Digital Behavior Change Interventions for the Prevention and Management of Type 2 Diabetes: Systematic Market Analysis

BACKGROUND

Advancements in technology offer new opportunities for the prevention and management of type 2 diabetes. Venture capital companies have been investing in digital diabetes companies that offer digital behavior change interventions (DBCIs). However, little is known about the scientific evidence underpinning such interventions or the degree to which these interventions leverage novel technology-driven automated developments such as conversational agents (CAs) or just-in-time adaptive intervention (JITAI) approaches.

OBJECTIVE

Our objectives were to identify the top-funded companies offering DBCIs for type 2 diabetes management and prevention, review the level of scientific evidence underpinning the DBCIs, identify which DBCIs are recognized as evidence-based programs by quality assurance authorities, and examine the degree to which these DBCIs include novel automated approaches such as CAs and JITAI mechanisms.

METHODS

A systematic search was conducted using 2 venture capital databases (Crunchbase Pro and Pitchbook) to identify the top-funded companies offering interventions for type 2 diabetes prevention and management. Scientific publications relating to the identified DBCIs were identified via PubMed, Google Scholar, and the DBCIs' websites, and data regarding intervention effectiveness were extracted. The Diabetes Prevention Recognition Program (DPRP) of the Center for Disease Control and Prevention in the United States was used to identify the recognition status. The DBCIs' publications, websites, and mobile apps were reviewed with regard to the intervention characteristics.

RESULTS

The 16 top-funded companies offering DBCIs for type 2 diabetes received a total funding of US $2.4 billion as of June 15, 2021. Only 4 out of the 50 identified publications associated with these DBCIs were fully powered randomized controlled trials (RCTs). Further, 1 of those 4 RCTs showed a significant difference in glycated hemoglobin A1c (HbA1c) outcomes between the intervention and control groups. However, all the studies reported HbA1c improvements ranging from 0.2% to 1.9% over the course of 12 months. In addition, 6 interventions were fully recognized by the DPRP to deliver evidence-based programs, and 2 interventions had a pending recognition status. Health professionals were included in the majority of DBCIs (13/16, 81%,), whereas only 10% (1/10) of accessible apps involved a CA as part of the intervention delivery. Self-reports represented most of the data sources (74/119, 62%) that could be used to tailor JITAIs.

CONCLUSIONS

Our findings suggest that the level of funding received by companies offering DBCIs for type 2 diabetes prevention and management does not coincide with the level of evidence on the intervention effectiveness. There is considerable variation in the level of evidence underpinning the different DBCIs and an overall need for more rigorous effectiveness trials and transparent reporting by quality assurance authorities. Currently, very few DBCIs use automated approaches such as CAs and JITAIs, limiting the scalability and reach of these solutions.

Advancing understanding of dietary and movement behaviours in an Asian population through real-time monitoring: Protocol of the Continuous Observations of Behavioural Risk Factors in Asia study (COBRA)

Background

Modifiable risk factors for non-communicable diseases, including eating an unhealthy diet and being physically inactive, are influenced by complex and dynamic interactions between people and their social and physical environment. Therefore, understanding patterns and determinants of these risk factors as they occur in real life is essential to enable the design of precision public health interventions.

Objective

This paper describes the protocol for the Continuous Observations of Behavioural Risk Factors in Asia study (COBRA). The study uses real-time data capture methods to gain a comprehensive understanding of eating and movement behaviours, including how these differ by socio-demographic characteristics and are shaped by people's interaction with their social and physical environment.

Methods

COBRA is an observational study in free-living conditions. We will recruit 1500 adults aged 21-69 years from a large prospective cohort study. Real-time data capture methods will be used for nine consecutive days: an ecological momentary assessment app with a global positioning system enabled to collect location data, accelerometers to measure movement, and wearable sensors to monitor blood glucose levels. Participants receive six EMA surveys per day between 8 a.m. and 9.30 p.m. to capture information on behavioural risk factors including eating behaviours and diet composition movement behaviours (physical activity, sedentary behaviour, sleep), and related contextual factors. The second wave of ecological momentary assessment surveys with a global positioning system enabled will be sent 6 months later. Data will be analysed using generalised linear models to examine associations between behavioural risk factors and contextual determinants.

Discussion

Findings from this study will advance our understanding of dietary and movement behaviours as they occur in real-life and inform the development of personalised interventions to prevent chronic diseases.

Corrigendum: Elena+ Care for COVID-19, a Pandemic Lifestyle Care Intervention: Intervention Design and Study Protocol

[This corrects the article DOI: 10.3389/fpubh.2021.625640.].

24-hour movement behaviour profiles and their transition in children aged 5.5 and 8 years - findings from a prospective cohort study

BACKGROUND

Time spent in movement behaviours, including physical activity (PA), sedentary behaviour (SB) and sleep, across the 24-h day may have distinct health consequences. We aimed to describe 24-h movement behaviour (24 h-MB) profiles in children and how profile membership changed from age 5.5 to 8 years.

METHODS

Children in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort were asked to wear an accelerometer (ActiGraph-GT3X+) on their wrist for seven consecutive days at ages 5.5 and 8 years to measure 24 h-MB patterns. Time spent in night sleep, inactivity (proxy for SB), light PA, moderate PA (MPA), and vigorous PA (VPA) per day were calculated using the R-package GGIR 2.0. Using latent profile analyses (n = 442) we identified 24 h-MB profiles, which were given animal names to convey key characteristics. Latent transition analyses were used to describe the profile membership transition from ages 5.5 to 8 years. Associations with sex and ethnicity were examined.

