

Nutritional supplementation with calcium and vitamin D: All subjects were supplied with

and asked to take one capsule, twice per day containing 600 mg calcium citrate and 200 IU of

vitamin D as cholecalciferol (total daily dose of 1200 mg calcium and 200 IU vitamin D per

day). The RDA for adults of calcium is 1200 mg per day and for vitamin D is 400 IU per day

(Dickinson, 2002). Adverse effects associated with oral calcium supplementation include

constipation, nausea, vomiting and kidney stones. Adverse effects associated with vitamin D

supplementation include nausea, vomiting, anorexia, dry mouth, metallic taste, and headache. To

minimize risks to subjects in this project, subjects will be carefully advised to discontinue the

study drugs and notify the investigators immediately if they experience any adverse effects or

symptoms that could possibly be related to the calcium and vitamin D. During the initial

screening period, subjects who reported having a history of intolerance, sensitivity, or any

allergies to either calcium or vitamin D supplements were excluded from the study.

Venipuncture. There is minimal risk associated with the blood drawing techniques used

in this study. Drawing blood from a vein causes discomfort, possible bruising, and is rarely

associated with infection, and uncommonly, faintness. A certified phlebotomy staff member

collected all blood in this study using proper sterile techniques to minimize these risks.









CHAPTER 4
ANALYSIS AND RESULTS

Descriptive Statistics

Participant demographics included in the analyses were the subjects age, IBD disease type,

disease duration, bowel resection and education level. There was no significant difference in age,

disease type or education level (Table 4-1). Participant baseline tests included in the analyses

were body mass index, systolic blood pressure, diastolic blood pressure, heart rate, Osteoporosis

Self-Efficacy Scale, lumbar spine bone mineral density, hip bone mineral density, femoral neck

bone mineral density, bone alkaline phosphatase, and urinary deoxypridinoline. The systolic

blood pressure, disease duration, and length of bowel resection were the only variables with a

statistical significance between the groups at baseline (Table 4-1 and 4-2).

* Hypothesis 1: Thirty-two weeks of progressive load-bearing walking exercise by adults
with IBD who are not taking osteoporosis medications will result in increased bone density
of the lumbar spine, hip and femoral neck (measured by dual-energy X-ray
absorptiometry) significantly greater than that of adults with IBD who do not exercise.
There was no significant difference between the groups for lumbar spine bone mineral
density (g/cm2) (F=1.493, p=0.241). There was a significant difference between the groups
for hip bone mineral density (g/cm2) (F=6.403, p=0.023). There was a significant
difference between the groups for the Femoral Neck bone mineral density (g/cm2)
(F=13.279, p=0.002). Figure 4-1 demonstrates the pre-test and post-test bone density
results.

* Hypothesis 2: Thirty-two weeks of progressive load-bearing walking exercise by adults
with IBD who are not taking osteoporosis medications will result in increased serum levels
ofBAP and increased ratios between BAP and DPD significantly greater than that of
adults with IBD who do not exercise.There was no significant difference between the
groups for urine BAP (F=0.818, p=0.384). There was no significant difference between the
groups for urine DPD (F=0.825, p=0.380).

* Hypothesis 3: Completion of a weeks exercise program by adults with IBD who are not
taking osteoporosis medications will result in improved self confidence in managing their
own care (measured by the Osteoporosis Self-Efficacy Scale) that are significantly higher
than those of adults with IBD who do not participate in exercise training. There was no
significant difference between the groups for Osteoporosis Self-Efficacy Scale scores
(F=0.651, p=0.434).









* Hypothesis 4: Thirty-two weeks of progressive load-bearing walking exercise by adults
with IBD will result in improved Systolic Blood Pressure. There was a no significant
difference between the groups for systolic blood pressure (F=0.532, p=0.478).

Descriptive Variables

Descriptive analyses failed to demonstrate significance between the experimental and

control group for body mass index (F=0.026, p=0.814), diastolic blood pressure (F=1.039,

p=0.325), and heart rate (F=0.046, p=0.833). The Body Mass Index (BMI) did not show a

significant difference between groups but met clinical significance for the exercise group. The

BMI decreased for the exercise group. This decreased the BMI from >30 to <30 (Figure 4-3),

resulting in a category change from obese to overweight. The reported compliance for calcium

and vitamin D were similar in both groups. The exercise group reported 96% compliance, while

the control group reported 95% compliance.

Table 4-1 Baseline data analysis: demographics
Total Control Exercise
Variable Sample Group Group F P
(n=16) (n=9) (n=7)
Age (yrs) 54.7 58.2 49.6 4.167 ns
Education (yrs) 13.8 13.7 13.9 0.119 ns
Disease duration (yrs) 20 23.2 15.9 5.519 0.04
Crohns or Crohns Colitis 10 7 3 1.521 0.23
Ulcerative Colitis 6 2 4 1.640 0.22
Length of bowel resection (cm) 874.5 869.5 5 6.631 0.02










Table 4-2 Baseline data analysis: dependent variables
Total Control Exercise
Variable Sample Group Group F P
(n= 16) (n=9) (n=7)
Body mass index (kg/m2) 30.04 29.11 30.67 0.39 ns
Systolic blood pressure (mmHg) 134.22 128.09 139.88 4.81 0.04
Diastolic blood pressure (mmHg) 79.11 79.51 78.63 0.04 ns
Heart rate (beats per minute) 76.11 77.62 74.25 0.96 ns
Osteoporosis self-efficacy scale (1-21) 15.04 13.41 16.24 0.65 ns
Lumbar spine bone mineral density
(g/cm2) 1.16 1.20 1.11 1.69 ns
Hip bone mineral density (g/cm2) 0.98 1.05 0.88 2.11 ns
Femoral neck bone mineral density
(g/cm2) 0.93 0.98 0.92 0.05 ns
Bone alkaline phosphatase (IU/L) 26.41 25.22 27.75 0.14 ns
Urinary deoxypridinoline (nmol/mmol
creatinine) 4.29 5.16 3.31 2.14 ns
ns: non significant


1 :000


0 ;000


- Lumbar Experimental
SLumbar Control
- Hip Experimental
*- Hip Control
Femoral Neck Experimental
Femoral Neck Control


Baseline Post-testing


Figure 4-1. Pre and post DEXA scan results













145.00


140.00



135.00


129 70
130.00
121


125.00



120.00
Baseline


Figure 4-2. Effects of exercise on systolic blood pressure


30.80

30.60

30.40

30.20

30.00

29.80

29.60

29.40

29.20

29.00

28.80


1 0 E67.


m SBP Exercise
* SBP Control


Post-testing


* BMI Exercise Group
* BMI Control Group


Baseline Post-testing


Figure 4-3. Effects of exercise on body mass index (BMI)









CHAPTER 5
DISCUSSION

Individuals with IBD have a up to 40% greater chance of having an osteoporosis-related

fracture in their lifetime than the general population (Frei et al., 2006). Studies have

demonstrated low bone mineral density in up to 75% for individuals with IBD. The pathogenesis

of bone loss in IBD is multifactorial, consisting of general risk factors for osteoporosis and

disease-specific factors. Studies are lacking for interventions, especially non-pharmacological,

on improving bone mineral density in IBD. Therefore, this study looked at a non-

pharmacological intervention to improve bone mineral density.

Discussion of Findings

The ANOVA statistics demonstrated systolic blood pressure had a statistical significance

between the groups at baseline (F=4.813, p=0.04) with the exercise group having pre-

hypertension. There is no obvious medical rationale to explain the difference in systolic blood

pressure at baseline. The disease duration and length of small bowel removed had a statistical

significance between the two groups. There were additional variables did reach clinical

significance. The results along with some observations are further discussed in this chapter.

Hypotheses

* Hypothesis 1: Thirty-two weeks of progressive load-bearing walking exercise by adults
with IBD who are not taking osteoporosis medications will result in increased bone density
of the lumbar spine, hip and femoral neck (measured by dual-energy X-ray
absorptiometry) significantly greater than that of adults with IBD who do not exercise. The
hip measurement consists of 3 regions, (1) femoral neck, (2) trochanteric, and (3)
intertrochanteric. This hypothesis had mixed results for bone density changes. Two of the 3
regions measured a difference in bone mineral density. There was a significant difference
between groups in bone density for the hip and femoral neck, but the results for the
femoral neck demonstrated a significant difference in the control group. The hip results
demonstrated a significant difference in the exercise group. Although the lumbar spine
experimental group increased over time while the control group decreased. The results of
the femoral neck may be explained by several mechanisms; lack of sufficient weight vest,
lack of time and distance walked and lack of further resistance training as demonstrated in
previous studies. The hypothesis was not supported by the results of the study.









* Hypothesis 2: Thirty-two weeks of progressive load-bearing walking exercise by adults
with IBD who are not taking osteoporosis medications will result in increased serum levels
of BAP and increased ratios between BAP and DPD significantly greater than that of
adults with IBD who do not exercise. There was no significant difference between groups
for serum BAP and urine DPD. This hypothesis was not supported by the results of the
study. This is possibly due to the low observed power leading to a Type II error.

* Hypothesis 3: Completion of a weeks exercise program by adults with IBD who are not
taking osteoporosis medications will result in improved self confidence in managing their
own care (measured by the Osteoporosis Self-Efficacy Scale) that are significantly higher
than those of adults with IBD who do not participate in exercise training. There was no
significant difference between groups for Osteoporosis Self-Efficacy Scale. This
hypothesis was not supported by the results of the study. This is possibly due to the low
observed power leading to a Type II error. In addition, this tool was designed and tested
mainly on females while the study group was all males.

* Hypothesis 4: Thirty-two weeks of progressive load-bearing walking exercise by adults
with IBD will result in improved systolic blood pressure (SBP). There was no significant
difference between groups for SBP. This hypothesis was not support by the results of the
study. Although a significant difference between groups was not met, the exercise group
had a clinically significant change in systolic blood pressure. The 12.88 mmHg decrease in
systolic blood pressure for the exercise group decreased the mean from pre-hypertensive to
normotensive, while the control group had no change in baseline SBP. There was no
addition medications started during the study that would contribute to the change in SBP.
Also, the change in SBP is expected and consistent with a physiological change to
exercise.


Descriptive Variables

The subjects baseline variables related to the disease state of IBD demonstrated significant

difference in disease duration and length of bowel removed between experimental and control

groups. The disease duration and length of bowel removed was significantly greater in the

control group. These findings would suggest that the control group would have a increased

factors for decreased BMD. These findings do not contribute to the results at post testing. There

was no significant difference between groups for type of IBD (Crohn's disease or UC). The

Body Mass Index (BMI) did not show a significant difference between groups but met clinical

significance for the exercise group. The BMI decreased for the exercise group. This decreased

the BMI from >30 to <30 (Figure 4-3), resulting in a category change from obese to overweight.









Increased BMI levels lead the other comorbidities such diabetes, renal disease, stroke and

coronary artery disease. The reported compliance for calcium and vitamin D were similar in both

groups. This similar intake of supplementary calcium and vitamin D would account for dietary

differences between groups. The exercise group reported 96% compliance, while the control

group reported 95% compliance. An observation was noted in the exercise group related to

frequency of contact. During the study, two methods of contact were utilized to follow the

exercise group, email and telephone. It was noted for subjects that contact took several attempts

(n=4) and required them to call back, the average miles walked was markedly lower than group

who had more frequent contact. The average weekly miles walked was 1.84. Among those four,

three utilized email and excel spreadsheets I provided them, and one was able to set a time each

week to call. The average miles walked was 6.27.

Limitations of Study

All studies have some degree of limitations. One limitation of this study included the

marked distance subjects lived from the study site. Another limitation of this study included the

home based protocol for exercise which does not allow for monitoring exercise participation.

There is a limitation with home based self reported exercise programs, but with weekly calls or

emails for log reports and measurement devices that record steps, subjects are more likely to

continue the program protocol. The next limitation involved recruitment of subjects. The study

was designed to minimize subjects to two trips to the Medical Center, many subjects did not

want to make the extra trips due to time and gas prices. The PI tried to coordinate matching the

study visits to other appointments at the medical center but still only had minimal effect with

recruitment. Over 300 subjects were screened for the study with only 18 recruited and 16

completing the study. This leads to the limitation of small sample sizes. Given the small sample

size, power was increased to minimize the chance of type II error. Even though there was a short









duration of treatment to the exercise group, exercise has been proven to cause changes in BMD

in as little as 24 weeks. The short duration was also utilized due to difficulty maintaining

enrollment to an extended exercise protocol.

Statistical Analysis Limitations

As discussed previously, power analysis for this study, based on the number of variables

under consideration, recommended a sample of 9 experimental and 9 controls. The final was 9

controls and 7 experimental. It is possible that the significance in this study was not reached due

to inadequate sample size. Type II errors occur when study findings fail to reject a false null

hypothesis. Type II errors generally occur from not having enough subjects in the sample size to

sufficiently test the hypothesis.

Strengths of Study

One of the strengths of this study included the consistency between groups with baseline

characteristics. Although one of the limitations was a home based program, the protocol outlined

weekly contact with the subjects who were exercising. This provided continue feedback and

support to comply with the exercise protocol.

Conclusions

The demographics did not demonstrate a statistical significance for IBD disease type. The

disease duration and length of bowel resection was statistically significant in the control group.

These are risk factors related to decrease BMD and absorption of nutrients for bone maintenance.

