Using Mobile Technology to Improve Bone-Related Lifestyle Risk Factors in Young Women With Low Bone Mineral Density: Feasibility Randomized Controlled Trial.

BACKGROUND: Poor bone health in adolescent and young adult females is a growing concern. Given the widespread use of mobile phones in this population, mobile health (mHealth) interventions may help improve health behaviors related to bone health in young women. OBJECTIVE: The goal of the study was to determine the acceptability and feasibility of an mHealth intervention called Tap4Bone in improving health behaviors associated with the risk of osteoporosis in young women. METHODS: The Tap4Bone mHealth intervention comprised the use of mobile phone apps, short messaging service (text messaging), and Web emails to encourage health behavior changes. The education group received osteoporosis prevention education leaflets. Changes in the bone health-related behaviors exercise, smoking, and calcium intake were assessed. User experiences and acceptance of the app were collected through focus group interviews. RESULTS: A total of 35 (22 completed, mean age 23.1 [SD 1.8] years) were randomized to either the mobile phone (intervention n=18) or education (control n=17) group. Although there were trends toward improvement in calcium intake, sports activity, and smoking behaviors in the mHealth intervention group compared to the education group, these were not statistically significant. CONCLUSIONS: The Tap4Bone mHealth intervention was shown to be acceptable and feasible in subsets of the participants. The intervention should be improved upon using participant feedback to improve functionality. Findings from this study may aid in the development and modification of health care apps to reduce participant attrition.

Comparison of Different Recruitment Methods for Sexual and Reproductive Health Research: Social Media-Based Versus Conventional Methods.

BACKGROUND: Prior research about the sexual and reproductive health of young women has relied mostly on self-reported survey studies. Thus, participant recruitment using Web-based methods can improve sexual and reproductive health research about cervical cancer prevention. In our prior study, we reported that Facebook is a promising way to reach young women for sexual and reproductive health research. However, it remains unknown whether Web-based or other conventional recruitment methods (ie, face-to-face or flyer distribution) yield comparable survey responses from similar participants. OBJECTIVE: We conducted a survey to determine whether there was a difference in the sexual and reproductive health survey responses of young Japanese women based on recruitment methods: social media-based and conventional methods. METHODS: From July 2012 to March 2013 (9 months), we invited women of ages 16-35 years in Kanagawa, Japan, to complete a Web-based questionnaire. They were recruited through either a social media-based (social networking site, SNS, group) or by conventional methods (conventional group). All participants enrolled were required to fill out and submit their responses through a Web-based questionnaire about their sexual and reproductive health for cervical cancer prevention. RESULTS: Of the 243 participants, 52.3% (127/243) were recruited by SNS, whereas 47.7% (116/243) were recruited by conventional methods. We found no differences between recruitment methods in responses to behaviors and attitudes to sexual and reproductive health survey, although more participants from the conventional group (15%, 14/95) chose not to answer the age of first intercourse compared with those from the SNS group (5.2%, 6/116; P=.03). CONCLUSIONS: No differences were found between recruitment methods in the responses of young Japanese women to a Web-based sexual and reproductive health survey.

Development and Testing of a Mobile Phone App for Self-Monitoring of Calcium Intake in Young Women.