RESULTS

We identified four profiles, "Rabbits" (very high-MPA/VPA, low-inactivity and average-night-sleep), "Chimpanzees" (high-MPA, low-inactivity and average-night-sleep), "Pandas" (low-PA, high-inactivity and high-night-sleep) and "Owls" (low-PA, high-inactivity and low-night-sleep), among children at both time points. At ages 5.5 and 8 years, the majority of children were classified into profiles of "Chimpanzees" (51 and 39%, respectively) and "Pandas" (24 and 37%). Half of the sample (49%), particularly "Rabbits", remained in the same profile at ages 5.5 and 8 years: among children who changed profile the predominant transitions occurred from "Chimpanzees" (27%) and "Owls" (56%) profiles to "Pandas". Sex, but not ethnicity, was associated with profile membership: compared to girls, boys were more likely to be in the "Rabbits" profile (adjusted OR [95% CI]: 3.6 [1.4, 9.7] and 4.5 [1.8, 10.9] at ages 5.5 and 8 years, respectively) and less likely to be in the "Pandas" profile (0.5 [0.3, 0.9] and 0.4 [0.2, 0.6]) at both ages.

CONCLUSIONS

With increasing age about half the children stayed in the same of four 24 h-MB profiles, while the predominant transition for the remaining children was towards lower PA, higher inactivity and longer sleep duration. These findings can aid development and implementation of public health strategies to promote better health.

STUDY REGISTRATION

This study was registered on 4th August 2010 and is available online at ClinicalTrials.gov: NCT01174875 .

Prevalence and patterns of physical activity, sedentary behaviour, and their association with health-related quality of life within a multi-ethnic Asian population

OBJECTIVE

The study aimed to examine the prevalence and sociodemographic correlates of physical activity and sedentary behaviour in the general population of the multi-ethnic nation of Singapore as part of the Knowledge, Practice and Attitudes towards Diabetes study, a cross-sectional and population-based survey. It also examined the relationship between physical activity, sedentary behaviour, and health-related quality of life (HRQoL).

METHODS

Physical activity and sedentary behaviour were assessed via the Global Physical Activity Questionnaire (GPAQ), while physical and mental HRQoL was assessed via the Short Form Health Survey (SF-12v2). Survey weights were employed to account for complex survey design. Multivariable logistic regression models were utilized to examine sociodemographic correlates of physical activity (insufficient vs. sufficient physical activity) and sedentary behaviour (< 7 h/day vs ≥7 h/day). Descriptive statistics were calculated to examine the percentage of time spent in different domains of physical activity. Multivariable linear regressions were conducted to examine the association between physical activity and sedentary behaviour with physical and mental HRQoL.

RESULTS

Two thousand eight hundred sixty seven participants recruited from February 2019 to March 2020 (prior to COVID-19 lockdown and related restrictions in Singapore) were included in the analyses. 83.3% of respondents had sufficient physical activity. Age (65 years and above) and income (SGD 2000 to 3999) were associated with a higher likelihood of insufficient physical activity. In contrast, those of Malay ethnicity and having one chronic physical condition were associated with a lower likelihood of insufficient physical activity. 47.7% reported that they had sedentary behaviour of ≥7 h/day. Older age and a primary school education were related to a lower likelihood of sedentary behaviour, while being single, having higher income, obesity, and multimorbidity were associated with higher sedentary behaviour. Insufficient physical activity was significantly associated with lower physical HRQoL but was not significantly associated with mental HRQoL. Sedentary behaviour was not significantly associated with mental or physical HRQoL.

CONCLUSION

About 17% of the population did not meet the minimum requirements for physical activity, while around half of the population spent a considerable time being sedentary. As insufficient physical activity was associated with poorer physical HRQoL, policymakers should promote moderate physical activity and encouraging the breaking up of prolonged sedentary periods within the middle- and high-income groups, especially at the workplace. Increased leisure-time exercise should be encouraged for those in the lower- income group.

Elena+ Care for COVID-19, a Pandemic Lifestyle Care Intervention: Intervention Design and Study Protocol

Background: The current COVID-19 coronavirus pandemic is an emergency on a global scale, with huge swathes of the population required to remain indoors for prolonged periods to tackle the virus. In this new context, individuals' health-promoting routines are under greater strain, contributing to poorer mental and physical health. Additionally, individuals are required to keep up to date with latest health guidelines about the virus, which may be confusing in an age of social-media disinformation and shifting guidelines. To tackle these factors, we developed Elena+, a smartphone-based and conversational agent (CA) delivered pandemic lifestyle care intervention. Methods: Elena+ utilizes varied intervention components to deliver a psychoeducation-focused coaching program on the topics of: COVID-19 information, physical activity, mental health (anxiety, loneliness, mental resources), sleep and diet and nutrition. Over 43 subtopics, a CA guides individuals through content and tracks progress over time, such as changes in health outcome assessments per topic, alongside user-set behavioral intentions and user-reported actual behaviors. Ratings of the usage experience, social demographics and the user profile are also captured. Elena+ is available for public download on iOS and Android devices in English, European Spanish and Latin American Spanish with future languages and launch countries planned, and no limits on planned recruitment. Panel data methods will be used to track user progress over time in subsequent analyses. The Elena+ intervention is open-source under the Apache 2 license (MobileCoach software) and the Creative Commons 4.0 license CC BY-NC-SA (intervention logic and content), allowing future collaborations; such as cultural adaptions, integration of new sensor-related features or the development of new topics. Discussion: Digital health applications offer a low-cost and scalable route to meet challenges to public health. As Elena+ was developed by an international and interdisciplinary team in a short time frame to meet the COVID-19 pandemic, empirical data are required to discern how effective such solutions can be in meeting real world, emergent health crises. Additionally, clustering Elena+ users based on characteristics and usage behaviors could help public health practitioners understand how population-level digital health interventions can reach at-risk and sub-populations.

Children's perceptions of factors influencing their physical activity: a focus group study on primary school children

Purpose

Establishing healthy lifestyle behaviours in primary school children is important, as these behaviours are likely to track into adulthood. This study aimed to explore the factors influencing physical activity (PA) in primary school children through their perspectives.

Approach

Eleven focus group discussions and one interview were conducted with 52 children (n = 29 girls) aged 9–12 years from two primary schools in Singapore. Data analyses were conducted using thematic analysis, deductively following the socio-ecological model (SEM) and inductively for themes at each SEM level.

