The current state of lifestyle intervention implementation research: where do we go next?

Randomized non-inferiority trial comparing an asynchronous remotely-delivered versus clinic-delivered lifestyle intervention

OBJECTIVE

Lifestyle interventions are effective, but those delivered via in-person group meetings have poor scalability and reach. Research is needed to establish if remotely delivered lifestyle interventions are non-inferior to in-person delivered lifestyle interventions.

METHODS

We conducted a randomized non-inferiority trial (N = 329) to compare a lifestyle intervention delivered remotely and asynchronously via an online social network (Get Social condition) to one delivered via in-person groups (Traditional condition). We hypothesized that the Get Social condition would result in a mean percent weight loss at 12 months that was not inferior to the Traditional condition. Additional outcomes included intervention delivery costs per pound lost and acceptability (e.g., convenience, support, modality preferences).

RESULTS

At 12 months, no significant difference in percent weight change was observed between the Get Social and Traditional conditions (2.7% vs. 3.7%, p = 0.17) however, criteria for non-inferiority were not met. The Get Social condition costs $21.45 per pound lost versus $26.24 for the Traditional condition. A greater percentage of Get Social condition participants rated participation as convenient (65% vs 44%; p = 0.001).

CONCLUSIONS

Results revealed a remotely-delivered asynchronous lifestyle intervention resulted in slightly less weight loss than an in-person version but may be more economical and convenient.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02646618; https://clinicaltrials.gov/ct2/show/NCT02646618 .

A holistic lifestyle mobile health intervention for the prevention of type 2 diabetes and common mental disorders in Asian women with a history of gestational diabetes: a randomised control trial with 3-year follow-up protocol

BACKGROUND

Women with a history of gestational diabetes mellitus (GDM) are 12-fold more likely to develop type 2 diabetes (T2D) 4-6 years after delivery than women without GDM. Similarly, GDM is associated with the development of common mental disorders (CMDs) (e.g. anxiety and depression). Evidence shows that holistic lifestyle interventions focusing on physical activity (PA), dietary intake, sleep, and mental well-being strategies can prevent T2D and CMDs. This study aims to assess the effectiveness of a holistic lifestyle mobile health intervention (mHealth) with post-GDM women in preventing T2D and CMDs in a community setting in Singapore.

METHODS

The study consists of a 1-year randomised controlled trial (RCT) with a 3-year follow-up period. Post-GDM women with no current diabetes diagnosis and not planning to become pregnant will be eligible for the study. In addition, participants will complete mental well-being questionnaires (e.g. depression, anxiety, sleep) and their child's socio-emotional and cognitive development. The participants will be randomised to either Group 1 (Intervention) or Group 2 (comparison). The intervention group will receive the "LVL UP App", a smartphone-based, conversational agent-delivered holistic lifestyle intervention focused on three pillars: Move More (PA), Eat Well (Diet), and Stress Less (mental wellbeing). The intervention consists of health literacy and psychoeducational coaching sessions, daily "Life Hacks" (healthy activity suggestions), slow-paced breathing exercises, a step tracker (including brisk steps), a low-burden food diary, and a journaling tool. Women from both groups will be provided with an Oura ring for tracking physical activity, sleep, and heart rate variability (a proxy for stress), and the "HAPPY App", a mHealth app which provides health promotion information about PA, diet, sleep, and mental wellbeing, as well as display body mass index, blood pressure, and results from the oral glucose tolerance tests. Short-term aggregate effects will be assessed at 26/27 weeks (midpoint) and a 1-year visit, followed by a 2, 3, and 4-year follow-up period.

DISCUSSION

High rates of progression of T2D and CMDs in women with post-GDM suggest an urgent need to promote a healthy lifestyle, including diet, PA, sleep, and mental well-being. Preventive interventions through a holistic, healthy lifestyle may be the solution, considering the inextricable relationship between physical and psychological health. We expect that holistic lifestyle mHealth may effectively support behavioural changes among women with a history of GDM to prevent T2D and CMDs.

TRIAL STATUS

The protocol study was approved by the National Healthcare Group in Singapore, Domain Specific Review Board (DSRB) [2023/00178]; June 2023. Recruitment began on October 18, 2023.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05949957. The first submission date is June 08, 2023.