These was not clearly demonstrated in this study. The study demonstrated statistical significance

for increase in femoral neck bone density but was in the control group. Also there was a

significant increase in hip bone for the exercise group, which consists of 3 regions, (1) femoral

neck, (2) trochanteric, and (3) intertrochanteric. The lumbar spine bone mineral density result

were not statistically significant but the results show a decrease in the controls while the exercise









group showed a increase suggesting a trend of exercise benefit. Two of the findings, systolic

blood pressure and body mass index, did not reach statistical significance but reach clinical

significance thus demonstrating benefits to exercise. The observation of the average miles

walked demonstrated a difference within the exercise group. Although there was an increased

average miles walked in the subjects with frequent contact, the total average miles walked were

possibly to low make an increase in BMD in the study's time frame.

Recommendations for Future Research

Unfortunately this study demonstrated some conflicting results for changes in bone mineral

density. But, the bone mineral density increase suggests possible benefit from the exercise

intervention. The clinical significance demonstrated with systolic blood pressure and body mass

index are consistent with a physiological change related to exercise. The significance of low

bone mineral density in IBD and the literature that supports exercise as an intervention for the

improvement on bone mineral density support further study. Any future studies should focus on

an adequate sample size, increase mechanical stress on the sites measure for BMD and increase

frequency of contact during the study.

Implications for Clinical Practice

This study demonstrated a clinically significant improvement in systolic blood pressure

and body mass index. This supports the importance of physical activity on multiple health

factors. Additionally, support and frequent contact appear to increase exercise compliance for

subject









APPENDIX A
DEMOGRAPHIC INFORMATION

(All information will be kept confidential)


Name

Address


last first m.i.

street and box number


city

Telephone home (


state


Today's date / /
mo day year


zip code


work (


Age Date of birth / /
mo day year
Marital status Race
single European American
married African American
divorced or separated Native American
widowed Hispanic
Asian
Other (please list)

Years of education completed (circle years completed)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
_high school graduate doctoral degree
bachelor's degree other degrees (list)
master's degree

Present work status Working full time. __part time.

Not employed. Reason: Medical Retired Other









APPENDIX B
MEDICAL HISTORY QUESTIONNAIRE

(All information will be kept confidential)

Please read the following health history questionnaire carefully and mark the most appropriate
answer to each question. If you are unsure about a question, just circle it and go on to the next
question.

General health history
Yes No

1. Has a doctor ever told you that you have heart disease?
2. Have you ever had a heart attack?
3. Has a doctor ever told you that you have high cholesterol?
S4. Have you had heart surgery?
5. Do you have a cardiac pacemaker?
6. Do you have high blood pressure?
7. Have you ever had a stroke?
8. Do you have diabetes?
9. Do you take insulin for diabetes?
S10. Have you had carotid artery surgery or an endarterectomy?
11. Do you have a heart valve problem?
S12. Has a doctor ever told you that you have an aneurysm?
13. Have you ever had heart failure?
S14. Has a doctor ever told you that you have an abnormal EKG?

Have you ever had, or do you now have, any of the following conditions?

Yes No
15. Rheumatic fever
16. Asthma
17. Chronic bronchitis
18. Emphysema
19. Varicose veins
20. Phlebitis
21. Arthritis
22. Rheumatism
23. Gout
24. Gastrointestinal problems
25. Epilepsy, or seizures
26. Dizziness or fainting spells
27. Loss of memory
28. Anemia
continued on next page









29. Chronic back pain
30. Kidney or bladder problems
S31. Nervous systems problems
32. Visual or hearing problems
33. Hepatitis or other liver diseases
34. Gall bladder problems
S35. Thyroid problems
36. Cancer or tumors
S38. Do you sometimes lose urine when you cough, sneeze, or laugh?
39. Any other major illness or surgery? If yes, please explain:
40. Are you allergic to any medications? If yes, please list:
S41. Are you now taking any prescription or non-prescription medications, including
hormones, vitamins, and other supplements? If yes, please list:

Smoking
Yes No
42. Have you ever smoked? If no, skip to diet
43. Do you smoke now? If yes, how many cigarettes per day?_. For how
many years?
If no, when did you quit?

Diet

44. What do you consider a good weight for yourself? lbs.
45. What do you weigh now? lbs.
46. What is the most you have ever weighed? lbs.
47. Do you drink alcoholic beverages? _yes no

Family health history

Have any of your blood relatives (your parents, brothers, sisters, uncles, aunts, cousins, or
children) ever had:
Yes No
48. Heart attack
49. High blood pressure
50. Stroke
51. Diabetes
52. High cholesterol
Additional comments concerning your personal or family health history:









APPENDIX C
OSTEOPOROSIS SELF-EFFICACY SCALE*

Name: Date:

Directions: Please read each of the following statements and indicate your feeling of confidence
by marking an "X" on the line below the statement

"If it were recommended that you do any of the following this week, how confident would you
be that you could?"

1. Begin a new or different exercise program

Not at all I IVery confident
confident

2. Change your exercise habits

Not at all I Very confident
confident

3. Put forth the effort required to exercise

Not at all I IVery confident
confident

4. Do exercises even if they are difficult

Not at all I Very confident
confident

5. Maintain a regular exercise program

Not at all I IVery confident
confident

6. Exercise for the appropriate length of time

Not at all I Very confident
confident

7. Do exercises even if they are tiring

Not at all I IVery confident
Confident









8. Stick to your exercise program

Not at all I Very confident
confident

9. Exercise at least three times a week

Not at all I Very confident
confident

10. Do the type of exercises you are supposed to do

Not at all I IVery confident
confident

11. Begin to eat more calcium-rich foods

Not at all I Very confident
confident

12. Increase your calcium intake

Not at all I IVery confident
confident

13. Consume adequate amounts of calcium-rich foods

Not at all I Very confident
Confident

14. Eat calcium-rich foods on a regular basis

Not at all I IVery confident
confident

15. Change your diet to include more calcium-rich foods

Not at all I Very confident
confident

16. Eat calcium-rich foods as often as you are supposed to

Not at all I IVery confident
confident









17. Select appropriate foods to increase your calcium intake


Not at all L
confident


IN


/ery confident


18. Stick to a diet which gives an adequate amount of calcium


Not at all L
confident


Very confident


19. Obtain foods that give an adequate amount of calcium


Not at all L
confident


IN


/ery confident


20. Remember to eat calcium-rich foods


Not at all L
confident


IN


/ery confident


21. Take calcium supplements if you don't get enough calcium from your diet


Not at all L
confident


Very confident


* Horan, M.L., Kim, K.K., Gendler, P., Froman, R.D., & Patel, M.D. (1998). Development and
evaluation of the Osteoporosis Self-Efficacy Scale. Research in Nursing and Health, 21, 395-
403.


i'


i'









APPENDIX D
TIMELINE


Table D-1. Load bearing walking schedule of )rogression
1 2-4 5-6 7-8 9-12 13-16 17-32
Weeks
Walking duration 20 20 30 30 40 45 50
(mins)
Vest weight % body 0 10 10 15 20 20 20
wt


Table D-2.


Timeline for individual subjects: Each subject will be required to participate in the
study for approximately 45 weeks


Week 1 Visit 1 (a): Orientation, complete documents, sign informed consent, complete the OSES.
Week 2 Visit 1 (b): Physical exam, DEXA scan, Blood draw, Random assignment to exercise or
control groups.
Week 3 Visit 2: Begin exercise training or control period, Issue calcium and vitamin D scripts
Week 35 Visit 3: DEXA scan, Blood draw, complete OSES, End of study










APPENDIX E
EXERCISE AND CALCIUM AND VITAMIN D SUPPLEMENTS LOG BOOKS


Exercise Log Book (subjects in exercise group only)


Front Cover

Exercise log book
Name
ID#

Please enter the date and time of
your exercise session. Total distance
walked (in miles), total number of
steps taken during the walk, and
total calories burned. Also, any
comments you would like
to make about that day's exercise.
Session.

Important telephone numbers:

Principal Investigator
Charles J Zeilman
office (352)376-1611 ext 6261
pager 1-877-739-0639


In case of an emergency
telephone 911


Pages


Date: Time
Miles walked:
Total steps:
Calories burned:

Comments








Date: Time
Miles walked:
Total steps:
Calories burned:

Comments


Log Book to be constructed of heavy, brightly colored paper and "check book" in size.











Calcium and vitamin D supplement log book


(for subjects in the exercise and control groups)


Front Cover Pages


Calcium and Vitamin D

Supplements Log Book
Name:
ID#:

Please take 1 capsule in the
morning and 1 capsule in the
evening. Take capsules 1 hour
before or after meals

Please check the box after you
have taken your calcium and
vitamin supplements



Important telephone numbers:

Principal Investigator
Charles J. Zeilman
office (352)376-1611 ext 6261
pager 1-877-730-0639





In case of an emergency
telephone 911


morning evening

Date:



HO
O O







__] H]
__] H]
___ HHD
___ HHD
__] H]









LIST OF REFERENCES


American College of Sports Medicine. (2000). ACSM's Guidelinesfor exercise testing and
prescription (6th ed.). Baltimore: Williams and Wilkins.

Baecke, J. A. H., Burema, J., & Frijiters, J. E. R. (1982). A short questionnaire for the
measurement of habitual physical activity in epidemiological studies. The American
Journal of Clinical Nutrition, 36(5), 936-942.

Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs: Prentice-Hall.

Bassett, C. A. (1971). Biophysical principals affecting bone structure. In G.H. Bourne (Ed.), The
biochemistry and physiology of bone (2nd ed.), p. 1, New York: Academic Press.

Bernstein, C. N., Blanchard, J. F., Leslie, W., Wajda, A., & Yu, N. (2000). The Incidence of
fracture among patients with inflammatory bowel disease: A population-based cohort
study. Annals of internal Medicine, 133(10), 795-799.

Black, D. M., Palermo, L., & Bauer, D. (2000). How well does bone mass predict long-term risk
of hip fracture. Osteoporosis International, I(Suppl. 2), S121.

Bloomfield, S., Williams, N., Lamb, D., & Jackson, R. (1993). Non-weight bearing exercise may
increase lumbar spine bone mineral density in healthy postmenopausal women. American
Journal ofPhysical Medicine and Rehabilitation, 72, 204-209.

Caplan, G. A., & Ward, J. A. (1993). The benefits of exercise in postmenopausal women.
Australian Journal of Public Health, 17, 23-26.

Carter, D. R. (1984). Mechanical loading histories and cortical bone remodeling. Calcification
Tissue International, 36(Suppl. 1), S19-S24.

Cooper, C. (2000). Global assessment of fracture risk. Osteoporosis International, 11 (suppl. 2),
S44.

Dickinson, A. (2002). Benefits of calcium and vitamin D: Building and maintaining healthy
bones. Retrieved January 15, 2003, from
http://www.crnusa.org/benpdfs/CRN003benefits_calciumandD.pdf

Frei, P., Fried, M., Hungerbuhler, V., Rammert, C., Rousson, V., & Kullak-Ublick, G. A. (2006).
Analysis of risk factors for low bone mineral density in inflammatory bowel disease.
Digestion, 73, 40-46.

Gillis, A. J. (1993). Determinants of a health-promoting lifestyle: An integrative review. Journal
ofAdvanced Nursing, 18(3), 345-353.









Gray, K. (2000). Bone-forming agents: New therapies for osteoporosis. Paper presented at the
World Congress on Osteoporosis 2000. Retrieved February 21, 2002, from
http://search.medscape.com/all-search?queryText=Bone-
forming%20agents:%20New%20therapies%20for%200steoporosis

Hagberg, J. M., Graves, J. E., Limacher, M., Woods, D. R., Leggett, S. H., & Cononie, C.
(1989). Cardiovascular responses of 70- to 79-year old men and women to exercise
training. Journal ofApplied Physiology, 66(6), 2589-2594.

Heaney, R. P. (2000). There should be a dietary guideline for calcium. American Journal of
Clinical Nutrition, 71(3), 658-670.

Hela, S., Nihel, M., Faten, L., Monia, F., Jalel, B., Azza, F., et al. (2005). Osteoporosis and
Crohn's disease. Joint Bone Spine, 72(5), 403-407.

Horan, M. L., Kim, K. K., Gendler, P., Froman, R. D., & Patel, M. D. (1998). Development and
evaluation of the Osteoporosis Self-Efficacy Scale. Research in Nursing and Health,
21(5), 395-403.

Huang, O., Lu, J., Zhou, Q., Liu, Y., & Wang, Q. (2000). Effect of calcium and vitamin D
supplementation on bone loss in postmenopausal Chinese women: A comparative study.
Osteoporosis International, 1](Suppl. 2), S183.

Jessup, J., Home, C., Vishen, R. K., & Wheeler, D. (2003). Effects of exercise on bone density,
balance and self-efficacy in older women. Biological Reserchfor Nursing 1(4), 171-181..
Kannus, P. (1999). Preventing osteoporosis, fall and fractures among elderly people.
British Medical Journal, 318(7178), 205-206.

Kelley, G. A. (1998). Aerobic exercise and bone density at the hip in postmenopausal women: A
meta-analysis. Preventive Medicine, 27(6), 798-807.

Kronhed, A. C. & Moller, M. (1998). Effects of physical exercise on bone mass, balance skill
and aerobic capacity in women and men with low bone mineral density, after one year of
training--a prospective study. Scandinavian Journal of Medicine and Science in Sports,
5(1), 290-298.

Lane, N. E., & Lukert, B. (1998). The science and theory of glucocorticoid-induced bone loss.
Endocrinol Metabolism Clinics of North America, 27(2), 465-483.