Results

At individual level, children’s perceived enjoyment, health benefits and expectation of rewards motivated them to engage in PA, while time constraints and their apathy towards PA hindered PA engagement. Children’s PA occasions at home were reported to be influenced by parental permission, priorities and availability, and the availability of preferred peers. Physical environmental factors such as opportunities for PA in school, access to facilities for PA and weather influenced children’s time spent on PA and the types of activities they engaged in.

Conclusion

This study summarized some factors that children have reported to influence their PA behaviour. These findings could help inform future interventions aimed at promoting PA among primary school children in Singapore.

The longitudinal association between early-life screen viewing and abdominal adiposity-findings from a multiethnic birth cohort study

IMPORTANCE

Screen viewing in adults has been associated with greater abdominal adiposity, with the magnitude of associations varying by sex and ethnicity, but the evidence is lacking at younger ages. We aimed to investigate sex- and ethnic-specific associations of screen-viewing time at ages 2 and 3 years with abdominal adiposity measured by magnetic resonance imaging at age 4.5 years.

METHODS

The Growing Up in Singapore Towards healthy Outcomes is an ongoing prospective mother-offspring cohort study. Parents/caregivers reported the time their child spent viewing television, handheld devices, and computer screens at ages 2 and 3 years. Superficial and deep subcutaneous and visceral abdominal adipose tissue volumes were quantified from magnetic resonance images acquired at age 4.5 years. Associations between screen-viewing time and abdominal adipose tissue volumes were examined by multivariable linear regression adjusting for confounding factors.

RESULTS

In the overall sample (n = 307), greater total screen-viewing time and handheld device times were associated with higher superficial and deep subcutaneous adipose tissue volumes, but not with visceral adipose tissue volumes. Interactions with child sex were found, with significant associations with superficial and deep subcutaneous and visceral adipose tissue volumes in boys, but not in girls. Among boys, the increases in mean (95% CI) superficial and deep subcutaneous and visceral adipose tissue volumes were 24.3 (9.9, 38.7), 17.6 (7.4, 27.8), and 7.8 (2.1, 13.6) mL per hour increase in daily total screen-viewing time, respectively. Ethnicity-specific analyses showed associations of total screen-viewing time with abdominal adiposity only in Malay children. Television viewing time was not associated with abdominal adiposity.

CONCLUSION

Greater total screen-viewing time (and in particular, handheld device viewing time) was associated with higher abdominal adiposity in boys and Malay children. Additional studies are necessary to confirm these associations and to examine screen-viewing interventions for preventing excessive abdominal adiposity and its adverse cardiometabolic consequences.

Accelerometer Profile of Physical Activity and Sedentary Behavior in a Multi-Ethnic Urban Asian Population

Purpose: Variability in accelerometry-data processing decisions limited data comparability across studies. We aimed to examine different accelerometry-data processing rules: varying bout lengths and allowance of 0- and 2-min interruptions on the total and bout-accumulated time spent in moderate-to-vigorous physical activity (MVPA) and sedentary behavior estimates, and describe the distribution of activity time based on counts per min (CPM) in granular categories. Method: Using the Singapore Health 2 survey, this study included 746 adults (41.8% women, median age 45.0 years) who provided valid ActiGraph GT3X+ accelerometer-data (≥4 valid days with ≥10-h/day). Quantile regression analysis adjusting for accelerometry daily wear time, age, and gender was performed to calculate the median and interquartile range of accelerometry estimates. Results: Median MVPA time accumulated in bouts of 1-min versus bouts of 10-min was 39.2 min/day and 6.0 min/day, respectively. MVPA time was higher when considering a 2-min interruption (range: 1.8-39.2 min/day) compared to 0-min interruption (range: 0-35.5 min/day) across bout lengths of 1- to 15-min. Participants were sedentary (≤100 CPM) for a daily median of 7.6 h/day. Median activities min/day on the lower-intensity activity spectrum (100-2499 CPM) decreased from 63.4 to 4.6 min/day, while on the higher-intensity activity spectrum (≥2500 CPM) was ≤2.9 min/day. Men generally spent more time in MVPA than women. Conclusions: This study highlights the differences in accelerometry estimates based on data processing decisions, and the importance of quantifying accelerometry-based activity time across the granular intensity spectrum. More studies are warranted to understand the determinants and health impact of these behaviors.

Associations of park access, park use and physical activity in parks with wellbeing in an Asian urban environment: a cross-sectional study

BACKGROUND

Relationships between park access, park use, and wellbeing remain poorly understood. The objectives of this study were to investigate: (1) perceived and objective park access in relation to park use and physical activity in parks; and; (2) perceived and objective park access, park use and physical activity in parks and their associations with wellbeing.

METHODS

An interviewer-assisted survey collected data on perceived time to walk to parks, park use time, park physical activity time and wellbeing (using a scale containing nine domains) amongst adult participants of the Singapore Multi-Ethnic Cohort. Geospatial maps of parks and the "walkable" street networks were created for the city-state of Singapore to objectively determine distances to accessible points on park boundaries. Multiple linear regression models estimated the importance of park access to park use and associations of park access and park use with wellbeing, adjusting for potential confounders.

RESULTS

Participants' (n = 3435) average age was 48.8 years (SD, 12.8), 44.8% were male and 72.6% were of Chinese ethnicity. Better perceived but not true park access was significantly associated with greater park use. Park access (perceived or true) was not associated with physical activity time in parks. Greater participant park time and physical activity time in parks were associated with higher wellbeing scores (p < 0.001). The differences in wellbeing scores between the reference groups, who spent negligible time in parks, and the highest quartiles of time in parks (10.8 h/month) and physical activity in parks (8.3 h/month) were 3.2 (95% CI 2.1-4.4) and 4.2 (95% CI 4.1-6.3) points out of 100 respectively. These associations were similar for most domains of wellbeing, with clear dose-response relationships.