Lifestyle interventions delivered by eHealth in chronic kidney disease: A scoping review

A method of overcoming barriers associated with implementing lifestyle interventions in CKD may be through the use of eHealth technologies. The aim of this review was to provide an up-to-date overview of the literature on this topic. Four bibliographical databases, two trial registers, and one database for conference proceedings were searched from inception to August 2023. Studies were eligible if they reported a lifestyle intervention using eHealth technologies. A narrative synthesis of the findings from the included studies structured around the type of eHealth intervention was presented. Where a sufficient number of studies overlapped in terms of the type of intervention and outcome measure these were brought together in a direction of effect plot. There were 54 included articles, of which 23 were randomised controlled trials (RCTs). The main component of the intervention for the included studies was mobile applications (n = 23), with the majority being in the dialysis population (n = 22). The majority of eHealth interventions were reported to be feasible and acceptable to participants. However, there was limited evidence that they were efficacious in improving clinical outcomes with the exception of blood pressure, intradialytic weight gain, potassium, and sodium. Although eHealth interventions appear acceptable and feasible to participants, there is insufficient evidence to make recommendations for specific interventions to be implemented into clinical care. Properly powered RCTs which not only demonstrate efficacy, but also address barriers to implementation are needed to enhance widespread adoption.

Designing and Developing a Mobile App for Management and Treatment of Gestational Diabetes in Nepal: User-Centered Design Study

BACKGROUND

Mobile apps can aid with the management of gestational diabetes mellitus (GDM) by providing patient education, reinforcing regular blood glucose monitoring and diet/lifestyle modification, and facilitating clinical and social support.

OBJECTIVE

This study aimed to describe our process of designing and developing a culturally tailored app, Garbhakalin Diabetes athawa Madhumeha-Dhulikhel Hospital (GDM-DH), to support GDM management among Nepalese patients by applying a user-centered design approach.

METHODS

A multidisciplinary team of experts, as well as health care providers and patients in Dhulikhel Hospital (Dhulikhel, Nepal), contributed to the development of the GDM-DH app. After finalizing the app's content and features, we created the app's wireframe, which illustrated the app's proposed interface, navigation sequences, and features and function. Feedback was solicited on the wireframe via key informant interviews with health care providers (n=5) and a focus group and in-depth interviews with patients with GDM (n=12). Incorporating their input, we built a minimum viable product, which was then user-tested with 18 patients with GDM and further refined to obtain the final version of the GDM-DH app.

RESULTS

Participants in the focus group and interviews unanimously concurred on the utility and relevance of the proposed mobile app for patients with GDM, offering additional insight into essential modifications and additions to the app's features and content (eg, inclusion of example meal plans and exercise videos).The mean age of patients in the usability testing (n=18) was 28.8 (SD 3.3) years, with a mean gestational age of 27.2 (SD 3.0) weeks. The mean usability score across the 10 tasks was 3.50 (SD 0.55; maximum score=5 for "very easy"); task completion rates ranged from 55.6% (n=10) to 94.4% (n=17). Findings from the usability testing were reviewed to further optimize the GDM-DH app (eg, improving data visualization). Consistent with social cognitive theory, the final version of the GDM-DH app supports GDM self-management by providing health education and allowing patients to record and self-monitor blood glucose, blood pressure, carbohydrate intake, physical activity, and gestational weight gain. The app uses innovative features to minimize the self-monitoring burden, as well as automatic feedback and data visualization. The app also includes a social network "follow" feature to add friends and family and give them permission to view logged data and a progress summary. Health care providers can use the web-based admin portal of the GDM-DH app to enter/review glucose levels and other clinical measures, track patient progress, and guide treatment and counseling accordingly.

CONCLUSIONS

To the best of our knowledge, this is the first mobile health platform for GDM developed for a low-income country and the first one containing a social support feature. A pilot clinical trial is currently underway to explore the clinical utility of the GDM-DH app.

Implementation of a group-based lifestyle intervention programme (Healthy Heart) in general practices in The Netherlands: a mixed-methods study

BACKGROUND

Lifestyle intervention programmes target behavioural risk factors that contribute to cardiovascular diseases (CVDs). Unfortunately, sustainable implementation of these programmes can be challenging. Gaining insights into the barriers and facilitators for successful implementation is important for maximising public health impact of these interventions. The Healthy Heart (HH) programme is an example of a combined lifestyle intervention programme.

AIM

To analyse the reach, adoption, and implementation of the HH programme.

DESIGN & SETTING

A mixed-methods study conducted in a general practice setting in The Netherlands.

METHOD

Quantitative data were collected from the Healthy Heart study (HH study), a non-randomised cluster stepped-wedge trial to assess the effect of the HH programme on patients at high risk of developing CVDs at practice level. Qualitative data were obtained through focus groups.