Lanyon, L. E. (1981). Bone remodeling mechanical stress and osteoporosis. In H.F. DeLuca,
H.M. Frost, & W.S.S. Jee (Eds.). Osteoporosis: Recent advances in ptIi1'thgelni and
treatment_(p. 129). Baltimore: University Park Press.

Lau, E. M. C., Woo, J., Leung, P. C., Swaminathan, R., & Leung, D. (1992). The effects of
calcium supplementation and exercise on bone density in elderly Chinese
women.Osteoporosis International, 2(4), 168-173.









Lawson, M. T. (2001). Evaluating and managing osteoporosis in men. The Nurse Practitioner,
26(5), 2649.

Manolagas, S. C., Weinstein, R. S. (1999). New developments in the pathogenesis and treatment
of steroid-induced osteoporosis. Journal of Bone and Mineral Research, 14(7),1061-1066.

McAuley, E., Bane, S. M., & Mihalko, S. L. (1995). Exercise in middle-aged adults: Self-
efficacy and self-presentational outcomes. Preventive Medicine, 24(4), 319-338.

National Institutes of Health. (1991). Osteoporosis research education and health promotion.
(NIH Publication No. 91-3216). Bethesda, MD: Author.

National Osteoporosis Foundation. (1997). Stand up to osteoporosis: Your guide to staying
healthy and independent through prevention and treatment. Washington, D.C.: Author.
O'Shea, B., Rosen, C. J., Guyatt, G., Cranney, A., Tugwell, P., & Black, D. (2000). A
meta-analysis of calcium supplementation for the prevention of postmenopausal
osteoporosis. Osteoporosis International 2000, 11(suppl. 2), S114.

Pollak, R. D.,, Karmeli, F.,, Eliakim, R., Ackerman, Z., Tabb, K., & Rachmilewitz, D.
(1998).Femoral neck osteopenia in patients with inflammatory bowel disease. The
American Journal of Gastroenterology, 93(9), 1483-1490.

Pollock, M.L. & Wilmore, J.H. (1995). Exercise in health and disease: Evaluation and
prescription for prevention and rehabilitation. Philadelphia: W.B. Saunders.

Reid, I. R, Heap, S. W. (1990). Determinants of vertebral mineral density in patients receiving
long-term glucocorticoid therapy. Archives ofInternal Medicine, 150(12),_2545-2548.

Riggs, B. L. & Melton, L. J. (1995). The worldwide problem of osteoporosis: Insights afforded
by epidemiology. Bone, 17(5), Supplement 1 505S-511S.

Sakellariou, G. T., Moschos, J., Berberidis, C., Mpoumponaris, A., Kadis, S., Molyvas, E., et al.
(2006). Bone density in young males with recently diagnosed inflammatory bowel disease.
Joint, Bone, Spine, 73(6), 725-728.

Shaw, J. M. & Snow, C. M. (1998). Weighted vest exercise improves indices of fall risk in older
women. Journal of Gerontology 53A(1), M53-M58.

Sheth, P. (1999). Osteoporosis and exercise: A review. The Mount Sinai Journal of Medicine,
66(3), 197-200.

Smith, E. L. (1988). Bone concerns, in M.M. Shangold (Ed.) Women and Exercise: Physiology
and Sports Medicine (pp. 79-87). Philadelphia: F.A. Davis.

Southerland, J. C., & Valentine, J. F. (2001). Osteopenia and osteoporosis in gastrointestinal
diseases: Diagnosis and treatment. Current Gastroenterology Reports, 3, 399-407.









Tonino, R. P., Meunier, P. J., & Emkey, R. D. (2000). Long-term efficacy and safety of
alendronate in the treatment of osteoporosis in postmenopausal women. Osteoporosis
International, 11(supplement 2), S202.

Valentine, J. F. & Sninsky, C. A. (1999). Prevention and Treatment of Osteoporosis in Patients
with Inflammatory Bowel Disease. The American Journal of Gastroenterology, 94(4), 878-
883.

Vincent, K. R. & Braith, R. W. (2002). Resistance exercise and bone turnover in elderly men and
women. Medicine and Science in Sports and Exercise, 34(1), 17-23.









BIOGRAPHICAL SKETCH

Charles Joseph Zeilman, III received his bachelor of science in nursing degree from the

University of Florida in 1995. He began his career as a staff nurse in the general surgery and

cardiac surgery unit at Shands Teaching Hospital in Gainesville, FL.

In 1998, Mr. Zeilman earned his master's degree in adult health from the University of

Florida. After receiving his degree, he took a Advance Registered Nurse Practitioner position in

the gastroenterology section at the North Florida/South Georgia Veteran's Healthcare System.

Mr. Zeilman is the 2006 recipient for the "Excellence in Nursing" annual award for

Advance Registered Nurse Practitioner. He has several publications during his work as an

ARNP. He is an affiliate faculty member for the College of Pharmacy at the University of

Florida. He has served on the Dean's Advisory Committee, College of Nursing at University of

Florida. He also is a guest lecturer for the College of Nursing at University of Florida.





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1 INFLAMMATORY BOWEL DISEASE, OSTEOPOROSIS, EXERCISE, AND BONE MINERAL DENSITY By CHARLES JOSEPH ZEILMAN III A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007

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2 2007 Charles Joseph Zeilman III

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3 To my parents who always stressed the value of education and the beli ef that anything is possible.

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4 ACKNOWLEDGMENTS I would like to thank my s upervising committee chair, Dr. James Vernon Jessup, for his guidance, encouragement and patience. I appreciat e his mentorship throughout my education and career that he has provided since 1994. I gratefully acknowledge and extend my appreciation to my supervising committee members (Saunjoo Yoon, PhD, Stephen Dodd, PhD, and John F. Valentine, MD). Each of them provided areas of specialty knowledge and moral support. I would like to thank Dr. Dodd for his support in learning effects of exercise on the human body, Dr. Yoon for her support and application of Nursing theory, and Dr. Valentin e for leadership, mentorship and education on treating patients with IBD. I also want to thank my best friend Todd Houchin who tolerated many days missed for events throughout this process. Lastly, I want to give special thanks to children Casey and Joey for their understanding and especially my wife Pam who tolerated and supported me.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 LIST OF FIGURES................................................................................................................ .........8 ABSTRACT....................................................................................................................... ..............9 CHAPTER 1 INTRODUCTION..................................................................................................................10 Background of the Problem....................................................................................................10 Purpose of Study............................................................................................................... ......11 Conceptual Framework...........................................................................................................11 Significance of this Study..................................................................................................... ..12 Research Hypotheses............................................................................................................ ..13 2 LITERATURE REVIEW.......................................................................................................14 Pathogenesis of Osteoporosis.................................................................................................14 Inflammatory Bowel Disease and Osteoporosis.....................................................................14 Risk Factors for Osteoporosis.................................................................................................15 Treatment and Prevention of Osteoporosis.............................................................................15 Nutritional Factors and Osteoporosis: Th e Role of Calcium and Vitamin D.........................16 Effects of Exercise on Bone Health........................................................................................17 Biochemical Markers of Bone Metabolism............................................................................18 Self-Efficacy and Exercise.....................................................................................................19 Literature Review Summary...................................................................................................20 3 MATERIALS AND METHODS...........................................................................................22 Research Design................................................................................................................ .....22 Sample and Setting............................................................................................................. ....23 Random Assignment to Treatment Groups............................................................................24 Measures and Research Variables..........................................................................................25 Independent variable.......................................................................................................25 Dependent variables........................................................................................................26 The osteoporosis self-efficacy scale (OSES)..................................................................27 Exercise measurements...................................................................................................28 Biochemical variables.....................................................................................................28 Procedures..................................................................................................................... ..........28 Exercise Group Protocols.......................................................................................................29 Data Analysis.................................................................................................................. ........31

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6 Potential Health Risks......................................................................................................... ....31 4 ANALYSIS AND RESULTS.................................................................................................34 Descriptive Statistics......................................................................................................... .....34 Descriptive Variables.......................................................................................................... ....35 5 DISCUSSION..................................................................................................................... ....38 Discussion of Findings......................................................................................................... ..38 Hypotheses..................................................................................................................... .........38 Descriptive Variables.......................................................................................................... ....39 Limitations of Study........................................................................................................... ....40 Statistical Analysis Limitations..............................................................................................41 Strengths of Study............................................................................................................. ......41 Conclusions.................................................................................................................... .........41 Recommendations for Future Research..................................................................................42 Implications for Clinical Practice...........................................................................................42 ABSTRACT A DEMOGRAPHIC INFORMATION......................................................................................43 B MEDICAL HISTORY QUESTIONNAIRE...........................................................................44 C OSTEOPOROSIS SELF-EFFICACY SCALE......................................................................46 D TIMELINE....................................................................................................................... ......49 E EXERCISE AND CALCIUM AND VITAMI N D SUPPLEMENTS LOG BOOKS...........50 LIST OF REFERENCES............................................................................................................. ..52 BIOGRAPHICAL SKETCH.........................................................................................................56

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7 LIST OF TABLES Table page 4-1 Baseline data analysis: demographics................................................................................35 4-2 Baseline data analysis: dependent variables......................................................................36 D-1 Load bearing walking schedule of progression.................................................................49 D-2 Timeline for individual subjects: Each subj ect will be required to participate in the study for approximately 45 weeks.....................................................................................49

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8 LIST OF FIGURES Figure page 2-1 Corticosteroids and bone mineral density..........................................................................21 4-1 Pre and post DEXA scan results........................................................................................36 4-2 Effects of exercise on systolic blood pressure...................................................................37 4-3 Effects of exercise on body mass index (BMI)..................................................................37

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9 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy INFLAMMATORY BOWEL DISEASE, OSTEOPOROSIS, EXERCISE, AND BONE MINERAL DENSITY By Charles J. Zeilman, III August 2007 Chair: James Vernon Jessup Major: Nursing Sciences Patients with inflammatory bowel disease (I BD) are at increased risk of developing osteopenia and osteoporosis. The purpose of this study was to examine the feasibility of a nonpharmacological nursing intervention designed to pr event bone loss, reduce the risk of fractures, and promote self-efficacy in adults with Infl ammatory Bowel Disease (IBD), Crohns disease and Ulcerative Colitis (UC). The intervention co nsisted of progressive load-bearing walking utilizing a weighted vest. Sixteen men, age 30 to 75 years, were recruited to participate in the study. Following baseline testing, subjects were ra ndomly assigned to an exercise group (n=7), or to a sedentary control group (n=9). Subjects in the exercise group pa rticipated in 32 weeks (three, 50 minute sessions/week) of exercise tr aining. Training consisted of a home based walking while wearing weighted vests. Me asurements included (1) dual-energy x-ray absorptiometry (DEXA) scans of the hip and lu mbar spine, (2) serum biochemical markers of bone formation, bone-specific alkaline phosphatase, marker of bone anabolism, and pyridinoline cross-links, an indicator of bone catabolism, or resorption, (3) Osteoporosis Self-Efficacy Scale and (4) change in systolic blood pressure. Resu lts showed no significant differences between the groups.

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10 CHAPTER 1 INTRODUCTION Background of the Problem Epidemiology of osteoporosis-related fractures In the United States, one in two women and one in eight men older than 50 years will suffer an osteoporosis-re lated fracture in their lifetime (Cooper, 2000). Of the more than 1.5 m illion fractures that occur each year, over 300,000 are fractures of the hip, 250,000 are fracture s of the distal forearm, 700,000 are vertebral fractures, and 250,000 are fractures at other site s (Riggs & Melton, 1995). A low bone mineral density (BMD) has been reported in 30-75% of patients with IBD in cross-sectional and prospective studies (Pollak et al., 1998). Compared to the ge neral population, patients with IBD have up to 40% more fractures (F rei et al., 2006). Most hip fractures are attr ibuted to falls at home while the majority of distal forearm (Co lles) fractures are cause d by extending the arm out to break a fall. Vertebral fractures have a multipli city of causes, but rarely result from a single traumatic event. Of all fractures, those to the hip are the most devastating as they result in the highest rate of morbidity a nd mortality (Kelley, 1998). It is estimated that up to 33% of a ll hip fractures occur in men. Although women typically experience hip fractures related to po stmenopausal osteoporosis, men of all ages with IBD experience increases morbidity and mortalit y due to steroid-relate d osteoporosis (Lawson, 2001). The incidence of fracture amo ng persons with IBD is 40% grea ter than that in the general population (Bernstein, Blanchard, Leslie, Wajda a nd Yu, 2000). Twenty-four percent of patients die in the year after a hip fractur e, and more than 40% are discharg ed from a hospital to a nursing home (National Osteoporosis Found ation [NOF], 1997). By the end of one year, one-third of those hip fracture patients are still in the nur sing home. In addition, a pproximately 50% of all people suffering a hip fracture will be unable to wa lk without assistance. Degenerative fractures