CONCLUSIONS

While perceived park access was strongly associated with park use and well-being, true park access was not, and neither park access measure was associated with park physical activity. Future studies could investigate the influence of park attributes on park use, physical activity in parks and wellbeing. The consistent associations of park use and particularly physical activity in parks with wellbeing suggest that promoting park use, and especially physical activity in parks, is a promising strategy for improving wellbeing in urban settings.

A Web-Based Time-Use Application to Assess Diet and Movement Behavior in Asian Schoolchildren: Development and Usability Study of My E-Diary for Activities and Lifestyle (MEDAL)

Background

Web-based time-use diaries for schoolchildren are limited, and existing studies focus mostly on capturing physical activities and sedentary behaviors but less comprehensively on dietary behaviors.

Objective

This study aims to describe the development of My E-Diary for Activities and Lifestyle (MEDAL)—a self-administered, web-based time-use application to assess diet and movement behavior—and to evaluate its usability in schoolchildren in Singapore.

Methods

MEDAL was developed through formative research and an iterative user-centric design approach involving small groups of schoolchildren (ranging from n=5 to n=15, aged 7-13 years). To test the usability, children aged 10-11 years were recruited from 2 primary schools in Singapore to complete MEDAL for 2 weekdays and 2 weekend days and complete a 10-item usability questionnaire.

Results

The development process revealed that younger children (aged <9 years) were less able to complete MEDAL independently. Of the 204 participants (118/204, 57.8% boys, and 31/201, 15.4% overweight) in the usability study, 57.8% (118/204) completed 3 to 4 days of recording, whereas the rest recorded for 2 days or less. The median time taken to complete MEDAL was 14.2 minutes per day. The majority of participants agreed that instructions were clear (193/203, 95.1%), that MEDAL was easy to use (173/203, 85.2%), that they liked the application (172/202, 85.1%), and that they preferred recording their activities on the web than on paper (167/202, 82.7%). Among all the factors evaluated, recording for 4 days was the least satisfactory component reported. Compared with boys, girls reported better recall ability and agreed that the time spent on completing 1-day entry was appropriate.

Conclusions

MEDAL appears to be a feasible application to capture diet and movement behaviors in children aged 10-12 years, particularly in the Asian context. Some gender differences in usability performance were observed, but the majority of the participants had a positive experience using MEDAL. The validation of the data collected through the application is in progress.

Tracking of Dietary Patterns From Pregnancy to 6 Years Post-pregnancy in a Multiethnic Asian Cohort: The Growing Up in Singapore Towards Healthy Outcomes (GUSTO) Study

Objectives

We assessed the stability of maternal dietary patterns from pregnancy to 6 years post-pregnancy and their associated-sociodemographic and lifestyle factors.

Methods

At 26–28 weeks’ gestation and 6 years post-pregnancy, 24-hour recalls and food frequency questionnaires were collected, respectively, from women in the GUSTO mother-offspring cohort (n = 709). Data on maternal sociodemographic and lifestyle factors were collected at recruitment and again during the 4 to 6-year follow-up visits. Dietary patterns were identified using principal component analysis and stability assessed using Pearson's correlation coefficients and Cohen's weighted kappa. Associations were assessed by multivariable logistic regression, with adjustment for covariates.

Results

The ‘Fruits, Vegetables and Legumes’ (FVL) and ‘Seafood, Noodle, Soup’ (SNS) patterns were identified at both time points, with poor correlation for the dietary pattern z-scores (correlation coefficients: 0.2 and 0.3, respectively) and modest agreement in tertile assignment (weighted κ: 0.11 and 0.15, respectively), suggesting poor stability. An ‘unhealthy’ pattern was only observed at 6 years post-pregnancy. Women with only primary/secondary level education tended to decrease adherence to FVL pattern over time. Women who had gestational diabetes during pregnancy tended to maintain high adherence to FVL pattern over time. Other health conditions such as hypertension during pregnancy and post-delivery development of type 2 diabetes and hypertension did not appear to influence change in women's diet. Women who showed increased adherence to FVL pattern also exhibited healthy lifestyle behaviours, such as being more physically active, post-pregnancy. Women who adhered more closely to the ‘unhealthy’ pattern at 6 years post-pregnancy tended to be younger, of Malay ethnicity, had lower education, had lower household income at 5 years post-pregnancy, were less physically active and had additional pregnancies.

Conclusions

Study findings may be used to inform the design of public health interventions for certain subgroups of women during pregnancy and at post-pregnancy that target key dietary and lifestyle risk behaviours.

Funding Sources

Singapore Ministry of Health's NMRC, Singapore—NMRC/TCR/004-NUS/2008; NMRC/TCR/012-NUHS/2014, SICS, A*STAR, and MOE Academic Research Fund.

Number of daily measurements needed to estimate habitual step count levels using wrist-worn trackers and smartphones in 212,048 adults

Daily step count is a readily accessible physical activity measure inversely related to many important health outcomes. However, its day-to-day variability is not clear, especially when measured by recent mobile devices. This study investigates number of measurement days required to reliably estimate the weekly and monthly levels of daily step count in adults using wrist-worn fitness trackers and smartphones. Data were from a 5-month physical activity program in Singapore. The 5-month period was divided into 22 weekly and 5 monthly time windows. For each time window, we leveraged data sampling procedures and estimated the minimum number of measurement days needed to achieve reliable mean daily step count with intraclass correlation coefficients (ICC) above 80%. The ICCs were derived using linear mixed effect models. We examined both simple random and random consecutive measurement days and conducted subgroup analysis by participant characteristics and tracking devices. Analysis of weekly and monthly step count included 212,048 and 112,865 adults, respectively. Fewer simple random measurement days are needed than random consecutive days for weekly time windows (mean 2.5, SD 0.5 vs mean 2.7, SD 0.5; p-value = 0.025). Similarly, monthly time windows require fewer measurements of simple random days than random consecutive days (mean 3.4, SD 0.5 vs mean 4.4, SD 0.5; p-value = 0.025). Younger participants and those tracking steps via smartphones consistently required more days. Being obese was associated with more measurement days for weekly time windows. In sum, to obtain reliable daily step count level, we recommend at least 3 measurement days for weekly and 5 days for monthly time window in adults. Fewer days could be considered for adults age 60+ years, while more days are required when tracking daily step via smartphones.

