Osteoprotective Knowledge in a Multiethnic Epilepsy Population

John O. Elliott, MPH; Brenda F. Seals, PhD, MPH; Mercedes P. Jacobson, MD


J Neurosci Nurs. 2008;40(1):14-24. 

In This Article


To our knowledge, this is the first study of people with epilepsy to focus on assessment of knowledge of calcium and exercise in relation to AED-induced osteoporosis. The medical literature during the past 20 years has established a strong link between several antiepileptic medications and metabolic bone loss (Pack, 2003); however, past studies have primarily emphasized determining, for various populations, which AEDs are worse for bone density. Prevention has focused on recommendations for DEXA screening and supplementation with calcium and vitamin D (Pack, Gidal, & Vazquez, 2004). Lifestyle recommendations, such as exercise and dietary calcium, often receive cursory mention. It is encouraging to see that the population in this study reported taking calcium supplements more frequently than in previous investigations, for example, that by Geller and Derman (2001).

The scores of participants in this study (mean OKT score = 11.71) were similar to the descriptive data from the OKT test designers (mean OKT score = 11.45; Table 4 ). People with epilepsy, however, had lower scores on the subscales (mean OKT calcium = 8.00 and mean OKT exercise = 7.16) than the scores reported by the test designers (mean OKT calcium = 11.74 and mean OKT exercise = 11.16). Because the validation study of the OKT was completed in 1991, one likely explanation is that significant educational gains have been made from public health messages during the past 16 years. Overall, however, compared to previous studies in various populations (N = 790; Table 4 ), people with epilepsy knew significantly less about osteoporosis. Participants did perform better than older Chinese men in one recent study (mean OKT calcium = 4.42 and mean OKT exercise = 5.73; Lee & Lai, 2006).

Results from the current investigation support a previous knowledge study of non-Caucasian women (not using the OKT) in which only one-third knew that postmenopausal status increased a woman's risk for osteoporosis. In addition, less than one-third knew that long-term steroid use, small body frame, lack of sunlight and vitamin D, oophorectomy, and amenorrhea were also risk factors. Most women believe incorrectly that being African American or Hispanic is protective for osteoporosis. Although African American and Latina women do have somewhat higher bone mass compared to Caucasian women, all groups have similar patterns of bone loss 5 years after menopause (Geller & Derman, 2001). In addition, the rate of hip fracture increases exponentially after age 70 in African American and Latina women compared to Caucasian women (Karagas, Lu-Yao, Barrett, Beach, & Baron, 1996).

Because osteoporosis knowledge has been positively correlated with prevention intention, age, and calcium intake (Chang, Chen, Chen, & Chung, 2003), much needs to be done to bridge the information gap between healthcare practitioners and their patients. As with other chronic health conditions such as diabetes or asthma, people with epilepsy need to receive ethnically relevant communication and educational materials from their healthcare practitioner. Such materials should be tailored to not only improve knowledge but also to enhance patients' confidence in their ability (self-efficacy) to perform the recommended behaviors.

The differences found for calcium knowledge, based on ethnicity, may possibly be attributable to lactose intolerance in African Americans and Hispanics, because dietary recommendations for calcium typically focus on dairy consumption (Jackson & Savaiano, 2001; Larkey et al., 2003). Approximately 75% of the world's adult populations have a genetically limited ability to digest lactose. In the United States, primary lactose intolerance is reported to occur in 15% of Caucasians, 53% of Mexican Americans, 100% of Native Americans, 80% of African Americans, and 90% of Asian Americans (Jarvis & Miller, 2002). There is evidence, however, that African American adolescents can adapt to a dairy-rich diet (Jarvis & Miller).

The problem of dietary calcium for those with lactose intolerance may also be approached by pointing out that there are other foods high in calcium, including vegetables, fish, beans, and nuts and seeds, that may be better dietary choices for those who cannot digest dairy products. People who decide not to consume dairy products because of cultural preference or lactose intolerance also need to rely more heavily on calcium-enriched foods and supplements to meet their daily requirements. Culturally relevant food diaries are needed for ethnically diverse populations. The OKT, although it has been used in non-Caucasian populations, may need to be adapted to assess more culturally relevant factors because dietary staples vary widely among African Americans, Latinos, and Asian Americans.