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11 of the osteoporotic spine are subtle, but kyphosis due to verteb ral collapse greatly diminishes quality of life for many older men. The health-c are cost of osteoporosis-related fractures is nearly $14 billion annually in th is country (NOF, 1997), but the cost in pain, suffering, lost personal freedom and independence cannot be meas ured. Moreover, with the demographic shift occurring in our population, the problem of oste oporosis-related morbidity and mortality will likely increase. Purpose of Study The purpose of this study was to examin e the feasibility of a home based nonpharmacological nursing intervention to preven t bone loss, reduce the ri sk of fractures, and promote self-efficacy in adults with Inflamma tory Bowel Disease (IBD), Crohn's disease and Ulcerative Colitis. The goal was to reduce morbidity associated with falls and bone fractures in this population. The intervention consisted of progressive load-bearing walking and daily calcium and vitamin D supplementation. Conceptual Framework Self-efficacy and exercise An active lifestyle is particularly important for adults given the broad constellation of physio logical, behavioral, cognitive, and biochemical outcomes that are influenced by physical activity. However, the majo rity of adults do not exercise or participate in sports on a regular basis per a National Health Interview Survey (National Institute of Health, 1991). There are a number of theoretical explana tions that provide an understanding of why individuals choose to participate or not participate in health-re lated behaviors. Recently, selfefficacy has received considerable support as a pr edictor of the initiation and maintenance of an exercise program for health and fitness. The c onstruct of self-efficacy is derived from Banduras social cognitive theory (1986). According to th e theory, people are motivated to engage in a behavior based on the belief that: (a) the behavior will result in a favorable outcome (outcome

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12 expectation), and (b) the individual is capable of executing the behavior (efficacy expectation). A meta-analysis of studies of health-related behaviors revealed cons istent support for the importance of self-efficacy as a determinant of healt hy lifestyles, including regular exercise (Gillis, 1993). Considerable literature further suggests that part icipation in exercise training has a positive influence on self-efficacy. McAuley, Bane, and Mihalko (1995) examined the effects of both long-term exercise participa tion and acute bouts of exercise on the physical self-efficacy of middle-aged men and women. In addition to de monstrating the utility of physical mastery experiences in influencing efficacy, McAule y Bane, and Mihalko (1995) reported some interesting patterns with respect to gender res ponses. Whereas men and women demonstrated significant gains in perceived capabilities in resp onse to both acute and long-term exercise, men initially were significantly more efficacious than women. I hypothesize that subjects in the exercise group would gain both the psychomotor skills and the self-e fficacy to continue exercising as part of a healthy lifestyle. Significance of this Study The evidence clearly demonstrates that exercise training can offer a nonpharmacological alternative for improving bone health in t hose who do not choose to take osteoporosis medications (e.g., Biphosphonates). Ot her benefits associated with regular exercise include a reduction in risk factors for many diseases, enha ncement of overall functional fitness and well being, and improved self-efficacy. It has not be en clearly determined, however, what type, magnitude, and duration of exercise would be th e most efficacious for adults with IBD. The exercise-training program descri bed in this proposal combines ground-reaction and joint-reaction forces to repeatedly place moderate, progres sive strain on the whole skeleton, but more specifically on the spine, femoral neck and hi p, of men with IBD. Subjects trained for 50 minutes/day, 3 days/week, for 32 weeks. The firs t exercise session was closely supervised for

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13 the subjects safety, and included warm-up and fl exibility exercises, followed by walking while wearing a weighted vest. Exercise with weight ed vests improved dynamic balance, leg strength and muscle mass in older women (Shaw & Snow, 1998). By walking while wearing vests with a moderate weight (20% of body wei ght), adults with IBD were able to safely apply a load-bearing strain to the bones of the spine and hip without the risk of pyl ometric (jumping or bouncing) or high impact maneuvers. It is anticipated th at the intervention would improve bone density, physiologic exercise induced changes in vital si gns, biochemical markers for bone resorption and formation, and self-efficacy in adults with IBD. Research Hypotheses Hypothesis 1 : Thirty-two weeks of progressive lo ad-bearing walking exercise by adults with IBD who are not taking os teoporosis medications woul d result in increased bone density of the lumbar spine, hip and fe moral neck (measured by dual-energy X-ray absorptiometry) significantly greater than that of adults with IBD who do not exercise. Hypothesis 2 : Thirty-two weeks of progressive lo ad-bearing walking exercise by adults with IBD who are not taking os teoporosis medications would result in increased serum levels of BAP and increased ratios between BAP and DPD significantly greater than that of adults with IBD who do not exercise. Hypothesis 3 : Completion of a weeks exercise progr am by adults with IBD who are not taking osteoporosis medications would resu lt in improved self confidence in managing their own care (measured by the Osteoporosis Self-Efficacy Scale) th at are significantly higher than those of adults with IBD w ho do not participate in exercise training. Hypothesis 4 : Thirty-two weeks of progressive lo ad-bearing walking exercise by adults with IBD would result in impr oved systolic blood pressure.

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14 CHAPTER 2 LITERATURE REVIEW Pathogenesis of Osteoporosis Osteopenia is defined as failure of the rate of osteoid tissue synthesis to keep up with the rate of bone loss without resp ect to cause. It is characterized by abnormally low bone mass/density and a disruption in the microarchi tecture of bone tissue, leading to a reduced effectiveness of trabecular cros s bracing (Sheth, 1999). This loss of bone connectivity results in bone fragility and fatigue. Once bone fatigue occurs osteoblastic apoptosis ensues, resulting in osteoporosis. If there is impact from a mechanical load, the bone may fract ure. Osteoporosis is clinically defined as bone mineral dens ity (BMD), measured by dual energy x-ray absorptiometry (DEXA) or computed tomography, of more than 2.5 standard deviations below the reference value for a normal, healthy adu lt (Black, Palermo, & Bauer, 2000). Osteoporotic fracture, however, is not a single disease with a single etiologic agent. It has multiple levels of pathogenesis that involve gene tic and cellular factors, deve lopmental proce sses of bone remodeling (bone growth in children and bone loss in aging), and environmental factors such as falls (Cooper, 2000). Although bone loss is a universal concomitant of advanced age affecting both men and women, it proceeds at a much faster rate in ga strointestinal disorders, hypogonadism, immobilization, organ transplant s or with certain medications. Inflammatory Bowel Disease and Osteoporosis The pathogenesis of bone loss in IBD is multifact orial, consisting of general risk factors for osteoporosis and disease-sp ecific factors including cor ticosteroid use, sex hormone deficiency, lack of physical ac tivity, vitamin D and calcium malabsorption secondary to active disease and/or intestinal resec tion, and secondary to osteoclast activation by proinflammatory cytokines (Southerland & Valentine, 2001). A ccording to a study on young males, mean age 26,

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15 who were steroid nave and a re cent diagnosis of IBD, 28% had a decreased bone mineral density (Sakellariou et al., 2006). Low body mass i ndex was an independent factor for low bone mineral density (Hela et al., 2005) Corticosteroid usage is the most common cause of secondary osteoporosis. Chronic or excess corticosteroid has multiple effects on bone metabolism. Corticosteroids not only decrease bone formation, they also in crease bone resorption (Manolagas & Weinstein, 1999). It has been demonstrated that corticosteroids in hibit osteoblast activity, which stimulates osteoclast activity thus incr easing bone resorption (Lawson, 2000). Due to the increased rate of bone resorpti on and inhibition of bone formati on, their usage associated with rapid bone loss. Reid and Heap demonstrated that subjects starting corticos teroid therapy lost a mean of 27% of the lumbar spine BMD within the first year of therapy. Risk Factors for Osteoporosis Risk factor identification for osteoporosis-r elated fractures is complex and agreement between leading population-based st udies is limited. It is clear th at corticosteroid usage is a major etiologic component and risk factor in bon e fragility (Figure 2-1). Regardless of gender, up to 50% of patients taking cor ticosteroids on a chronic basis sustain osteoporotic factures (Lane & Lukert, 1998). Establishe d risk factors for osteoporotic fractures in men include a family history of osteoporosis, Caucasian, physi cal inactivity, low calcium and vitamin D intake, previous history of fracture, mental depressi on, tobacco smoking, long-term use of steroids, benzodiazepines, and anticonvulsant medi cations, gastrointestional disease and hyperparathyroidism (Cooper, 2000). Treatment and Prevention of Osteoporosis The treatment and prevention of osteopor osis includes both pharmacologic and nonpharmacologic interventions. There have been great advances in the pharmacologic treatment of osteoporosis in the past 15 years. The an tiresorptive bisphosphonate agents, alendronate

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16 (Fosamax) and risedronate (Actonel ) have b een shown in clinical studies to reduce spine fractures by about 50% when used in combinati on with estrogen replacement therapy (ERT) in aestrogenic women (Tonino, Meunier, & Emkey, 2000). The bisphosphonates have serious side effects, however, including esophageal ulceratio n, nausea, vomiting, diarrhea, hypocalcemia, and renal toxicity. Other drugs have been investigated for the treatment of osteoporosis. In the 1980s, sodium fluoride, an anabolic ag ent, was widely advocated as a treatment that reduced fractures by improving BMD. Although BMD in treated subj ects increased, they had significantly more fractures of the lower extremities than the pla cebo control subjects (Gray, 2000). Unfortunately, there is low compliance with osteoporosis drug ther apy primarily due to cost. For example, daily alendronate costs approximately $50 monthly. For many patients this cost makes drug therapy an unrealistic option for the prevention and treatment of osteoporosis. Nutritional Factors and Osteoporosis: The Role of Calcium and Vitamin D Nutrition is a modifiable risk factor for os teoporosis. There is substantial evidence that adequate calcium and vitamin D intake influences all aspects of bone h ealth throughout the life cycle, from the development of peak bone mass in adolescents, to the maintenance of bone mass in adults, to the reduction of bone loss and fracture in the elderly (Heaney, 2000). A metaanalysis of 15 randomized clini cal trials found that Calcium supplementation improved BMD at all skeletal sites in postmenopausal women (OS hea et al., 2000). Other researchers found that daily supplementation with 1000 mg calcium pl us 400 IU vitamin D (ergocalciferol) for 12 months inhibited bone remodeli ng and significantly increase d BMD in women who were 10 years postmenopause (Huang, Lu, Zhou, Liu, & Wa ng, 2000). Additionally, individuals with IBD are at increased risk for vitamin D and calci um malabsorption seconda ry to active disease and/or intestinal resections.

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17 Effects of Exercise on Bone Health Although there is substantial evidence that physical activity stimulates bone formation, research on the mechanisms by which bone is affected by mechanical stress is in its early stages. In 1892, Wolff (Smith, 1988, p. 81) hypothesized that weight bearing compresses and bends long bones, consequently strengthening them and making them less likely to fracture. Weight bearing (gravity) and muscle co ntraction are the major mechanical forces on bone. Bone mass increases with greater weight bearing, mu scle contraction or both and d ecreases with immobilization or weightlessness. The degree of bone change is proportional to the difference in magnitude and frequency of the mechanical stimulus from norma l. Bassett (1971) indicated that bone functions as a piezoelectric crystal, genera ting an electric charge in propor tion to the forces applied to the bone. Bone matrix is removed from areas of positiv e charge and laid down in areas of negative charge. Carter (1984) hypothesized that mech anical forces produce microfractures, which stimulate osteoclastic rem odeling coupled with osteobl astic activity. Lanyon (1981) demonstrated that both the rate and magnitude of strain influenced bone remodeling. He monitored bone mineral in the radii of sheep under artificial stimulation. No change occurred with strain magnitude less than that of the animal's normal walk ing load. With higher strain magnitude and normal strain rates, periosteal bone deposition increase d slightly. When both magnitude and rate were higher than in normal wa lking, periosteal bone in creased substantially. Thus bone, like muscle, requires a specific magnitude and rate of stimulus in order to stimulate hypertrophy. Although the specific level and magnit ude of exercise to imp rove bone density in humans has not been clearly delineated, most studi es indicate 20 to 30 minutes of weight-bearing exercise, 3 to 4 days per week will maintain skeletal health. Exercise is considered to be an attractive alternative to pharmacologic interventions for preventing and treating osteoporosis Numerous case-control and retrospective and prospective

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18 cohort studies suggest that exer cise improves balance, coordina tion, and bone strength and thus reduces the incidence and the severity of fall -related fractures (Kannus, 1999). Unfortunately, no clinical trials have examined th e effects of exercise on osteopenia or osteoporosis in men with IBD. Numerous studies of the effects of ex ercise on osteoporosis in postmenopausal women have been conducted, however, but with conf licting results. For example, one study found no change in femoral neck BMD (Bloomfield, Williams, Lamb, & Jackson, 1993), while a second study reported no change in BMD at the femora l neck or Wards triangle, but did find a significant increase in the trochanteric region (Kronhed & Moller, 1998). A third study reported significant increases in BMD at the femoral ne ck, Wards triangle, a nd trochanteric region (Caplan & Ward, 1993), while a fourth study reported that exercise alone ha d no effect at any of the hip sites, but that exercise and calcium supplementation had a positive effect on the femoral neck (Lau, Woo, Leung, Swaminathan, & Le ung, 1992). A more recent study from Jessup, Horne, Vishen, and Wheeler (2003) reported sign ificant improvements in bone mineral density of the femoral neck and lumbar vertebra in postmenopausal women following 8 months of exercise training and calcium supplementation. The training consisted of 30-60 minutes of walking, three days/week while wearing weighted vests. Subjects also took 1000 mg calcium citrate and 400 IU vitamin D da ily during the study period (Appe ndix F). Taken together these studies show 4 to 12 months of exercise can inhibit bone loss and improve BMD in adults. Biochemical Markers of Bone Metabolism Previous studies of the effects of resistan ce exercise training on BM D have utilized the analyses of serum chemical markers of bone meta bolism. Serum levels of osteocalcin (OC) and bone-specific alkaline phosphatase (BAP), both mark ers of bone anabolism, have been shown to be sensitive to alterations in bone metabolis m following disease, menopause, and hormone replacement therapy. Serum pyridin oline cross-links (PYD) are an indicator of bone catabolism,