Long-term Effectiveness of mHealth Physical Activity Interventions: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Mobile health (mHealth) interventions can increase physical activity (PA); however, their long-term impact is not well understood.

OBJECTIVE

The primary aim of this study is to understand the immediate and long-term effects of mHealth interventions on PA. The secondary aim is to explore potential effect moderators.

METHODS

We performed this study according to the Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched PubMed, the Cochrane Library, SCOPUS, and PsycINFO in July 2020. Eligible studies included randomized controlled trials of mHealth interventions targeting PA as a primary outcome in adults. Eligible outcome measures were walking, moderate-to-vigorous physical activity (MVPA), total physical activity (TPA), and energy expenditure. Where reported, we extracted data for 3 time points (ie, end of intervention, follow-up ≤6 months, and follow-up >6 months). To explore effect moderators, we performed subgroup analyses by population, intervention design, and control group type. Results were summarized using random effects meta-analysis. Risk of bias was assessed using the Cochrane Collaboration tool.

RESULTS

Of the 2828 identified studies, 117 were included. These studies reported on 21,118 participants with a mean age of 52.03 (SD 14.14) years, of whom 58.99% (n=12,459) were female. mHealth interventions significantly increased PA across all the 4 outcome measures at the end of intervention (walking standardized mean difference [SMD] 0.46, 95% CI 0.36-0.55; P<.001; MVPA SMD 0.28, 95% CI 0.21-0.35; P<.001; TPA SMD 0.34, 95% CI 0.20-0.47; P<.001; energy expenditure SMD 0.44, 95% CI 0.13-0.75; P=.01). Only 33 studies reported short-term follow-up measurements, and 8 studies reported long-term follow-up measurements in addition to end-of-intervention results. In the short term, effects were sustained for walking (SMD 0.26, 95% CI 0.09-0.42; P=.002), MVPA (SMD 0.20, 95% CI 0.05-0.35; P=.008), and TPA (SMD 0.53, 95% CI 0.13-0.93; P=.009). In the long term, effects were also sustained for walking (SMD 0.25, 95% CI 0.10-0.39; P=.001) and MVPA (SMD 0.19, 95% CI 0.11-0.27; P<.001). We found the study population to be an effect moderator, with higher effect scores in sick and at-risk populations. PA was increased both in scalable and nonscalable mHealth intervention designs and regardless of the control group type. The risk of bias was rated high in 80.3% (94/117) of the studies. Heterogeneity was significant, resulting in low to very low quality of evidence.

CONCLUSIONS

mHealth interventions can foster small to moderate increases in PA. The effects are maintained long term; however, the effect size decreases over time. The results encourage using mHealth interventions in at-risk and sick populations and support the use of scalable mHealth intervention designs to affordably reach large populations. However, given the low evidence quality, further methodologically rigorous studies are warranted to evaluate the long-term effects.

Motivations to exercise in young men following a residential weight loss programme conducted in National Service - a mixed methods study

Background

Physical activity is a critical component of lifestyle interventions to reduce body weight and maintain weight loss. The goal of this study was to examine the motivations to exercise in young men following a 5-month residential weight loss programme conducted in the Singapore military as part of National Service.

Methods

We conducted a sequential mixed methods study starting with three focus groups comprising 21 programme instructors. Fifteen former programme participants aged 20.8 years (±1.4) with an average body mass index (BMI) of 29.3 kg/m² (±4.6) were interviewed in-depth over a total duration of 9 h. Another 487 current programme participants aged 20.8 years (±1.1), BMI 27.1 kg/m² (±2.6), completed a survey on weight loss, physical fitness, and motivations to exercise using the Behaviours Regulating Exercise Questionnaire (BREQ-3). Qualitative data was coded thematically using the six constructs of exercise motivation described by self-determination theory: amotivation, external, introjected, identified and integrated regulation and intrinsic motivation. Quotes from interviewees were cross-tabulated according to their weight maintenance trajectories. BREQ-3 responses were analysed according to initial body mass index (BMI), percentage weight loss and fitness.

Results

Over the course of the residential programme interview and survey participants experienced an average weight loss of 15.6 kg (±6.5) and 13.0 kg (±5.4) respectively. Among the fifteen interviewees seven had gained no more than 34% of initial weight loss 6 months after completing the programme while another eight had gained more than 51%. We elicited three key themes from the data: (1) Barriers to exercise; (2) diminishing extrinsic motivation; and (3) unidentified exercise benefits. The integration of findings uncovered reinforcing motivational patterns in the areas of health, fitness, camaraderie and identified regulation. Narratives of self-acceptance and shift-work environments gave rise to potentially deleterious motivational patterns. Our findings suggest that successful transition from a residential programme to independent weight management requires a more deliberate pivot from predominantly extrinsic to intrinsic motivational approaches.

Conclusion

Residential programmes such as the one investigated here, should develop a deliberate transition strategy, replace weight loss targets with physical performance goals and promote sports that are appropriate for young men affected by overweight and obesity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10373-z.

Activity in nature mediates a park prescription intervention's effects on physical activity, park use and quality of life: a mixed-methods process evaluation

Background

This process evaluation explored the implementation and mechanisms of impact of a Park Prescription Intervention trial (PPI), including the effects of hypothesised mediators (motivation, social support, recreational physical activity [PA], park use and park PA) on trial outcomes.

Methods

Participants from the community were randomly allocated to intervention (n = 80) or control (n = 80) group. The intervention included baseline counselling, a prescription of exercise in parks, materials, three-month follow-up counselling and 26 weekly group exercise sessions in parks. Process evaluation indicators were assessed at three- and six-months. Implementation indicators included participation rates in intervention components and survey questions plus focus group discussions (FGDs) to understand which components participants valued. FGDs further assessed barriers and facilitators to intervention participation. To explore mechanisms of impact, linear regression was used to compare objectively measured PA between quantiles of group exercise participation. Structural equation modelling (SEM) explored hypothesised mediation of the significant intervention effects. Framework analysis was conducted for FGDs.