BACKGROUND: Interventions to prevent osteoporosis by increasing dairy intake or physical activity in young women have been limited to increasing osteoporosis knowledge and awareness. However, findings have shown that this does not always lead to a change in behaviors. Self-monitoring using mobile devices in behavioral interventions has yielded significant and positive outcomes. Yet, to our knowledge, mobile self-monitoring has not been used as an intervention strategy to increase calcium intake, particularly in young women, for better bone health outcomes. OBJECTIVE: As development and testing of mobile app-based interventions requires a sequence of steps, our study focused on testing the acceptability and usability of Calci-app, a dietary app to self-monitor calcium consumption, before it is used in a behavioral change intervention in young women aged 18-25 years. METHODS: Calci-app development followed 4 steps: (1) conceptualization, (2) development and pretesting, (3) pilot testing, and (4) mixed methods evaluation. RESULTS: We present the development process of Calci-app and evaluation of the acceptability and usability of the app in young women. Overall, 78% (31/40) of study participants completed the 5-day food record with high compliance levels (defined as more than 3 days of full or partial completion). There was a significant reduction in the proportion of participants completing all meal entries over the 5 days (P=.01). Participants generally found Calci-app easy and convenient to use, but it was time-consuming and they expressed a lack of motivation to use the app. CONCLUSIONS: We present a detailed description of the development process of Calci-app and an evaluation of its usability and acceptability to self-monitor dietary calcium intake. The findings from this preliminary study demonstrated acceptable use of Calci-app to self-monitor calcium consumption. However, for regular and long-term use the self-monitoring function in Calci-app could be expanded to allow participants to view their total daily calcium intake compared with the recommended daily intake. Additionally, to facilitate sustainable lifestyle behavior modifications, a combination of various behavior change techniques should be considered, such as education, goal setting, and advice to participants based on their stage of change. The feedback on barriers and facilitators from testing Calci-app will be used to design a bone health mHealth intervention to modify risky lifestyle behaviors in young women for better bone health outcomes.

Bone Mineral Changes in Epilepsy Patients During Initial Years of Antiepileptic Drug Therapy.

Antiepileptic drug (AED) therapy is associated with decreased bone mineral density; however, the time course for this development is unclear. The aim of this study was to evaluate bone mineral changes during the initial years of AED therapy in AED-naive, newly diagnosed epilepsy patients compared with non-AED users. In 49 epilepsy patients newly started on AEDs and in 53 non-AED users of both genders, bone mineral density (BMD) and bone mineral content were measured using dual-energy X-ray absorptiometry at baseline (within the first year of therapy) and at least 1 yr later. Bone changes between the 2 assessments, adjusted for age, height, and weight, were calculated as the annual rate of change. The median duration of AED therapy was 3.5 mo at baseline and 27.6 mo at follow-up. No overall difference was found in mean BMD and bone mineral content measures between user and nonuser cohorts in both cross-sectional baseline and the annual rate of change (p > 0.05). However, users on carbamazepine monotherapy (n = 11) had an increased annual rate of total hip (-2.1% vs -0.8%, p = 0.020) and femoral neck BMD loss (-2.1% vs -0.6%, p = 0.032) compared to nonusers. They also had a marginally higher rate of femoral neck BMD loss (-2.1%, p = 0.049) compared with valproate (-0.1%, n = 13) and levetiracetam users (+0.6%, n = 13). During the initial years of AED treatment for epilepsy, no difference was found in bone measures between AED users as a group and nonuser cohorts. However, the data suggested that carbamazepine monotherapy was associated with increased bone loss at the hip regions, compared to users of levetiracetam or valproate and nonusers. Larger studies of longer duration are warranted to better delineate the bone effects of specific AEDs, with further consideration of the role of early dual-energy X-ray absorptiometry scanning and careful AED selection in potentially minimizing the impact on bone health in these patients.

Improving Vitamin D Status and Related Health in Young Women: The Safe-D study - Part B.