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19 or resorption. In theory, an increase in BMD wo uld be reflected by an increase in OC and BAP as well as in increase in the ratios between OC and BAP and PYD. Vi ncent and Braith (2002) analyzed serum levels of OC, BAP, and PYD in a group of men and women before and after 6 months of low-intensity (LEX ) or high-intensity (HEX) resi stance exercise training. Although there were no differences in serum levels of the three biochemical markers between the LEX, HEX and control groups, nor between the male a nd female subjects at the beginning of the study, they were significant increases in OC in bot h the HEX and LEX groups after 6 months of training. BAP increased significan tly for the HEX group but not for the LEX or control groups. They also found that the ratios of OC and BAP to PYD increased in the exercise groups but not in the controls after the 6-month period. They c oncluded that the increases in the biochemical markers of bone anabolism and the increased ratio s of OC and BAP to PYD were consistent with increases in BMD measured by dual-energy x-ra y absorptiometry observed in the exercise groups. These three biochemical markers may help explain the alterations that occur in bone turnover as a result of disease, menopause, horm one replacement and other therapies as well as exercise training. In a multifactorial analysis of risk factors for decreased bone mineral density in inflammatory bowel disease, the biochemical marker DPD were c onsistently elevated indicating an increase in bone resorption (Bartram et al., 2006). Self-Efficacy and Exercise An active lifestyle is particularly importan t for older adults give n the broad constellation of physiological, behavioral, cognitive, and biochemical outcomes that are influenced by physical activity. The majority of adults, however, do not exercise or participate in sports on a regular basis according to the National Health Interview Survey (NIH, 1991). There are a number of theoretical explanati ons that provide an understandi ng of why individuals choose to participate or not participate in health-relate d behaviors. Recently, self-efficacy has received

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20 considerable support as a predicto r of the initiation and maintenanc e of an exercise program for health and fitness. The constr uct of self-efficacy is derive d from Banduras social cognitive theory (1986). According to the theory, people are motivated to engage in a behavior based on the belief that: (a) the behavior will result in a favorable outcome (outcome expectation), and (b) the individual is capable of executing the beha vior (efficacy expectation). A meta-analysis of studies of health-related behavior s revealed consistent support fo r the importance of self-efficacy as a determinant of healthy lifes tyles, including regul ar exercise (Gillis, 1993). A considerable literature further suggests that participation in exercise training has a positive influence on selfefficacy. McAuley, Bane, and Mihalko (1995) examin ed the effects of both long-term exercise participation and acute bouts of exercise on the physical self-efficacy of middle-aged men and women. In addition to demonstrating the utility of physical mastery expe riences in influencing efficacy, McAuley, Bane and Mihalko (1995) reported some interesting patte rns with respect to gender responses. Whereas men and women de monstrated significant gains in perceived capabilities in response to both acute and longterm exercise, men initially were significantly more efficacious than women. We hypothesize that subjects in the exerci se group will gain both the psychomotor skills and the self -efficacy to continue exercising as part of a healthy lifestyle. Literature Review Summary The literature has demonstrated that osteopor osis is a significan t healthcare concern. Osteoporosis is associated with a high morbidity and mortality rate and is a risk factor for fractures. Due to the long-term us of corticoste roid drugs and other factors, patients with inflammatory bowel disease (IBD) are at in creased risk of developing osteopenia and osteoporosis compared to the general population. There have been multiple interventions that have demonstrated an improvement in BMD. The li terature review has demonstrated exercise as an effective non-pharmacological intervention for BMD.

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21 Figure 2-1. Corticosteroids and bone mineral density

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22 CHAPTER 3 MATERIALS AND METHODS Research Design This study was a randomized parallel design to examine the effects of progressive loadbearing walking exercise in adults with IBD and a prior history of steroid usage but not within the last 12 months and who have chosen not to take osteoporosis medications. Following initial screening and testing procedures subjects were randomly assigned to an exercise group or a sedentary control group. The principa l investigator (PI) supervised the testing of all subjects and the initial exercise training session of subj ects randomized to the exercise group. The coinvestigator assisted with the te sting and training. The control gr oup did not participate in regular exercise during the study period. Sixteen adults, ag e 21 to 75 years, were recruited to participate in the study. Following baseline testing, subjec ts were randomly assigned to an exercise group (n=7), or to a sedentary contro l group (n=9). Subjects in the exercise group were issued a weighted vest, a pedometer/step counter, an exercise log-book, Calcium/Vitamin D log-book and instructed in their use. Traini ng consisted of stretching and flex ibility calisthenics and walking while wearing weighted vests. Subjects comple ted three, 50 minute exer cise sessions/week for 32 weeks at home. Measurements for all subjects included: (1) dual-energy x-ray absorptiometry (DEXA) scans of the hip and lumbar spine, (2) biochemical markers of bone metabolism: serum bone specific alkaline phosphatase (BAP) and urinary deoxypridino line (DPD), (3) Osteoporosis Self-Efficacy Scale (OSES) and (4) systolic bl ood pressure. All variables were measured at baseline and after 32 weeks. Statistical analys es compared changes in Systolic Blood Pressure, bone density of the femoral neck, hip and lumbar spine, serum levels of BAP and DPD and the ratios between the BAP and DPD, and scores on the OSES within and between the two groups.

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23 This research project was approved by the Un iversity of Florida, Institutional Review Board and North Florida/South Georgia Vetera ns Health Care System Subcommittee for Investigation. Sample and Setting Eighteen men, aged 21 to 75 years, were recru ited from the Gastroenterology clinics at the North Florida/South Georgia Vete rans Health Care Center. Sa mple size calculations revealed that a sample size of 18 subjects (n=9 in each group) would give a statistical power of 0.80. However, due to recruitment difficulties that will be discussed later, the study was halted with a final sample size of 16 subjects, 9 in control and 7 in exercise gr oups. To estimate the effect size, the investigators assumed there would be no ch anges in variables in the control group, and a standard deviation for the changes from baseline sc ores in the experimental group. The standard deviation estimates are based on the results from previous studies conducted by the investigators and from the literature review (Jessup, Horne, Vishen, & Wheeler, 2003; Vincent & Braith, 2002). Inclusion criteria Subjects selected were adults with IBD, who were not currently taking hormones (e.g., testosterone), osteoporosis medicati ons, or steroids, and have not done so for the prior 12 months. Subjects agreed to undergo two DEXA scans of their lumbar spine, femoral neck and dominant hip, to take 1200mg of calcium and 400 IU vitamin D daily, and to participate in either an exercise group or a non-exercise group for 32 weeks. In addition, all subjects selected were sedentary (i.e., not currently participati ng in regular exercises such as walking, jogging, cycling, dance ae robics, strength training, etc., and have not done so for the previous 12 months). There was no exclusion of subjects from the study ba sed on race or ethnic origin. Subject attrition was mi nimized by weekly phone calls by th e investigator to subjects in both groups. During these phone calls the inves tigator will answer questions and offer

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24 encouragement to follow study protocols. E ach subject was also paid a $100.00 honorarium (prorated) for participating in the study. Exclusion criteria Subjects were excluded from the study if their medical history or physical examination demonstrates evidence of significant cardiovascul ar disease or other disorders that would prevent safe participat ion in the study. The follo wing conditions were considered exclusionary: Hospitalizations within the past 12 months for angina pectoris, myocardial infarction, coronary artery revascularizati on procedures (angioplasty and/ or coronary artery bypass-graft surgery), or any othe r cardiac surgeries. Congestive heart failure, cardiac pacemakers heart rate >100 or <50 at rest. Blood pressure (uncontrolled or controlled by medications): Resting systolic blood pressure>160 mmHg and/or resting di astolic blood pressure >100 mmHg. Duel-energy x-ray absorptiometry (DEXA) scan revealing bone mineral density of lumbar vertebra 2, 3, and 4 or femoral neck of the dominant hip greater than 3.5 standard deviations below that of a normal, healthy adult. Diabetes mellitus or other metabolic or endocrine disorders re quiring hospitalization within the past 12 months. Neuromuscular or orthopedic limitati ons to normal, unassisted ambulation. Known or suspected sensitivity to calcium or vitamin D supplements. Any other medical, cognitive impairment, or psychiatric conditions, which, based on the clinical expertise of the inve stigators or the subjects pers onal health-care provider would make participation in the study not in the subject's best interest. Random Assignment to Treatment Groups Following the baseline screening and testing procedures, subjects were randomly assigned to either the exercise or c ontrol groups using a computerized random number generator. All subjects were asked to not change their usual daily eating habits duri ng the study, and subjects assigned to the control group were asked to conti nue their usual activities of daily living but to

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25 not begin an exercise program during the 32-week study period. To minimize individual variations in the dietary intake of calcium and vitamin D, subj ects in both groups were asked to discontinue taking any over-t he-counter calcium or vitamin D supplements or any multivitamin/mineral supplements containing calc ium or vitamin D during the study period as it was provided by the study. Subjects in both groups were issued a 90-day supply (180 doses) of medication bottles containing 600-mg calcium citrat e and 200 IU vitamin D as cholecalciferol. After contacting the subj ects on their adherence to the medications the PI then refilled the subjects 90 day supply (180 doses) of medications. Subjects were instructed to take one capsule every morning and one capsule every evening at least 1 hour before or after eating a meal and record in a daily log book (total daily dose of 1200 mg calcium a nd 400 IU vitamin D). Subjects were instructed that if they should miss taking a scheduled capsule, to not "double-up" by taking 2 capsules, but rather to conti nue taking the capsules with the next scheduled dose. Subjects were also instructed to immediat ely notify the investig ator(s) if they experience any type of adverse reaction that could be associated with the calcium or vitamin D such as nausea, vomiting, constipation, dry mouth, meta llic taste, or skin rashes. Subjects were asked to bring their log usage of calcium/vitamin D and bring thei r medication bottles to th e investigators at the Malcolm Randall Veterans Medical Center, Gainesville Florida at the end of the study (Appendix E). They were also asked to notify the investigators if there are any changes in their health status or prescription medications during the study period. Measures and Research Variables Independent variable The independent variables in this study is progressive load-bearing walking exercise. The exercise-training program descri bed in this proposal combines ground-reaction and joint-reaction forces to repeatedly place moderate, progres sive strain on the whole skeleton, but more

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26 specifically on the spine, femoral neck and hi p, of men with IBD. Subjects trained for 50 minutes a day, 3 days a week, for 32 weeks. Dependent variables The dependent or outcome variables measured in this study included bone density of the lumber spine, hip and femoral neck of the dominant leg, Osteoporosis Self-Efficacy Scale, exercise measurements and biochemical variables. Bone density of the lumbar spine (L-2, 3, a nd 4), hip and the femoral neck of the dominant leg measured by a Lunar Prodigy Bone Densitometer at the Nuclear Medicine Department, Malcolm Randall Veterans Medical Center, Gainesville, Florida. The Lunar instrument uses a technique known as dual-energy x-ray absorp tiometry (DEXA) to perform non-invasive estimates of BMD in specific regions of the body (Lunar Prodigy ). DEXA utilizes a pencilbeam x-ray filtered to provide the two distinct ener gy peaks necessary to distinguish bone from soft tissue. Dual NaI scintillation crystals are us ed to separately detect the two x-ray energies. The technique for separating x-ray output into two distinct energy levels is known as K-edge filtration. In K-edge filtering, a rare earth element is placed in the beam path and x-rays are sharply attenuated at energy levels particular to that element. L unar uses samarium as the filter material because it produces energy peaks at 46.8keV and 80keV, which have proven to be most effective at differentiating between soft tissu e and bone tissue. The DEXA scans were conducted by a radiology technician especia lly trained to operate the Luna r DEXA equipment. The subjects were asked to lie on the table where padding and adjustable straps were placed to prevent movement. The scan took approximately 15 mi nutes for each subject. Once the scan was completed, the Lunar equipment produces a print out indicating the BMD in g/cm and the BMD percentage compared with young healthy normal cont rols (the T score with standard deviations

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27 above or below normal). The density in g/cm and th e T scores were used in the data analyses of this study. Subjects with bone mine ral densities of the femoral neck or lumbar spine greater than 3.5 SD below young healthy normal controls were excluded from the study. The osteoporosis self-e fficacy scale (OSES) The OSES instrument, developed and evaluate d by Horan and colleagues (1998), is a selfadministered instrument, worded at a sixth grade readability level that consists of 21 items in a visual analog format. The lower anchor of a 10-cm line is labeled not at all confident and the upper end is labeled very confident. The phase If it were recommended that you do any of the follow this week, how confident would you be that you could is used as the stem for the items. Items include such statements as begin a new or different exercise program, exercise for the appropriate length of time, and do exercises even if they are tiring. Subjects were asked to indicate the degree of confidence they feel in th eir ability to do the activity by placing an X on the line that is calibrated from 0 to 100mm on each of the 21 items. Horan and colleagues evaluated the criterion-related validity of th e OSES by comparing responses on the instrument from 201 women, ages 35 to 95, with responses on the Atherosclerosis Risk in Communities (ARIC)/Baecke Habitual Physical Activity (A BHPAQ; Baecke, Burema, & Frijiters, 1982) instrument. The ABHPAQ measures self-efficacy on a sport/leisure scale and on a general exercise scale. Controlling fo r biographic (age, height, and we ight) variables and experiential (years of education, friends, family, or both w ith osteoporosis) variables, the OSES had a correlation of 0.52 (p< 0.01) with th e sport/leisure scores and a co rrelation of 0.65 (p<0.01) with the general exercise scores of the ABHPAQ instru ment. The internal consistency estimates of the OSES were also strong (0.94) (Horan, Ki m, Gendler, Froman, & Patel, 1998).