Results

Participants were middle-aged (mean 51, SD ± 6.3 years), predominantly female (79%) and of Chinese ethnicity (81%). All intervention participants received baseline counselling, the park prescription and materials, whilst 94% received the follow-up counselling. Mean minutes of moderate-to-vigorous PA/week (95% CI) differed by group exercise participation (p = 0.018): 0% participation (n = 18) 128.3 (69.3, 187.2) minutes, > 0–35.9% participation (n = 18) 100.3 (36.9, 163.6) minutes, > 35.9–67.9% participation (n = 17) 50.5 (− 4.9, 105.9) minutes and > 67.9% participation (n = 18) 177.4 (122.0, 232.8) minutes. Park PA at three-months had significant mediating effects (95% CI) on recreational PA 26.50 (6.65, 49.37) minutes/week, park use 185.38 (45.40, 353.74) minutes/month, park PA/month 165.48 (33.14, 334.16) minutes and psychological quality of life score 1.25 (0.19, 2.69) at six-months. Prioritising time with family and preferences for unstructured activities were barriers to intervention participation. Human interaction via follow-up or group exercise were facilitators.

Conclusion

This process evaluation showed park PA consistently mediated effects of the PPI, suggesting activity in parks was a mechanism of its effects. To optimise effectiveness, participants’ preference for prioritising time with family through family involvement and tailoring the intervention to participants’ preferences for structured or unstructured PA could be considered in future studies.

Trial registration

ClinicalTrials.gov NCT02615392, 26 November 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10177-1.

The Association of Different Types of Leisure Time Physical Activities with Cardiometabolic Outcomes in Singapore-Findings from the Multi-Ethnic Cohort Study

The study aimed to investigate the association between leisure time physical activity (LTPA) subtypes and cardiometabolic outcomes in the Singapore Multi-Ethnic Cohort (MEC). Self-reported data on socio-demographics, lifestyle factors, LTPA subtypes, and health screening data on body-mass index (BMI), waist circumference (WC), systolic and diastolic blood pressure (SBP and DBP), triglycerides (TG), and HDL-and LDL cholesterol were collected. Multivariable linear regression analyses were used adjusting for confounders. The mean age of 9768 participants was 45.2 ± 12.5 years (57.3% female, 47.3% Chinese, 26.0% Malay, and 26.8% Indians). Overall, 65.8% engaged in LTPA, and walking, strength/fitness and running were most common. Higher total LTPA was associated with lower WC, DBP, TG, a trend towards lower BMI, and higher SBP and HDL. Running was beneficially associated with all outcomes except for SBP and LDL. Balance exercises (BMI, SBP and DBP), cycling (BMI, WC and HDL), and strength/fitness (BMI, WC, TG and HDL) were also favorably associated with a number of outcomes, whereas ball games (DBP and TG), dancing (HDL) and other LTPA (DBP) were only favorably associated with selected outcomes. Unfavorable associations were found for total LTPA (SBP), strength/fitness (SBP), golf (DBP) and swimming (BMI and WC). Further research is warranted to inform future health promotion efforts.

Sleep Duration, Sleep Quality and Physical Activity, but Not Sedentary Behaviour, Are Associated with Positive Mental Health in a Multi-Ethnic Asian Population: A Cross-Sectional Evaluation

BACKGROUND

We assessed the associations of sleep, physical activity and sedentary behaviour with positive mental health (PMH) in the multi-ethnic population of Singapore.

METHODS

The Singapore Health 2 study is a nationally representative cross-sectional survey among residents aged 18-79 years. A PMH instrument was administered to 1925 participants to obtain total PMH and six sub-component scores. Self-rated sleep duration, sleep quality, sedentary behaviour and physical activity were assessed. Multivariable linear regression analyses were conducted.

RESULTS

The mean age of the participants was 40.1 (SD 14.3) years. Sleep duration (≥8 h/night: β = 0.17,95% CI: 0.02-0.32; 7-< 8 h/night: β = 0.17,95% CI: 0.03-0.30 versus <6 h/night, p = 0.002), sleep quality (very good: β = 0.45,95% CI: 0.29-0.60; fairly good: β = 0.20,95% CI: 0.06-0.33 versus very/fairly bad; ptrend < 0.001) and physical activity (high: β = 0.19,95% CI: 0.05-0.32; moderate: β = 0.15, 95% CI: 0.03-0.27 versus low; ptrend < 0.001) were directly associated with total PMH. Sedentary behaviour was not significantly associated with PMH. Sleep duration, sleep quality and physical activity were directly associated with the PMH sub-components 'emotional support' and 'personal growth and autonomy'.

CONCLUSIONS

Duration and quality of sleep and physical activity were directly associated with PMH in an urban Asian population. These findings support incorporating sleep and physical activity interventions to improve population mental health.

Multiple modifiable lifestyle factors and the risk of perinatal depression during pregnancy: Findings from the GUSTO cohort

BACKGROUND

Studies have identified lifestyle risk factors for perinatal depression, but none have examined the cumulative effect of these risk factors in pregnant women.

METHODS

We considered the following six factors during pregnancy: poor diet quality (Healthy eating index for Singapore pregnant women<median), poor sleep quality (global Pittsburgh sleep quality index score > 5), physical inactivity (<600 MET-minutes/week), vitamin D insufficiency (<50 nmol/l), smoking before or during pregnancy, and the perceived need for social support. Probable depression was assessed using the Edinburgh postnatal depression scale during pregnancy (>15) and at three months postpartum (≥13). Prevalence risk ratios were calculated with Poisson regressions while adjusting for potential confounders.

