Short-Term Effectiveness of a Mobile Phone App for Increasing Physical Activity and Adherence to the Mediterranean Diet in Primary Care: A Randomized Controlled Trial (EVIDENT II Study)

How Mobile App Design Impacts User Responses to Mixed Self-Tracking Outcomes: Randomized Online Experiment to Explore the Role of Spatial Distance for Hedonic Editing

Background

Goal setting is among the most common behavioral change techniques employed in contemporary self-tracking apps. For these techniques to be effective, it is relevant to understand how the visual presentation of goal-related outcomes employed in the app design affects users’ responses to their self-tracking outcomes.

Objective

This study examined whether a spatially close (vs distant) presentation of mixed positive and negative self-tracking outcomes from multiple domains (ie, activity, diet) on a digital device’s screen can provide users the opportunity to hedonically edit their self-tracking outcome profile (ie, to view their mixed self-tracking outcomes in the most positive light). Further, this study examined how the opportunity to hedonically edit one’s self-tracking outcome profile relates to users’ future health behavior intentions.

Methods

To assess users’ responses to a spatially close (vs distant) presentation of a mixed-gain (vs mixed-loss) self-tracking outcome profile, a randomized 2×2 between-subjects online experiment with a final sample of 397 participants (mean age 27.4, SD 7.2 years; 71.5%, 284/397 female) was conducted in Germany. The experiment started with a cover story about a fictitious self-tracking app. Thereafter, participants saw one of four manipulated self-tracking outcome profiles. Variables of interest measured were health behavior intentions, compensatory health beliefs, health motivation, and recall of the outcome profile. We analyzed data using chi-square tests (SPSS version 23) and moderated mediation analyses with the PROCESS macro 2.16.1.

Results

Spatial distance facilitated hedonic editing, which was indicated by systematic memory biases in users’ recall of positive and negative self-tracking outcomes. In the case of a mixed-gain outcome profile, a spatially close (vs distant) presentation tended to increase the underestimation of the negative outcome (P=.06). In the case of a mixed-loss outcome profile, a spatially distant (vs close) presentation facilitated the exact recognition of the positive outcome (P=.04). When the presentation of self-tracking outcomes provided the opportunity for hedonic editing, users with a low (vs high) health motivation produced compensatory health beliefs, which led to lower health behavior intentions (index of moderated mediation=0.0352, 95% CI 0.0011-0.0923).

Conclusions

When spatial distance between the presentations of mixed self-tracking outcomes provided the opportunity to hedonically edit one’s self-tracking outcome profile, users recalled their self-tracking outcomes in a more positive light. Especially for users with lower health motivation, the opportunity to hedonically edit one’s mixed self-tracking outcome profile led to reduced health behavior intentions. To prevent the occurrence of hedonic editing in users’ responses to visually presented self-tracking outcome profiles, further research is necessary to determine the ideal distance that should be employed in the app design for the presentation of mixed self-tracking outcomes on a digital device’s screen.

Smartphone apps and the nutrition care process: Current perspectives and future considerations

OBJECTIVE

To provide dietitians with practical guidance on incorporating smartphone applications (apps) in the nutrition care process (NCP) to optimize patient education and counseling.

METHODS

The current evidence-base for mobile health (mHealth) apps was searched using PubMed and Google Scholar. Where and how apps could be implemented by dietitians across the four steps of the NCP is discussed.

RESULTS

With functionality to automatically convert patient dietary records into nutrient components, nutrition assessment can be streamlined using nutrition apps, allowing more time for dietitians to deliver education and nutrition counseling. Dietitians could prescribe apps to provide patients with education on nutrition skills and in counseling for better adherence to behavior change. Improved patient-provider communication is also made possible through the opportunity for real-time monitoring and evaluation of patient progress via apps. A practical framework termed the 'Mobile Nutrition Care Process Grid' provides dietitians with best-practice guidance on how to use apps.

CONCLUSIONS

Including apps into dietetic practice could enhance the efficiency and quality of nutrition care and counseling delivered by dietitians.

PRACTICE IMPLICATIONS

Apps should be considered an adjunct to enable dietetic counseling and care, rather than to replace the expertise, social support and accountability provided by dietitians.