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28 Exercise measurements A pedometer was used to measure the time, distance and adherence to the exercise protocol. Each subject was provided a pe dometer/step counter (Fitness Pedometer 360 Sportline Inc., Campbell, CA) and instructed in its use. The pedometer will record up to 100,000 steps. The pedometer also measured time the s ubject has walked. After their walks, subjects were asked to log the time, mileag e, and steps in a logbook provided. Biochemical variables Non-fasting blood and urine samples were collected from each subject at baseline and at 32 weeks. Bone-specific alkaline phosphatase (BAP) was measured in serum using an AlkphaseB enzymatic immunoassay kit (EIA) (Metra Bios ystems, Mountain View, CA). The assay is highly specific for BAP, cross-reacting 8% with liver alkaline phosphatase and not significantly with other alkali ne phosphatase isoenzymes. Urin ary deoxypyridinoline (DPD) was measured from Quest Diagnostics Nichols In stitute utilizing lumine scent immunoassay To explore the possible influence of load-bearing exercise on the stat e of bone metabolism, ratios of BAP (anabolic indicator) to DPD (cat abolic indicator) were calculated. Procedures A timeline for individual subjects can be found in Appendix D Table 2. Below is a description of Visit 1 Part a, Visit 1 Part b, and Visit 2. Visit 1 Part a. Potential subjects were invited to an orientation se ssion at the Malcolm Randall Veterans Medical Center Gainesville Florida. The investigators explained the purposes, procedures, potential risks and bene fits, and general conditions for the study. Questions were encouraged and time was allowed for subjects' inquiries prior to agreeing to participate in the study. Subjects who agreed to participate were asked to sign an informed

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29 consent document and to complete demographic and health-history que stionnaires. Subjects were then asked to complete the Osteoporosis Self-Efficacy Scale (O SES, Appendix C). Visit 1 Part b. Subjects who have completed Visit 1(a) underwent a physical examination conducted by the PI, including res ting heart rate and blood pressure measurements. Subjects who met the preliminary inclusion criteria were given an appointment to vis it the Nuclear Medicine Department, Malcolm Randall Veterans Medical Cent er, Gainesville, Florida for DEXA scans of their spine, femoral neck and hip. Subjects were informed by telephone of the results of their DEXA scans and whether they met the inclusi on criteria for the study. Subjects who met the inclusion criteria were scheduled to attend Visit 2. They were as ked to wear comfortable, loosefitting clothing and rubber soled walking shoes suitable for exercising when they attend Visit 2. Visit 2 Blood drawing: Visit 2 was conducted at the Malco lm Randall Veterans Medical Center, Gainesville Florida. The lab collect ed a 30-mL blood sample from each subject via venipuncture and obtained urine samp le. During this visit, the subj ects in the experimental group were instructed in proper stretching and warm up exercises prior to exercise. Subjects were instructed regarding proper footwear, clothing, and hydration for exercising. The control group was instructed to not engage in any new exercise programs. Exercise Group Protocols The investigators monitored all exercise tr aining progress either by weekly telephone or email correspondence with each subject in the exercise group. All exercise training was conducted according to the guidelines published by the American College of Sports Medicine (ACSM, 2000). Subjects in the exercise group completed 32 weeks (three, 50 minute bouts/week) of walking at a normal pace while wear ing weighted vests. S ubjects were instructed regarding proper footwear, clothing, and hydratio n for exercising. Each exercise session will

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30 begin with 10 minutes of stretching and warm-up calisthenics, and end with 10 minutes of cool down walking and stretching. Load-bearing walking Subjects were issued and fitted with an adjustable lightweight nylon vest (All Pro Weight Adjustable Exercise Vest Fit-1, Inc., Salisbury, Ma). The vest has foam cushioning for the shoulders, chest, a nd back, and has twenty pockets with Velcro closures on the front and back that will each accommodate a 0.48 kg (1 lb) weight. The pockets can accommodate a total of 18.2 kg ( 40 lbs). For the first week, the subjects walked wearing only the vest (without weights). Weights were added gradually for all subjects to increase load bearing up to max of 20 pounds of weight du ring weeks 9-12 (Appendi x D Table 1: Load bearing walking schedule of progression). Each subject was provided a pedometer/step counter (Fitness Pedometer 360 Sportline Inc., Campbell, CA) and instructed in its use. The pedometer will record up to 100,000 steps. The pedometer also measured time the subject has walked. After their walks, subjects were aske d to log the time, mileag e, and steps in a logbook provided. The PI either contacted by telephone or email each subject weekly to inquire about progress and to discuss any con cerns or problems the subject ma y be experiencing. The exercise log-book information was collected every 7 days when the subjects we re contacted by the investigator as described above. End-point testing. End-point testing was conducted no longe r than 5 days after the end of the training/control periods. Visit 3 Visit 3 was conducted at the Malc olm Randall Veterans Medical Center, Gainesville Florida at the end of the 32-week study period for th e experimental and the control group. Repeat resting heart rate and blood pressure measurements were obtained. Urine sample and 30 mL of blood sample were collected in the laboratory at the Ma lcolm Randall Veterans

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31 Medical Center, Gainesv ille Florida.subjects were then be asked to complete the OSES instrument and DEXA scans of the lumbar spine, femoral neck and dominant hip were repeated exactly as in Visit 1, Part b. Data Analysis The data analysis for this study was conducted using the Statistical P ackage for the Social Sciences (SPSS) program, version 15.0 (SPSS Inc., Chicago, IL). Descriptive statistics were first obtained to provide summary measures for both exercise and cont rol groups. Descriptive characteristics were compared between groups using analysis of variance (ANOVA). All statistical analyses were performed using the SPS S statistical software pr ogram. An alpha level of p 0.05 was required for sta tistical signi ficance. As previously discussed, subj ects were recruited from the North Florida/ South Georgia Veterans Healthcare System. Over 300 partic ipants were initially assessed for the study, however only 18 actually began th e program with 16 completing th e study. The two participants did not complete the study, one c ontrol subject was not able to ar range travel for the post test evaluation and one experimental subject moved and was not able to make the trip for post test evaluation. Thus the data analysis was perfor med on the 9 participants who comprised the control group and 7 participants who comprised the treatment group. Potential Health Risks The risks associated with this study protoc ol include the risks associated with DEXA scans, venipuncture, exercise tr aining, and the oral administra tion of calcium and vitamin D. There were no potential psychological, social, legal, or other risks to subjects participating in this project. Risks are discussed in the paragraphs below. Dual-energy x-ray absorptiometry (DEXA) s cans. The radiation exposure from a Lunar Prodigy bone density scan of the spine and hip ranges from 1 millirems (mREMs),

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32 depending on the body size (thickness and density) of the individual subject. Compared with 70 mREMs from a typical two-view chest x-ray, or up to 100 mREMs from some dental x-rays, radiation exposure from the DEXA scan is minimal. In fact, the radiation dose is so low that no external shielding is required for either the su bject or the technologist performing the test (Lunar Prodigy 2000). In this project, each subject ha d two DEXA scans approximately 8 months apart. The risks of the exercise tr aining, walking, was minimized in this project by the study design: (1) the rigid exclusion cr iteria eliminated subjects with unstable cardiovascular or other diseases, (2) all subjects underwent a physical ex amination prior to exer cise testing, (3) the principal investigator, a regist ered nurse and an Advance Nurs e Practitioner experienced in exercise testing and training of older adults, conducted all exerci se tests, (4) subjects were instructed in proper stretching and warm-up t echniques prior to testi ng, (5) subjects were instructed to stop and notify the investigator if th ey notice any type of pain or discomfort during the testing, and (6) following test ing, subjects were instructed on proper stretching and cooldown calisthenics to minimize musc le/joint soreness. Walking for exercise is associated with very little cardiovascular risk. Only one fatal event has occu rred over the past 15 years of exercise training at the Aerobics Activity Center in Dallas; an even t rate of less than one in over one-million miles of walking and running (Pollo ck & Wilmore, 1995). A five-year follow-up study of the risks of strenuous ex ercise in 2,935 men women, 17 to 76 years of age, reported two fatal cardiovascular events in over 370,000 pers on-hours of exercise which represented over 1,600,000 miles of walking and runni ng (Hagberg et al., 1989). The risks associated with training in this project also included the potential for minor mu sculoskeletal injuries from the weighted-vest walking exercises.

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33 The risks of musculoskeletal injuries and falling during the weighted-vest walking were minimized in this project. Subjects were fitted w ith an adjustable lightweight nylon vest that has foam cushioning for the shoulders, chest, and back, and has ten pockets with Velcro closures on the front and back that will each accommodate a 0.48kg (1lb) weight. During the first week of training, subjects walked wearing the vest wit hout weights; weight was added gradually to increase load bearing to 20% of the subjects body weight dur ing the 40-week study period. Nutritional supplementation with calcium and vitamin D: All subjects were supplied with and asked to take one capsule, twice per day co ntaining 600 mg calcium ci trate and 200 IU of vitamin D as cholecalciferol (total daily dos e of 1200 mg calcium and 200 IU vitamin D per day). The RDA for adults of calcium is 1200 mg per day and for vitamin D is 400 IU per day (Dickinson, 2002). Adverse effects associated with oral calcium supplementation include constipation, nausea, vomiting a nd kidney stones. Adverse effect s associated with vitamin D supplementation include nausea, vomiting, anorexia, dry mouth, metallic taste, and headache. To minimize risks to subjects in this project, subjects will be carefully advised to discontinue the study drugs and notify the investig ators immediately if they expe rience any adverse effects or symptoms that could possibly be related to the calcium and vitamin D. During the initial screening period, subjects who reported having a history of intolerance, sensitivity, or any allergies to either calcium or vitamin D s upplements were excluded from the study. Venipuncture There is minimal risk associated with the blood drawing techniques used in this study. Drawing blood from a vein cause s discomfort, possible br uising, and is rarely associated with infection, and uncommonly, fain tness. A certified phlebotomy staff member collected all blood in this study using proper sterile techniques to minimize these risks.

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34 CHAPTER 4 ANALYSIS AND RESULTS Descriptive Statistics Participant demographics included in the analys es were the subjects age, IBD disease type, disease duration, bowel resection an d education level. There was no significant difference in age, disease type or education level (Table 4-1). Participant baseline tests included in the analyses were body mass index, systolic blood pressure, dias tolic blood pressure, h eart rate, Osteoporosis Self-Efficacy Scale, lumbar spine bone mineral density, hip bone mineral density, femoral neck bone mineral density, bone alkaline phosphatase and urinary deoxypridinoline. The systolic blood pressure, disease duration, a nd length of bowel rese ction were the only variables with a statistical significance between the groups at baseline (Table 4-1 and 4-2). Hypothesis 1: Thirty-two weeks of progressi ve load-bearing walking exercise by adults with IBD who are not taking os teoporosis medications will re sult in increased bone density of the lumbar spine, hip and femora l neck (measured by dual-energy X-ray absorptiometry) significantly greater than th at of adults with IBD who do not exercise. There was no significant difference between the groups for lumbar spine bone mineral density (g/cm2) (F=1.493, p=0.241). There was a significant difference between the groups for hip bone mineral density (g/cm2) (F=6.403, p=0.023). There was a significant difference between the groups for the Femoral Neck bone mineral density (g/cm2) (F=13.279, p=0.002). Figure 4-1 demonstrates th e pre-test and posttest bone density results. Hypothesis 2: Thirty-two weeks of progressi ve load-bearing walking exercise by adults with IBD who are not taking oste oporosis medications will resu lt in increased serum levels of BAP and increased ratios between BAP and DPD significan tly greater than that of adults with IBD who do not exercise.There was no significant difference between the groups for urine BAP (F=0.818, p=0.384). There was no significant difference between the groups for urine DPD (F=0.825, p=0.380). Hypothesis 3: Completion of a weeks exercise program by adults with IBD who are not taking osteoporosis medications will result in improved self confid ence in managing their own care (measured by the Osteoporosis Self-Effi cacy Scale) that are significantly higher than those of adults with IBD who do not pa rticipate in exercise training. There was no significant difference between the groups fo r Osteoporosis Self-Efficacy Scale scores (F=0.651, p=0.434).