RESULTS

Of 535 pregnant women, 207 (39%) had zero or one risk factor, 146 (27%) had two, 119 (22%) had three, 48 (9%) had four, and 15 (3%) had ≥5 risk factors at 26-28 weeks' gestation. These six lifestyle habits contributed to 32% of the variance in depressive symptoms during pregnancy. The prevalence of being probably depressed was 6.4 (95% CI 2.1, 19.8; p_trend < 0.001) for expecting women who had ≥4 risk factors compared to women who had ≤1 risk factor. No association was observed between the number of risk factors and depressive symptoms at 3 months postpartum (p_trend = 0.746).

CONCLUSION

Pregnant women with ≥4 lifestyle risk factors showed a higher prevalence of depression during pregnancy, while no associations were observed for postpartum depression.

CLINICAL TRIAL REGISTRATION

This cohort is registered under the Clinical Trials identifier NCT01174875; http://www.clinicaltrials.gov/ct2/show/NCT01174875?term=GUSTO&rank=2.

The physical activity at work (PAW) study protocol: a cluster randomised trial of a multicomponent short-break intervention to reduce sitting time and increase physical activity among office workers in Thailand

BACKGROUND

High levels of sedentary behaviour (SB) are associated with non-communicable diseases. In 2016, the estimated total healthcare expenditure from physical activity (PA) in Thailand added up to $190 million in international dollars. The challenge to reduce SB and increase PA among office workers is more urgent now than ever as Thailand is transforming itself from a predominantly rural country to an increasingly urban one. This study will investigate the effectiveness of a multicomponent short break intervention on the reduction of SB during office hours.

METHODS/DESIGN

This two-armed Physical Activity at Work (PAW) cluster randomised controlled trial will recruit 360 office workers from 18 offices in the Thailand's Ministry of Public Health (MOPH). Offices will be randomised to either the intervention group or the control group. The multicomponent intervention is informed by the Social Ecological Model and Behaviour Change Techniques (BCTs) and contains four components: (i) organisational, including heads of the participating divisions leading exercises, sending encouragement text messages and acknowledging efforts; (ii) social, including team movement breaks and team-based incentives; (iii) environmental, including posters to encourage exercise; and (iv) individual components including real-time PA feedback via an individual device. The main intervention component will be a short break intervention. The primary outcome of this study is the sedentary time of office workers. Secondary outcomes include time spent on PA, cardiometabolic outcomes, work productivity, musculoskeletal pain, and quality of life. The study also includes process and economic evaluations from the individual and societal perspective.

DISCUSSION

The study will be the first experimental study in Thailand to investigate the effect of a short-break intervention at the workplace on SBs of office workers and health outcomes. The study will also include a cost-effectiveness analysis to inform investments on short break interventions under the Universal Healthcare Coverage in Thailand, which includes health promotion and disease prevention component.

TRIAL REGISTRATION

The PAW study has been registered at the Thai Clinical Trials Registry (TCTR) under the study ID TCTR20200604007 . Registered 02 June 2020,.

Understanding physical activity and sedentary behaviour among preschool-aged children in Singapore: a mixed-methods approach

OBJECTIVES

This study investigated physical activity (PA) and sedentary behaviour (SB) among preschool-aged children in Singapore and potential correlates at multiple levels of the socioecological model from in-school and out-of-school settings.

DESIGN

A cross-sectional study using a mixed-methods approach.

PARTICIPANTS

Parent-child dyads from six preschools in Singapore.

METHODS

PA and SB of children (n=72) were quantified using wrist-worn accelerometers for seven consecutive days. Three focus group discussions (FGDs) among 12 teachers explored diverse influences on children's activities, and System for Observing Play and Leisure Activity in Youth (SOPLAY) assessed PA environment and children's activity levels at preschools. Seventy-three parents completed questionnaires on home and neighbourhood factors influencing children's PA and SB. Descriptive analyses of quantitative data and thematic analysis of FGDs were performed.

RESULTS

Based on accelerometry, children (4.4±1.1 years) spent a median of 7.8 (IQR 6.4-9.0) hours/day in SB, and 0.5 (0.3-0.8) hours/day in moderate-to-vigorous physical activity (MVPA). MVPA was similar throughout the week, and SB was slightly higher on non-school days. In preschools, SOPLAY showed more children engaging in MVPA outdoors (34.0%) than indoors (7.7%), and absence of portable active play equipment. FGDs revealed issues that could restrict active time at preschool, including academic requirements of the central curriculum and its local implementation. The teachers had varying knowledge about PA guidelines and perceived that the children were sufficiently active. In out-of-school settings, parents reported that their children rarely used outdoor facilities for active play and spent little time in active travel. Few children (23.5%) participated in extracurricular sports, but most (94.5%) reported watching screens for 1.5 (0.5-3.0) hours/day.

CONCLUSION

MVPA was low and SB was high in preschool-aged children in an urban Asian setting. We identified diverse in-school and out-of-school correlates of PA and SB that should be taken into account in health promotion strategies.

Correlates of sedentary behaviour in Asian adults: A systematic review

The objective of this study is to systematically review the evidence on correlates of sedentary behaviour (SB) among Asian adults. We searched for studies that examined individual, environmental, and political/cultural correlates of total and domain-specific SB (transport, occupation, leisure, and screen time) in Asian adults published from 2000 onwards in nine scientific databases. Two reviewers independently screened identified references. Following quality assessment of included studies, we performed narrative synthesis that considered differences based on SB measurements, regions, and population characteristics (PROSPERO: CRD42018095268). We identified 13 249 papers of which we included 49, from four regions and 12 countries. Researchers conducted cross-sectional analyses and most relied on SB self-report for SB measurement. Of the 118 correlates studied, the following associations were consistent: higher age, living in an urban area (East Asia), and lower mental health with higher total SB; higher education with higher total and occupational SB; higher income with higher leisure-time SB; higher transit density with higher total SB in older East Asians; and being an unmarried women with higher SB in the Middle East. We encourage more research in non-high-income countries across regions, further exploration of important but neglected correlates using longitudinal designs and qualitative research, and the use of objective instruments to collect SB data.

Effectiveness of prescribing physical activity in parks to improve health and wellbeing - the park prescription randomized controlled trial

Background

Programs promoting population health through physical activity (PA) and exposure to nature are popular, but few have been evaluated in randomized-controlled trials (RCTs).