BACKGROUND: Vitamin D deficiency is highly prevalent and associated with increased risk of a number of chronic health conditions including cardiovascular disease, poor bone and muscle health, poor mental health, infection, and diabetes. Vitamin D deficiency affects millions of Australians, potentially causing considerable suffering, economic loss, and mortality. OBJECTIVE: To measure the effectiveness of a (1) mobile-based app (behavioral) and (2) pharmacological intervention to increase circulating 25-hydroxyvitamin D (serum 25 OHD) levels and health outcomes over 4 months of intervention compared with usual care in a cohort of young women with suboptimal serum 25 OHD levels (25-75 nmol/L). METHODS: Participants with 25 OHD levels 25 to 75 nmol/L are invited to participate in this study. Participants are randomized to one of three groups in 1:1:1 ratio: a mobile phone-based application, vitamin D supplementation (1000 IU/day), and a control group. Data collection points are at baseline, 4, and 12 months post baseline with the major endpoints being at 4 months. A wide-range of information is collected from participants throughout the course of this study. General health, behavioral and demographic information, medications, smoking, alcohol and other substance use, health risk factors, nutrition, eating patterns and disorders, and mental health data are sourced from self-administered, Web-based surveys. Clinical data include anthropometric measurements, a silicone skin cast of the hand, cutaneous melanin density, bone mineral density, and body composition scans obtained through site visits. Main analyses will be conducted in two ways on an intention-to-treat (ITT) basis using the last observation carried forward approach as an imputation for missing data, and on a per protocol basis to compare the intervention arms against the control group at 4 and 12 months. RESULTS: Publication of trial results is anticipated in 2017. CONCLUSIONS: The study will allow assessment of the effects of a mobile-based app behavioral intervention and vitamin D supplementation on vitamin D status and will evaluate the effects of improving vitamin D levels on several health outcomes.

Guidelines and Recommendations for Developing Interactive eHealth Apps for Complex Messaging in Health Promotion.

BACKGROUND: The now ubiquitous catchphrase, "There's an app for that," rings true owing to the growing number of mobile phone apps. In excess of 97,000 eHealth apps are available in major app stores. Yet the effectiveness of these apps varies greatly. While a minority of apps are developed grounded in theory and in conjunction with health care experts, the vast majority are not. This is concerning given the Hippocratic notion of "do no harm." There is currently no unified formal theory for developing interactive eHealth apps, and development is especially difficult when complex messaging is required, such as in health promotion and prevention. OBJECTIVE: This paper aims to provide insight into the creation of interactive eHealth apps for complex messaging, by leveraging the Safe-D case study, which involved complex messaging required to guide safe but sufficient UV exposure for vitamin D synthesis in users. We aim to create recommendations for developing interactive eHealth apps for complex messages based on the lessons learned during Safe-D app development. METHODS: For this case study we developed an Apple and Android app, both named Safe-D, to safely improve vitamin D status in young women through encouraging safe ultraviolet radiation exposure. The app was developed through participatory action research involving medical and human computer interaction researchers, subject matter expert clinicians, external developers, and target users. The recommendations for development were created from analysis of the development process. RESULTS: By working with clinicians and implementing disparate design examples from the literature, we developed the Safe-D app. From this development process, recommendations for developing interactive eHealth apps for complex messaging were created: (1) involve a multidisciplinary team in the development process, (2) manage complex messages to engage users, and (3) design for interactivity (tailor recommendations, remove barriers to use, design for simplicity). CONCLUSIONS: This research has provided principles for developing interactive eHealth apps for complex messaging as guidelines by aggregating existing design concepts and expanding these concepts and new learnings from our development process. A set of guidelines to develop interactive eHealth apps generally, and specifically those for complex messaging, was previously missing from the literature; this research has contributed these principles. Safe-D delivers complex messaging simply, to aid education, and explicitly, considering user safety.

A Comparison of Self-Reported and Objective Physical Activity Measures in Young Australian Women.