Short- and long-term effectiveness of a smartphone application for improving measures of adiposity: A randomised clinical trial – EVIDENT II study

Background: Evidence on the efficacy of smartphone applications (apps) for reducing body weight and other measurements of adiposity sustainably is not conclusive. Objective: To evaluate the effect of adding an app for 3 months to traditional counselling on physical activity (PA) and a heart-healthy diet for the modification of measurements of adiposity at 3 and 12 months after intervention. Methods: This randomised clinical trial included 833 subjects. The counselling and app group (IG) had 415 subjects, while 418 were included in the counselling only group (CG). The primary outcome was adiposity measurements at 3 and 12 months after intervention. The secondary outcome was the effect of the intervention by sex. Intervention: Counselling on a heart-healthy diet and PA was given to both groups. The IG also received training in the use of a smartphone app designed to promote a heart-healthy diet and PA, and this group was given access to this application for 3 months. Outcome measurements included waist circumference (WC), body mass index (BMI) and Clínica Universidad de Navarra – body adiposity estimator (CUN-BAE). Results: In the IG at 12 months, the following decreased: WC −0.72 cm (95% confidence interval [CI]: −2.35 to −0.02) and CUN-BAE −0.35 (95% CI: −0.63 to −0.06). These decreases were only observed in women. After baseline adjustment, the beneficial effect was maintained in the IG compared to the CG at 12 months in terms of WC (−0.67; 95% CI: −0.29 to −0.02) and CUN-BAE (−0.57; 95% CI: −1.10 to −0.04), but only in women. Conclusions: An intervention of nutritional counselling and PA plus the smartphone app with personalised recommendations compared to CG showed beneficial results in terms of reduction of abdominal obesity and the percentage of body fat in women, but not in men.

EVIDENT 3 Study: A randomized, controlled clinical trial to reduce inactivity and caloric intake in sedentary and overweight or obese people using a smartphone application: Study protocol

INTRODUCTION

Mobile technology, when included within multicomponent interventions, could contribute to more effective weight loss. The objective of this project is to assess the impact of adding the use of the EVIDENT 3 application, designed to promote healthy living habits, to traditional modification strategies employed for weight loss. Other targeted behaviors (walking, caloric-intake, sitting time) and outcomes (quality of life, inflammatory markers, measurements of arterial aging) will also be evaluated.

METHODS

Randomized, multicentre clinical trial with 2 parallel groups. The study will be conducted in the primary care setting and will include 700 subjects 20 to 65 years, with a body mass index (27.5-40 kg/m), who are clinically classified as sedentary. The primary outcome will be weight loss. Secondary outcomes will include change in walking (steps/d), sitting time (min/wk), caloric intake (kcal/d), quality of life, arterial aging (augmentation index), and pro-inflammatory marker levels. Outcomes will be measured at baseline, after 3 months, and after 1 year. Participants will be randomly assigned to either the intervention group (IG) or the control group (CG). Both groups will receive the traditional primary care lifestyle counseling prior to randomization. The subjects in the IG will be lent a smartphone and a smartband for a 3-month period, corresponding to the length of the intervention. The EVIDENT 3 application integrates the information collected by the smartband on physical activity and the self-reported information by participants on daily food intake. Using this information, the application generates recommendations and personalized goals for weight loss.

DISCUSSION

There is a great diversity in the applications used obtaining different results on lifestyle improvement and weight loss. The populations studied are not homogeneous and generate different results. The results of this study will help our understanding of the efficacy of new technologies, combined with traditional counseling, towards reducing obesity and enabling healthier lifestyles.

ETHICS AND DISSEMINATION

The study was approved by the Clinical Research Ethics Committee of the Health Area of Salamanca ("CREC of Health Area of Salamanca") on April 2016. A SPIRIT checklist is available for this protocol. The trial was registered in ClinicalTrials.gov provided by the US National Library of Medicine-number NCT03175614.

A Feasible and Efficacious Mobile-Phone Based Lifestyle Intervention for Filipino Americans with Type 2 Diabetes: Randomized Controlled Trial

Background

Filipino Americans have a high prevalence of obesity, type 2 diabetes (T2D), and cardiovascular disease compared with other Asian American subgroups and non-Hispanic whites. Mobile health (mHealth) weight loss interventions can reduce chronic disease risks, but these are untested in Filipino Americans with T2D.