Objective

To investigate the effectiveness of a park prescription intervention (PPI) for improving total moderate-to-vigorous PA (MVPA), other PA related behaviors, quality of life (QoL) and cardio-metabolic health among adults.

Methods

Healthy individuals aged 40 to 65 years were recruited through community health screenings and randomly assigned to 1) PPI: face-to-face Park Prescription + invitation to weekly exercise sessions in parks, or 2) control: standard PA materials. After the six-month intervention, participants completed accelerometer assessments, questionnaires on health behaviors and QoL, and health screenings. Independent sample t-tests were used to compare outcomes between groups, with secondary analysis adjusted for co-variates via multiple linear regression. A p-value <0.05 was considered statistically significant.

Results

Eighty participants were allocated to each group. Participants with mean age of 51.1 (Standard Deviation: 6.3) years were predominantly female (79%) and of Chinese ethnicity (81%). Participation in the group exercise started at 48% and declined to 24% by week 26. At six-months, 145 (91%) participants attended health screenings for outcome measure collection, and 126 (79%) provided valid accelerometer data. Time spent in MVPA favored the PPI group but this difference was not statistically significant (4.4 (− 43.8, 52.7) minutes/week; when removing 2 extreme outliers 26.8 (− 9.7, 63.4) minutes/week). Time spent in parks (147.5 (2.1, 292.9) minutes/month), PA in parks (192.5 (59.5, 325.5) minutes/month), and recreational PA (48.7 (1.4, 96.0) minutes/week) were significantly greater in the PPI group. PPI also significantly improved psychological QoL (4.0 (0.0, 8.0).

Discussion

PPI improved park use, PA in parks, recreational PA, and psychological QoL but not total MVPA. Future RCTs’ are warranted to investigate PPI in different target populations and to provide further evidence for improvements in health outcomes.

Trial registration

ClinicalTrials.gov NCT02615392, 26 November 2015.

Determinants of Physical Activity and Screen Time Trajectories in 7th to 9th Grade Adolescents-A Longitudinal Study

Physical activity (PA) in youth tends to decline with increasing age, while sedentary behaviour including screen time (ST) increases. There are adolescents, however, whose PA and ST do not follow this pattern. The aim of this study is (i) to examine trajectories in PA and ST from grade 7-9 among students in Berlin, and (ii) to investigate the relationship of these trajectories with individual factors and school type. For the present analyses, changes in students' PA and ST across three time points from 7th to 9th grade were assessed via self-report questionnaires. Positive and negative trajectories were defined for both PA (positive: increasing or consistently high, negative: decreasing or consistently low) and ST (vice versa). Multivariable logistic regression analyses were performed to identify possible predictors of PA and ST trajectories. In total, 2122 students were included (50.2% girls, mean age 12.5 (standard deviation 0.7) years). Compared to grade 7, less students of grade 9 fulfilled PA and ST recommendations (PA: 9.4% vs. 13.2%; ST: 19.4% vs. 25.0%). The positive PA trajectory included 44% of all students (63% boys), while the positive ST trajectory included 21% of all students (30% boys). Being a boy was significantly associated with a positive PA trajectory, while being a girl, having a high socioeconomic status, and attending a high school, were significantly associated with a positive ST trajectory. Different PA and ST trajectories among adolescents should be taken into account when implementing prevention programs for this target group.

A Mobile Health Team Challenge to Promote Stepping and Stair Climbing Activities: Exploratory Feasibility Study

Background

Mobile health (mHealth) approaches are growing in popularity as a means of addressing low levels of physical activity (PA).

Objective

This study aimed to determine the validity of wearables in measuring step count and floor count per day and assess the feasibility and effects of a 6-week team challenge intervention delivered through smartphone apps.

Methods

Staff and students from a public university were recruited between 2015 and 2016. In phase 1, everyone wore a Fitbit tracker (Charge or Charge HR) and an ActiGraph for 7 days to compare daily step count estimated by the two devices under free-living conditions. They were also asked to climb 4 bouts of floors in an indoor stairwell to measure floor count which was compared against direct observation. In phase 2, participants were allocated to either a control or intervention group and received a Fitbit tracker synced to the Fitbit app. Furthermore, the intervention group participants were randomized to 4 teams and competed in 6 weekly (Monday to Friday) real-time challenges. A valid day was defined as having 1500 steps or more per day. The outcomes were as follows: (1) adherence to wearing the Fitbit (ie, number of days in which all participants in each group were classified as valid users aggregated across the entire study period), (2) mean proportion of valid participants over the study period, and (3) the effects of the intervention on step count and floor count determined using multiple linear regression models and generalized estimating equations (GEEs) for longitudinal data analysis.

Results

In phase 1, 32 of 40 eligible participants provided valid step count data, whereas all 40 participants provided valid floor count data. The Fitbit trackers demonstrated high correlations (step count: Spearman ρ=0.89; P<.001; floor count: Spearman ρ=0.98; P<.001). The trackers overestimated step count (median absolute error: 17%) but accurately estimated floor count. In phase 2, 20 participants each were allocated to an intervention or control group. Overall, 24 participants provided complete covariates and valid PA data for analyses. Multiple linear regressions revealed that the average daily steps was 15.9% higher for the intervention group (95% CI −8.9 to 47.6; P=.21) during the final two intervention weeks; the average daily floors climbed was 39.4% higher (95% CI 2.4 to 89.7; P=.04). GEE results indicated no significant interaction effects between groups and the intervention week for weekly step count, whereas a significant effect (P<.001) was observed for weekly floor count.

Conclusions

The consumer wearables used in this study provided acceptable validity in estimating stepping and stair climbing activities, and the mHealth-based team challenge interventions were feasible. Compared with the control group, the participants in the intervention group climbed more stairs, so this can be introduced as an additional PA promotion target in the context of mHealth strategies. Methodologically rigorous studies are warranted to further strengthen this study’s findings.