Because exercise also is an important osteoprotective behavior, concerns that affect people's willingness to exercise also should be addressed. In urban areas, people often report feeling it is unsafe to exercise in their neighborhood. They may, however, have access to the local YMCA, high school gym, or community center. To assist in the adoption of exercise behavior, patients must overcome the fear of seizures during physical exercise. The lack of understanding among many health professionals about epilepsy must also be addressed because unnecessary restriction of physical activity can have a profound effect on bone health, as well as on mortality, morbidity, and quality of life. Exercise participation recommendations should be reviewed with regard to seizure control, medications, proper diet, rest, and the close monitoring of AED levels. If these aspects are taken into account, then people with epilepsy can participate in most types of physical activity, including some contact sports (Howard, Radloff, & Sevier, 2004).

In people with epilepsy, age and gender appear to have little impact on knowledge related to osteoporosis, compared with such socioeconomic factors as minority status, years of education, and yearly income. This finding supports the medical literature for nonepilepsy populations (Werner, 2005). It was somewhat unexpected that men had OKT scores similar to those of women, because osteoporosis is often thought to be a "female" disease. However, this finding may be due to the much smaller number of males completing the survey. Education of people with epilepsy needs to address the fact that bone loss from AEDs affects both men and women and that the target learning needs for men may be different from those for women.

In a survey of young women, the respondents ranked what sources they would most likely use to learn about osteoporosis: 28% chose magazines, handouts, and brochures as their first choice, and 18% preferred a short 5-minute talk during an office medical visit (Kasper, Peterson, & Allegrante, 2001). Minority women, on the other hand, preferred talking with their healthcare practitioner over receiving printed materials (Geller & Derman, 2001). A review of osteoporosis coverage in women's magazines and newspaper articles found that risk factors were outlined in most articles; however, much of the information was ambiguous and incomplete (Wallace & Ballard, 2003). Educational videos have been shown to improve patient knowledge in a study population that included Caucasian (86%), African American (10.5%), and Asian (3.5%) participants (Kulp, Rane, & Bachmann, 2004).

For people to become engaged in the behavior change process, they must not only become aware of a particular health problem and the recommended precautions through knowledge-based interventions, they must also know whether their current behavior meets the recommended guidelines (Blalock, 2005). Providing feedback to women about calcium intake decreased the percentage of people who had never thought about osteoporosis by 23% in one prospective study, although the action-based plan (those who have decided to adopt preventative behaviors) was not associated with changes in knowledge or beliefs (Blalock et al., 2000). Therefore, people who have never thought about osteoporosis are likely to benefit the most from nutrition education aimed at increasing confidence in their abilities to adopt osteoprotective behaviors (Brug, Glanz, & Kok, 1997).

The use of a brief assessment tool such as the one developed by Blalock, Norton, Patel, Cabral, and Thomas (2003) may help practitioners assess patients' calcium intake within the short time frame of an office appointment. Nurses and health educators knowledgeable about osteoprotective concepts may help facilitate the adoption of osteoprotective behaviors. For example, they can recommend such primary prevention measures as nutritional supplementation, diet, and exercise as ways of reducing AED-induced metabolic bone changes. Such education would help improve risk communication, prevention, and treatment for people with epilepsy.

For people with childhood exposure to AEDs or more than 5 years of adult AED use (especially enzyme-inducing AEDs), and for women older than 50 years of age (regardless of length of AED use), a DEXA scan should be performed periodically (Pack et al., 2004). It has been found that unfavorable DEXA screening results increase the adoption of preventative behaviors such as use of calcium supplements (Patel et al., 2003) and exercise (Marci, Anderson, Viechnicki & Greenspan, 2000). In this study, having a present diagnosis of bone loss was significant only for calcium knowledge, and there were no significant differences in those with a history of fracture. This pattern is cause for concern, because 40% of participants reported experiencing a previous fracture. Given the overall safety of calcium (with vitamin D) supplementation and many forms of exercise for those with epilepsy, these preventative actions continue to be important osteoprotective recommendations for this population.

A final consideration is selection of AEDs. Because efficacy is generally similar among the various AEDs, prescribing patterns may be different depending on insurance status, concomitant medications, comorbidities, and child-bearing potential. Enzyme-inducing AEDs are more likely to be used as first-line treatment when patients are uninsured, under-insured, or on public assistance. However, because seizure control takes precedence over other concerns, it is not particularly likely that a nurse practitioner or a physician would change a patient's seizure medication simply on the basis that it negatively impacts bone health.