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35 Hypothesis 4: Thirty-two weeks of progressi ve load-bearing walking exercise by adults with IBD will result in improved Systolic Blood Pressure. There was a no significant difference between the groups for syst olic blood pressure (F=0.532, p=0.478). Descriptive Variables Descriptive analyses failed to demonstrat e significance between the experimental and control group for body mass index (F=0.026, p= 0.814), diastolic blood pressure (F=1.039, p=0.325), and heart rate (F=0.046, p=0.833). Th e Body Mass Index (BMI) did not show a significant difference between groups but met clin ical significance for th e exercise group. The BMI decreased for the exercise group. This decr eased the BMI from >30 to <30 (Figure 4-3), resulting in a category change from obese to overweight. The reported compliance for calcium and vitamin D were similar in both groups. The exercise group reported 96% compliance, while the control group reported 95% compliance. Table 4-1 Baseline data analysis: demographics Variable Total Sample Control Group Exercise Group F P (n=16) (n=9) (n=7) Age (yrs) 54.758.249.6 4.167ns Education (yrs) 13.813.713.9 0.119ns Disease duration (yrs) 2023.215.9 5.5190.04 Crohns or Crohns Colitis 1073 1.5210.23 Ulcerative Colitis 624 1.6400.22 Length of bowel resection (cm) 874.5869.55 6.6310.02

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36 Table 4-2 Baseline data an alysis: dependent variables Variable Total Sample Control Group Exercise Group F P (n=16) (n=9) (n=7) Body mass index (kg/m2) 30.0429.1130.67 0.39ns Systolic blood pressure (mmHg) 134.22128.09139.88 4.810.04 Diastolic blood pressure (mmHg) 79.1179.5178.63 0.04ns Heart rate (beats per minute) 76.1177.6274.25 0.96ns Osteoporosis self-efficacy scale (1-21) 15.0413.4116.24 0.65ns Lumbar spine bone mineral density (g/cm2) 1.161.201.11 1.69ns Hip bone mineral density (g/cm2) 0.981.050.88 2.11ns Femoral neck bone mineral density (g/cm2) 0.930.980.92 0.05ns Bone alkaline phosphatase (IU/L) 26.4125.2227.75 0.14ns Urinary deoxypridinoline (nmol/mmol creatinine) 4.295.163.31 2.14ns ns: non significant Figure 4-1. Pre and pos t DEXA scan results Lumbar Experimental Lumbar Experimental Lumbar Control Lumbar Control Hip Experimental Hip Experimental Hip Control Hip Control Femoral Neck Experimental Femoral Neck Control Femoral Neck Control Femoral Neck Experimental 0.8000 0.8500 0.9000 0.9500 1.0000 1.0500 1.1000 1.1500 1.2000 1.2500 Baseline Post-testing Lumbar Experimental Lumbar Control Hip Experimental Hip Control Femoral Neck Experimental Femoral Neck Control

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37 Figure 4-2. Effects of exercise on systolic blood pressure Figure 4-3. Effects of exerci se on body mass index (BMI) 139.88 127.00 129.70 130.67 120.00 125.00 130.00 135.00 140.00 145.00 Baseline Post-testing SBP Exercise SBP Control 30.67 29.96 29.53 29.55 28.80 29.00 29.20 29.40 29.60 29.80 30.00 30.20 30.40 30.60 30.80 Baseline Post-testing BMI Exercise Group BMI Control Group Obese BMI>30

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38 CHAPTER 5 DISCUSSION Individuals with IBD have a up to 40% grea ter chance of having an osteoporosis-related fracture in their lifetime than the genera l population (Frei et al., 2006). Studies have demonstrated low bone mineral density in up to 75% for individuals with IBD. The pathogenesis of bone loss in IBD is multifactorial, consisting of general risk factors for osteoporosis and disease-specific factors. Studies are lacking for interventions, especially non-pharmacological, on improving bone mineral density in IBD. Therefore, this study looked at a nonpharmacological intervention to improve bone mineral density. Discussion of Findings The ANOVA statistics demonstr ated systolic blood pressure had a statistical significance between the groups at baselin e (F=4.813, p=0.04) with the exercise group having prehypertension. There is no obvious medical rationale to explain the difference in systolic blood pressure at baseline. The diseas e duration and length of small bowel removed had a statistical significance between the two groups. There were additional variables did reach clinical significance. The results along with some observations are further discussed in this chapter. Hypotheses Hypothesis 1: Thirty-two weeks of progressive load -bearing walking exercise by adults with IBD who are not taking os teoporosis medications will re sult in increased bone density of the lumbar spine, hip and femora l neck (measured by dual-energy X-ray absorptiometry) significantly greater than that of adults with IBD who do not exercise. The hip measurement consists of 3 regions, (1 ) femoral neck, (2) trochanteric, and (3) intertrochanteric. This hypothe sis had mixed results for bone density changes. Two of the 3 regions measured a difference in bone minera l density. There was a significant difference between groups in bone density for the hip and femoral neck, but the results for the femoral neck demonstrated a significant diffe rence in the control group. The hip results demonstrated a significant difference in th e exercise group. Although the lumbar spine experimental group increased over time while th e control group decrea sed. The results of the femoral neck may be explained by several mechanisms; lack of sufficient weight vest, lack of time and distance walked and lack of further resistance training as demonstrated in previous studies. The hypothesis was not supported by the re sults of the study.

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39 Hypothesis 2: Thirty-two weeks of progressi ve load-bearing walking exercise by adults with IBD who are not taking oste oporosis medications will resu lt in increased serum levels of BAP and increased ratios between BAP and DPD significan tly greater than that of adults with IBD who do not exercise. There was no significant diffe rence between groups for serum BAP and urine DPD. This hypothesi s was not supported by the results of the study. This is possibly due to the low observe d power leading to a Type II error. Hypothesis 3: Completion of a weeks exercise program by adults with IBD who are not taking osteoporosis medications will result in improved self confiden ce in managing their own care (measured by the Osteoporosis Self-Effi cacy Scale) that are significantly higher than those of adults with IBD who do not pa rticipate in exercise training. There was no significant difference between groups for Osteoporosis Self-Efficacy Scale. This hypothesis was not supported by th e results of the study. This is possibly due to the low observed power leading to a Type II error. In addition, this tool was designed and tested mainly on females while the study group was all males. Hypothesis 4: Thirty-two weeks of progressi ve load-bearing walking exercise by adults with IBD will result in improved systolic blood pressure (SBP). There was no significant difference between groups for SBP. This hypot hesis was not support by the results of the study. Although a significant difference between groups was not met, the exercise group had a clinically significant change in systolic blood pr essure. The 12.88 mmHg decrease in systolic blood pressure for the exercise group decreased the mean from pre-hypertensive to normotensive, while the cont rol group had no change in baseline SBP. There was no addition medications started during the study that would contribute to the change in SBP. Also, the change in SBP is expected and c onsistent with a phys iological change to exercise. Descriptive Variables The subjects baseline variables related to the disease state of IBD demonstrated significant difference in disease duration a nd length of bowel removed betw een experimental and control groups. The disease duration and length of bowel removed was significantly greater in the control group. These findings would suggest th at the control group would have a increased factors for decreased BMD. These findings do not c ontribute to the results at post testing. There was no significant difference between groups for t ype of IBD (Crohns disease or UC). The Body Mass Index (BMI) did not show a significant difference between groups but met clinical significance for the exercise group. The BMI decreas ed for the exercise group. This decreased the BMI from >30 to <30 (Figure 4-3), resulting in a category change from obese to overweight.

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40 Increased BMI levels lead the other comorbiditie s such diabetes, renal disease, stroke and coronary artery disease. The re ported compliance for calcium and vitamin D were similar in both groups. This similar intake of supplementary calcium and vitamin D would account for dietary differences between groups. Th e exercise group reported 96% compliance, while the control group reported 95% compliance. An observation was noted in the exercise group related to frequency of contact. During th e study, two methods of contact were utilized to follow the exercise group, email and telephone. It was noted for subjects that contact took several attempts (n=4) and required them to call back, the average miles walked was markedly lower than group who had more frequent contact. The average weekly miles walked was 1.84. Among those four, three utilized email and excel spreadsheets I prov ided them, and one was able to set a time each week to call. The average miles walked was 6.27. Limitations of Study All studies have some degree of limitations One limitation of this study included the marked distance subjects lived from the study si te. Another limitation of this study included the home based protocol for exercise which does not allow for monitoring ex ercise participation. There is a limitation with home based self reporte d exercise programs, but with weekly calls or emails for log reports and measurement devices th at record steps, subjects are more likely to continue the program protocol. The next limitation involved recr uitment of subjects. The study was designed to minimize subjects to two trips to the Medical Center, many subjects did not want to make the extra trips due to time and gas prices. The PI tried to coordinate matching the study visits to other appointments at the medical center but still only had minimal effect with recruitment. Over 300 subjects were screened for the study with only 18 recruited and 16 completing the study. This leads to the limitation of small sample sizes. Given the small sample size, power was increased to mini mize the chance of type II error. Even though there was a short

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41 duration of treatment to the exercise group, exer cise has been proven to cause changes in BMD in as little as 24 weeks. The short duration wa s also utilized due to difficulty maintaining enrollment to an extended exercise protocol. Statistical Analys is Limitations As discussed previously, power analysis fo r this study, based on the number of variables under consideration, recommended a sample of 9 experimental and 9 controls. The final was 9 controls and 7 experimental. It is possible that the significance in this study was not reached due to inadequate sample size. Type II errors occu r when study findings fail to reject a false null hypothesis. Type II errors generally occur from not having enough subjects in the sample size to sufficiently test the hypothesis. Strengths of Study One of the strengths of this study included th e consistency between groups with baseline characteristics. Although one of the limitations was a home based program, the protocol outlined weekly contact with the subjec ts who were exercising. This pr ovided continue feedback and support to comply with the exercise protocol. Conclusions The demographics did not demonstrate a statis tical significance for IBD disease type. The disease duration and length of bowel resection was st atistically si gnificant in the control group. These are risk factors related to decrease BMD a nd absorption of nutrients for bone maintenance. These was not clearly demonstrated in this study. The study demons trated statistical significance for increase in femoral neck bone density but was in the control group. Also there was a significant increase in hip bone for the exercise group, which consists of 3 regions, (1) femoral neck, (2) trochanteric, and (3) in tertrochanteric. The lumbar sp ine bone mineral density result were not statistically significant but the results sh ow a decrease in the controls while the exercise

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42 group showed a increase suggesting a trend of exer cise benefit. Two of the findings, systolic blood pressure and body mass index, did not reach statistical significance but reach clinical significance thus demonstrating benefits to ex ercise. The observation of the average miles walked demonstrated a difference within the exercise group. Although th ere was an increased average miles walked in the subjects with frequent contact, the total average miles walked were possibly to low make an increase in BMD in the studys time frame. Recommendations for Future Research Unfortunately this study demonstrated some co nflicting results for changes in bone mineral density. But, the bone mineral density increase suggests possible benefit from the exercise intervention. The clinical signi ficance demonstrated with syst olic blood pressure and body mass index are consistent with a phys iological change related to ex ercise. The significance of low bone mineral density in IBD and the literature th at supports exercise as an intervention for the improvement on bone mineral density support furt her study. Any future studies should focus on an adequate sample size, increase mechanical stress on the sites measure for BMD and increase frequency of contact during the study. Implications for Clinical Practice This study demonstrated a clinically signifi cant improvement in systolic blood pressure and body mass index. This supports the importan ce of physical activity on multiple health factors. Additionally, support and frequent contact appear to increase exercise compliance for subject

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43 APPENDIX A DEMOGRAPHIC INFORMATION (All information will be kept confidential) Name ___ Todays date __ /___ /_____ last first m.i. mo day year Address __________________________________________________________________ street and box number ____________________________________________________________________________ city state zip code Telephone home ( __ )____ ___ work ( ___ )_______________ Age Date of birth /__ / mo day year Marital status Race __ single European American __ married African American __ divorced or separated Native American __ widowed Hispanic Asian _______Other (please list) Years of education complete d (circle years completed) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 high school graduate doctoral degree bachelor's degree other degrees (list) master's degree Present work status __ Working full time. __ part time. __ Not employed. Reason: __ Medical ___ Retired ___ Other

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44 APPENDIX B MEDICAL HISTORY QUESTIONNAIRE (All information will be kept confidential) Please read the following health history questionn aire carefully and mark the most appropriate answer to each question. If you are unsure about a question, just circle it and go on to the next question. General health history Yes No 1. Has a doctor ever told you that you have heart disease? 2. Have you ever had a heart attack? 3. Has a doctor ever told you th at you have high cholesterol? 4. Have you had heart surgery? 5. Do you have a cardiac pacemaker? 6. Do you have high blood pressure? 7. Have you ever had a stroke? 8. Do you have diabetes? 9. Do you take insulin for diabetes? 10. Have you had carotid artery surgery or an endarterectomy? 11. Do you have a heart valve problem? 12. Has a doctor ever told you that you have an aneurysm? 13. Have you ever had heart failure? 14. Has a doctor ever told you that you have an abnormal EKG? Have you ever had, or do you now ha ve, any of the following conditions? Yes No 15. Rheumatic fever 16. Asthma 17. Chronic bronchitis 18. Emphysema 19. Varicose veins 20. Phlebitis 21. Arthritis 22. Rheumatism 23. Gout 24. Gastrointestinal problems 25. Epilepsy, or seizures 26. Dizziness or fainting spells 27. Loss of memory 28. Anemia continued on next page

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45 29. Chronic back pain 30. Kidney or bladder problems 31. Nervous systems problems 32. Visual or hearing problems 33. Hepatitis or other liver diseases 34. Gall bladder problems 35. Thyroid problems 36. Cancer or tumors 38. Do you sometimes lose urine when you cough, sneeze, or laugh? 39. Any other major illness or surgery? If yes, please explain: __ __ 40. Are you allergic to any me dications? If yes, please list: __ __ 41. Are you now taking any prescription or non-prescription medications, including hormones, vitamins, and other supp lements? If yes, please list: Smoking Yes No 42. Have you ever smoked? If no, skip to diet 43. Do you smoke now? If yes, how many cigarettes per day? For how many years? If no, when did you quit? Diet 44. What do you consider a good weight for yourself? lbs. 45. What do you weigh now? lbs. 46. What is the most you have ev er weighed? lbs. 47. Do you drink alcoholic beverages? yes no Family health history Have any of your blood relatives (your parents, br others, sisters, uncles, aunts, cousins, or children) ever had: Yes No 48. Heart attack 49. High blood pressure 50. Stroke 51. Diabetes 52. High cholesterol Additional comments concerning your pers onal or family health history: ________________________________________________________________________

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46 APPENDIX C OSTEOPOROSIS SELF-EFFICACY SCALE* Name:__________________________________________Date:_______________________ Directions: Please read each of the following statements and indica te your feeling of confidence by marking an "X" on the line below the statement "If it were recommended that you do any of the following this week, how confident would you be that you could?" 1. Begin a new or differe nt exercise program Not at all Very confident confident 2. Change your exercise habits Not at all Very confident confident 3. Put forth the effort required to exercise Not at all Very confident confident 4. Do exercises even if they are difficult Not at all Very confident confident 5. Maintain a regular exercise program Not at all Very confident confident 6. Exercise for the appropriate length of time Not at all Very confident confident 7. Do exercises even if they are tiring Not at all Very confident Confident

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47 8. Stick to your exercise program Not at all Very confident confident 9. Exercise at least three times a week Not at all Very confident confident 10. Do the type of exercise s you are supposed to do Not at all Very confident confident 11. Begin to eat more calcium-rich foods Not at all Very confident confident 12. Increase your calcium intake Not at all Very confident confident 13. Consume adequate amounts of calcium-rich foods Not at all Very confident Confident 14. Eat calcium-rich foods on a regular basis Not at all Very confident confident 15. Change your diet to include more calcium-rich foods Not at all Very confident confident 16. Eat calcium-rich foods as often as you are supposed to Not at all Very confident confident

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48 17. Select appropriate foods to increase your calcium intake Not at all Very confident confident 18. Stick to a diet which gives an adequate amount of calcium Not at all Very confident confident 19. Obtain foods that give an adequate amount of calcium Not at all Very confident confident 20. Remember to eat calcium-rich foods Not at all Very confident confident 21. Take calcium supplements if you don' t get enough calcium from your diet Not at all Very confident confident Horan, M.L., Kim, K.K., Gendler, P., Froman, R.D., & Patel, M.D. (1998). Development and evaluation of the Osteoporosis Self-Efficacy S cale. Research in Nursing and Health, 21 395403.