Objective

The objective of this study was to assess feasibility and potential efficacy of a pilot, randomized controlled trial (RCT) of a culturally adapted mHealth weight loss lifestyle intervention (Pilipino Americans Go4Health [PilAm Go4Health]) for overweight Filipino Americans with T2D.

Methods

This was a 2-arm pilot RCT of the 3-month PilAm Go4Health intervention (phase 1) with an active waitlist control and 3-month follow-up (phase 2). The waitlist control received the PilAm Go4Health in phase 2, whereas the intervention group transitioned to the 3-month follow-up. PilAm Go4Health incorporated a Fitbit accelerometer, mobile app with diary for health behavior tracking (steps, food/calories, and weight), and social media (Facebook) for virtual social support, including 7 in-person monthly meetings. Filipino American adults ≥18 years with T2D were recruited from Northern California. Feasibility was measured by rates of recruitment, engagement, and retention. Multilevel regression analyses assessed within and between group differences for the secondary outcome of percent weight change and other outcomes of weight (kg), body mass index (BMI), waist circumference, fasting plasma glucose, HbA1c, and steps.

Results

A total of 45 Filipino American adults were enrolled and randomized. Mean age was 58 (SD 10) years, 62% (28/45) were women, and mean BMI was 30.1 (SD 4.6). Participant retention and study completion were 100%, with both the intervention and waitlist group achieving near-perfect attendance at all 7 intervention office visits. Groups receiving the PilAm Go4Health in phase 1 (intervention group) and phase 2 (waitlist group) had significantly greater weight loss, −2.6% (−3.9 to −1.4) and −3.3% (−1.8 to −4.8), respectively, compared with the nonintervention group, resulting in a moderate to small effect sizes (d=0.53 and 0.37, respectively). In phase 1, 18% (4/22) of the intervention group achieved a 5% weight loss, whereas 82% (18/22) maintained or lost 2% to 5% of their weight and continued to maintain this weight loss in the 3-month follow-up. Other health outcomes, including waist circumference, BMI, and step counts, improved when each arm received the PilAm Go4Health, but the fasting glucose and HbA1c outcomes were mixed.

Conclusions

The PilAm Go4Health was feasible and demonstrated potential efficacy in reducing diabetes risks in overweight Filipino Americans with T2D. This study supports the use of mHealth and other promising intervention strategies to reduce obesity and diabetes risks in Filipino Americans. Further testing in a full-scale RCT is warranted. These findings may support intervention translation to reduce diabetes risks in other at-risk diverse populations.

Trial Registration

Clinicaltrials.gov NCT02290184; https://clinicaltrials.gov/ct2/show/NCT02290184 (Archived by WebCite at http://www.webcitation.org/6vDfrvIPp)

Effectiveness of a multifactorial intervention based on an application for smartphones, heart-healthy walks and a nutritional workshop in patients with type 2 diabetes mellitus in primary care (EMID): study protocol for a randomised controlled trial

INTRODUCTION

New information and communication technologies (ICTs) may promote lifestyle changes, but no adequate evidence is available on their combined effect of ICTs with multifactorial interventions aimed at improving diet and increasing physical activity in patients with type 2 diabetes mellitus (DM2). The primary objective of this study is to assess the effect of a multifactorial intervention to increase physical activity and adherence to Mediterranean diet in DM2. METHODS AND ANALYSIS: Study scope and population: The study will be conducted at 'La Alamedilla' primary care research unit in Salamanca (Spain). 200 patients with DM2 of both sexes, aged 25-70 years and who meet the inclusion criteria and sign the informed consent will be recruited. Each participant will attend the clinic at baseline and 3 and 12 months after intervention.

INTERVENTION

Both groups will be given short advice on diet and physical activity. The intervention group will also take five heart-healthy walks and attend a group session on diet education and will be trained on use of an application for smartphone (EVIDENT II) for 3 months.

VARIABLES AND MEASUREMENT INSTRUMENTS

The main study endpoints will be changes in physical activity, as assessed by a pedometer and the International Physical Activity Questionnaire, and adherence to the Mediterranean diet, as evaluated by an adherence questionnaire and the Diet Quality Index. Anthropometric parameters and laboratory values, lifestyles and quality of life will also be assessed.

ETHICS AND DISSEMINATION

It was approved by the Clinical Research Ethics Committee of Salamanca on 28/11/2016.

TRIAL REGISTRATION

NCT02991079; Pre-results.