BACKGROUND: The evidence for beneficial effects of recommended levels of physical activity is overwhelming. However, 70% of Australians fail to meet these levels. In particular, physical activity participation by women falls sharply between ages 16 to 25 years. Further information about physical activity measures in young women is needed. Self-administered questionnaires are often used to measure physical activity given their ease of application, but known limitations, including recall bias, compromise the accuracy of data. Alternatives such as objective measures are commonly used to overcome this problem, but are more costly and time consuming. OBJECTIVE: To compare the output between the Modified Active Australia Survey (MAAS), the International Physical Activity Questionnaire (IPAQ), and an objective physical activity measure-the SenseWear Armband (SWA)-to evaluate the test-retest reliability of the MAAS and to determine the acceptability of the SWA among young women. METHODS: Young women from Victoria, Australia, aged 18 to 25 years who had participated in previous studies via Facebook advertising were recruited. Participants completed the two physical activity questionnaires online, immediately before and after wearing the armband for 7 consecutive days. Data from the SWA was blocked into 10-minute activity times. Follow-up IPAQ, MAAS, and SWA data were analyzed by comparing the total continuous and categorical activity scores, while concurrent validity of IPAQ and MAAS were analyzed by comparing follow-up scores. Test-retest reliability of MAAS was analyzed by comparing MAAS total physical activity scores at baseline and follow-up. Participants provided feedback in the follow-up questionnaire about their experience of wearing the armband to determine acceptability of the SWA. Data analyses included graphical (ie, Bland-Altman plot, scatterplot) and analytical (ie, canonical correlation, kappa statistic) methods to determine agreement between MAAS, IPAQ, and SWA data. RESULTS: A total of 58 participants returned complete data. Comparisons between the MAAS and IPAQ questionnaires (n=52) showed moderate agreement for both categorical (kappa=.48, P<.001) and continuous data (r=.69, P<.001). Overall, the IPAQ tended to give higher scores. No significant correlation was observed between SWA and IPAQ or MAAS continuous data, for both minute-by-minute and blocked SWA data. The SWA tended to record lower scores than the questionnaires, suggesting participants tended to overreport their amount of physical activity. The test-retest analysis of MAAS showed moderate agreement for continuous outcomes (r=.44, P=.001). However, poor agreement was seen for categorical outcomes. The acceptability of the SWA to participants was high. CONCLUSIONS: Moderate agreement between the MAAS and IPAQ and moderate reliability of the MAAS indicates that the MAAS may be a suitable alternative to the IPAQ to assess total physical activity in young women, due to its shorter length and consequently lower participant burden. The SWA, and likely other monitoring devices, have the advantage over questionnaires of avoiding overreporting of self-reported physical activity, while being highly acceptable to participants.

Falls and fractures in patients chronically treated with antiepileptic drugs.

OBJECTIVE: To evaluate fractures and falls in epilepsy patients taking antiepileptic drugs (AED) and to assess their awareness of AED-related bone health, falls, and fracture risk. METHODS: A cross-sectional study was conducted in epilepsy patients taking AEDs and in nonepileptic non-AED users. Information on falls and fracture history was collected. RESULTS: A total of 150 AED users were compared with 506 non-AED users. Users had greater odds of fracture at spine (odds ratio [OR] 3.92; confidence interval [CI] 1.08-14.16; p = 0.037), clavicle (OR 3.75; CI 1.24-11.34; p = 0.019), and ankle sites (OR 2.34; CI 1.01-5.42; p = 0.048), increased odds for osteoporosis (OR 4.62; CI 1.40-15.30; p = 0.012), and fracture occasions (OR 2.64; CI 1.29-5.43; p = 0.008). We estimate that with every year of AED use the odds of fractures increase by 4%-6%, or 40% per decade for any fracture (OR 1.40; CI 1.02-1.91) and 60% for seizure-related fractures (OR 1.63; CI 1.10-2.37). Non-seizure-related fractures (69% of cumulative fractures) occurred more than seizure-related fractures during therapy. Female users, compared to female nonusers, had more non-seizure falls (31% vs 17%, p = 0.027) and multiple falls (18% vs 5%, p = 0.028) in the preceding year. Fewer than 30% of epilepsy patients knew of the association of AED use with increased risk for fractures, decreased bone mineral density, or falls. CONCLUSIONS: Epilepsy patients taking AEDs had a higher risk of fractures, which was highest in those with longer-term AED exposure. Female AED users had a higher prevalence of falls than matched nonusers. Awareness among epilepsy patients regarding risks of falling and fractures was low.