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49 APPENDIX D TIMELINE Table D-1. Load bearing walk ing schedule of progression Weeks 1 2-4 5-6 7-8 9-12 13-16 17-32 Walking duration (mins) 20 20 30 30 40 45 50 Vest weight % body wt 0 10 10 15 20 20 20 Table D-2. Timeline for individual s ubjects: Each subject will be required to participate in the study for approximately 45 weeks Week 1 Visit 1 (a): Orientation, complete documents, sign informed consent, complete the OSES. Week 2 Visit 1 (b): Physical exam, DEXA scan, Blood draw, Random assignment to exercise or control groups. Week 3 Visit 2: Begin exercise training or cont rol period, Issue calcium and vitamin D scripts Week 35 Visit 3: DEXA scan, Blood draw, complete OSES, End of study

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50 APPENDIX E EXERCISE AND CALCIUM AND VITAMI N D SUPPLEMENTS LOG BOOKS Exercise Log Book (subjects in exercise group only) Front Cover Pages Exercise log book Name____________________ Date :_________Time _________ ID#____________ Miles walked: _________._____ Total steps: ______________ Please enter the date and time of Calories burned:_____________ your exercise session. Total distance walked (in miles), total number of Comments____________________ steps taken during the walk, and total calories burned. Also, any comments you would like to make about that days exercise. Session. Important telephone numbers: Principal Investigator Date:___________Time_______ Charles J Zeilman Miles walked:__________._____ office (352)376-1611 ext 6261 Total steps: ________________ pager 1-877-739-0639 Calories burned:____________ Comments____________________ In case of an emergency telephone 911 Log Book to be constructed of heavy, brightly colored paper and check book in size.

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51 Calcium and vitamin D supplement log book (for subjects in the exercise and control groups) Front Cover Pages Calcium and Vitamin D morning evening Supplements Log Book Date: Name:_____________________ ID#: _____________________ Please take 1 capsule in the morning and 1 capsule in the evening. Take capsules 1 hour before or after meals Please check the box after you have taken your calcium and vitamin supplements Important telephone numbers: Principal Investigator Charles J. Zeilman office (352)376-1611 ext 6261 pager 1-877-730-0639 In case of an emergency telephone 911

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52 LIST OF REFERENCES American College of Sports Medicine. (2000). ACSM's Guidelines for exercise testing and prescription (6th ed.). Baltimore: Williams and Wilkins. Baecke, J. A. H., Burema, J., & Frijiters, J. E. R. (1982). A short questionnaire for the measurement of habitual physical ac tivity in epidemiological studies. The American Journal of Clinical Nutrition, 36 (5), 936-942. Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs: Prentice-Hall. Bassett, C. A. (1971). Biophysical principals affecting bone struct ure. In G.H. Bourne (Ed.), The biochemistry and physiology of bone (2nd ed.), p. 1, New York: Academic Press. Bernstein, C. N., Blanchard, J. F., Leslie, W., Wajda, A., & Yu, N. (2000). The Incidence of fracture among patients with inflammatory bowel disease: A population-based cohort study. Annals of Internal Medicine, 133 (10), 795-799. Black, D. M., Palermo, L., & Bauer, D. (2000). How well does bone mass predict long-term risk of hip fracture. Osteoporosis International 11 (Suppl. 2), S121. Bloomfield, S., Williams, N., Lamb, D., & Jacks on, R. (1993). Non-weight bearing exercise may increase lumbar spine bone mineral de nsity in healthy postmenopausal women. American Journal of Physical Medicine and Rehabilitation, 72 204-209. Caplan, G. A., & Ward, J. A. (1993). The bene fits of exercise in postmenopausal women. Australian Journal of Public Health, 17, 23-26. Carter, D. R. (1984). Mechanical loading histories and cortical bone remodeling. Calcification Tissue International, 36( Suppl. 1), S19-S24. Cooper, C. (2000). Global assessment of fracture risk. Osteoporosis International, 11 (suppl. 2), S44. Dickinson, A. (2002). Benefits of calcium and vitamin D: Building and maintaining healthy bones. Retrieved January 15, 2003, from http://www.crnusa.org/benpdfs/ CRN003benefits_calciumandD.pdf Frei, P., Fried, M., Hungerbuhler, V., Rammert, C., Rousson, V., & Kullak-Ublick, G. A. (2006). Analysis of risk factors for low bone minera l density in inflammatory bowel disease. Digestion, 73 40-46. Gillis, A. J. (1993). Determinants of a health-promoting lifesty le: An integrative review. Journal of Advanced Nursing, 18 (3) 345-353.

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53 Gray, K. (2000). Bone-forming agents: New therapies for osteoporosis. Paper presented at the World Congress on Osteoporosis 2000 Retrieved February 21, 2002, from http://search.medscape.com/ all-search?queryText=Boneforming%20agents:%20New%20the rapies%20for%20osteoporosis Hagberg, J. M., Graves, J. E., Limacher, M., Woods, D. R., Leggett, S. H., & Cononie, C. (1989). Cardiovascular respons es of 70to 79-year old men and women to exercise training. Journal of Applied Physiology, 66 (6), 2589-2594. Heaney, R. P. (2000). There should be a dietary guideline for calcium. American Journal of Clinical Nutrition, 71 (3), 658-670. Hela, S., Nihel, M., Faten, L., Monia, F., Jale l, B., Azza, F., et al. (2005). Osteoporosis and Crohn's disease. Joint Bone Spine, 72 (5), 403-407. Horan, M. L., Kim, K. K., Gendler, P., Froman, R. D., & Patel, M. D. (1998). Development and evaluation of the Osteoporosis Self-Efficacy Scale. Research in Nursing and Health, 21 (5), 395-403. Huang, O., Lu, J., Zhou, Q., Liu, Y., & Wang, Q. (2000). Effect of calcium and vitamin D supplementation on bone loss in postmenopausal Chinese women: A comparative study. Osteoporosis International, 11 (Suppl. 2), S183. Jessup, J., Horne, C., Vishen, R. K., & Wheeler, D. (2003). Effects of exercise on bone density, balance and self-efficacy in older women. Biological Reserch for Nursing 1 (4), 171-181. Kannus, P. (1999). Preventing osteoporosis, fa ll and fractures am ong elderly people. British Medical Journal, 318 (7178), 205-206. Kelley, G. A. (1998). Aerobic exer cise and bone density at the hi p in postmenopausal women: A meta-analysis. Preventive Medicine, 27 (6), 798-807. Kronhed, A. C. & Moller, M. (1998). Effects of physical exercise on bone mass, balance skill and aerobic capacity in women and men with low bone mineral density, after one year of training--a prospective study. Scandinavian Journal of Medicine and Science in Sports, 5 (1), 290-298. Lane, N. E., & Lukert, B. (1998). The science an d theory of glucocorticoid-induced bone loss. Endocrinol Metabolism Clin ics of North America, 27 (2) 465-483. Lanyon, L. E. (1981). Bone remodeling mechanical stress and osteoporosis. In H.F. DeLuca, H.M. Frost, & W.S.S. Jee (Eds.). Osteoporosis: Recent advances in pathogenesis and treatment (p. 129). Baltimore: University Park Press. Lau, E. M. C., Woo, J., Leung, P. C., Swaminat han, R., & Leung, D. (1992). The effects of calcium supplementation and exercise on bone density in elderly Chinese women. Osteoporosis International, 2 (4) 168-173.

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54 Lawson, M. T. (2001). Evaluating an d managing osteoporosis in men. The Nurse Practitioner, 26 (5), 2649. Manolagas, S. C., Weinstein, R. S. (1999). New de velopments in the pathogenesis and treatment of steroid-induced osteoporosis. Journal of Bone and Mineral Research, 14 (7),1061-1066. McAuley, E., Bane, S. M., & Mihalko, S. L. ( 1995). Exercise in middle-aged adults: Selfefficacy and self-presentational outcomes. Preventive Medicine, 24 (4), 319-338. National Institutes of Health. (1991). Osteoporos is research education and health promotion. ( NIH Publication No. 91-3216 ) Bethesda, MD: Author. National Osteoporosis Foundation. (1997). Stand up to osteoporosis: Your guide to staying healthy and independent thr ough prevention and treatment. Washington, D.C.: Author. OShea, B., Rosen, C. J., Guyatt, G., Cranney, A., Tugwell, P., & Black, D. (2000). A meta-analysis of calcium supplementati on for the prevention of postmenopausal osteoporosis. Osteoporosis International 2000 11 (suppl. 2), S114. Pollak, R. D., Karmeli, F., Eliakim, R., Ackerman, Z., Tabb, K., & Rachmilewitz, D. (1998).Femoral neck osteopenia in patient s with inflammatory bowel disease. The American Journal of Gastroenterology, 93 (9), 1483-1490. Pollock, M.L. & Wilmore, J.H. (1995). Exercise in health and disease: Evaluation and prescription for prevention and rehabilitation Philadelphia: W.B. Saunders. Reid, I. R, Heap, S. W. (1990). Determinants of vertebral mineral density in patients receiving long-term glucocorticoid therapy. Archives of Internal Medicine, 150 (12) 2545-2548. Riggs, B. L. & Melton, L. J. (1995). The worldwid e problem of osteoporosis : Insights afforded by epidemiology Bone, 17(5), Supplement 1 505S-511S. Sakellariou, G. T., Moschos, J., Berb eridis, C., Mpoumponaris, A., Kadis, S., Molyvas, E., et al. (2006). Bone density in young males with recent ly diagnosed inflammatory bowel disease. Joint, Bone, Spine, 73 (6), 725-728. Shaw, J. M. & Snow, C. M. (1998). Weighted vest exercise improves indices of fall risk in older women. Journal of Gerontology 53A (1), M53-M58. Sheth, P. (1999). Osteoporosis and exercise: A review. The Mount Sinai Jour nal of Medicine, 66 (3), 197-200. Smith, E. L. (1988). Bone concerns, in M.M. Shangold (Ed.) Women and Exercise: Physiology and Sports Medicine (pp. 79-87). Philadelphia: F.A. Davis. Southerland, J. C., & Valentine, J. F. (2001). Osteopenia and osteoporosis in gastrointestinal diseases: Diagnosis and treatment. Current Gastroenterology Reports, 3, 399-407.

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55 Tonino, R. P., Meunier, P. J., & Emkey, R. D. (2000). Long-term efficacy and safety of alendronate in the trea tment of osteoporosis in postmenopausal women. Osteoporosis International, 11( supplement 2), S202. Valentine, J. F. & Sninsky, C. A. (1999). Prev ention and Treatment of Osteoporosis in Patients with Inflammatory Bowel Disease. The American Journal of Gastroenterology, 94 (4), 878883. Vincent, K. R. & Braith, R. W. (2002). Resist ance exercise and bone turn over in elderly men and women. Medicine and Science in Sports and Exercise, 34 (1) 17-23.

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56 BIOGRAPHICAL SKETCH Charles Joseph Zeilman, III received his bachel or of science in nursing degree from the University of Florida in 1995. He began his career as a staff nurse in the general surgery and cardiac surgery unit at Shands Teaching Hospital in Gainesville, FL. In 1998, Mr. Zeilman earned his masters degree in adult health from the University of Florida. After receiving his degree, he took a Advance Registered Nurse Practitioner position in the gastroenterology section at the North Florid a/South Georgia Veteran s Healthcare System. Mr. Zeilman is the 2006 recipient for the E xcellence in Nursing annual award for Advance Registered Nurse Practitioner. He has several publications during his work as an ARNP. He is an affiliate faculty member for the College of Pharmacy at the University of Florida. He has served on the Deans Advisory Committee College of Nurs ing at University of Florida. He also is a guest le cturer for the College of Nursi ng at University of Florida.