RESULTS

Out of 73 approached general practices, 55 implemented the HH programme. A total of 1082 patients agreed to participate in the HH study, of whom 64 patients were referred to the HH programme and 41 patients participated. Several barriers for participation were identified such as time investment, lack of risk perception, and being confident in changing lifestyle on their own. Important barriers for healthcare providers (HCPs) to refer a patient were time investment, lack of information to sufficiently inform patients, and preconceived notions regarding which patients the programme was suitable for.

CONCLUSION

This study has offered insights from a patient and HCP perspective regarding barriers and facilitators for implementation of the group-based lifestyle intervention programme. The identified barriers and facilitators, and the suggested improvements, can be used by others who wish to implement a similar programme.

Mothers In Motion Program: Implementation Process and Acceptability by Community

BACKGROUND

Implementing lifestyle behavior programs in real-world settings challenges researchers. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has implemented and sustained Mothers In Motion (MIM)'s client videos for clients to promote healthy lifestyle behaviors, and train-the-trainer videos, for personnel to enhance motivational interviewing techniques since 2015 and 2016, respectively. This paper describes the implementation processes and the results of client video implementation acceptability by WIC personnel.

METHODS

To document the implementation process, we applied the Framework for Adaptation and Modifications to Evidence-Based Implementation Strategies (FRAME-IS). To evaluate implementation acceptability, we conducted semi-structured interviews with 15 WIC personnel. A qualitative analysis was conducted to identify the common themes.

RESULTS

The facilitators for client video implementation were the inclusion of the target audience and family members addressing daily challenges, easy implementation, and compatibility with daily practice. While videos online facilitated implementation, videos in DVD format could challenge implementation.

CONCLUSIONS

Future lifestyle intervention programs aimed for future implementation in community settings may consider the inclusion of the target audience and their family members and take into consideration easy implementation and compatibility.

The Relationship Between How Participants Articulate Their Goals and Accomplishments and Weight Loss Outcomes: Secondary Analysis of a Pilot of a Web-Based Weight Loss Intervention

BACKGROUND

In behavioral weight loss interventions, participants are asked to set weekly goals to support long-term habits that lead to weight loss. Although participants are asked to set and accomplish weekly goals, we do not know how often they do this and whether doing so is associated with weight loss. Web-based weight loss interventions allow for the analysis of participant engagement data, including how participants articulate their goals and accomplishments.

OBJECTIVE

Using engagement data from a web-based weight loss intervention, we examined whether participants articulating their goals and accomplishments in measurable and repeating terms were associated with greater weight loss.

METHODS

Adults with overweight or obesity received a 12-week Facebook-delivered weight loss intervention based on the Diabetes Prevention Program Lifestyle Intervention. Participants replied to conversation threads that queried about their goals and accomplishments. Two independent coders classified participants' posts that articulated goals or accomplishments as measurable or repeating. Crude and age-adjusted linear regression models were used to examine the relationship between the frequency of post type and percent weight loss.

RESULTS

Participants (N=53; n=48, 91% female; n=48, 91% non-Hispanic White) were on average 46.2 (SD 10.5) years old with a mean BMI of 32.4 (SD 4.8) kg/m2. Over 12 weeks, participants shared a median of 4 (IQR 1-8) posts that reported goals and 10 (IQR 4-24) posts that reported accomplishments. Most participants shared ≥1 post with a goal (n=43, 81%) and ≥1 post with an accomplishment (n=47, 89%). Each post reporting a goal was associated with 0.2% greater weight loss (95% CI -0.3% to 0.0%). Sharing ≥1 post with a repeating goal was associated with an average of 2.2% greater weight loss (95% CI -3.9% to -0.4%). Each post with a repeating goal was associated with an average of 0.5% greater weight loss (95% CI -1.0% to 0.0%). Sharing ≥1 post with measurable and repeating goals was associated with an average of 1.9% greater weight loss (95% CI -3.7% to -0.2%). Sharing each post with an accomplishment was associated with an average of 0.1% greater weight loss (95% CI -0.1% to 0.0%). Every post with an accomplishment that was repeating was associated with an average of 0.2% greater weight loss (95% CI -0.3% to 0.0%). Sharing other types of goals and accomplishments was not associated with weight loss.

CONCLUSIONS

In a web-based weight loss intervention, stating goals in repeating or both measurable and repeating terms was associated with greater weight loss, but simply stating them in measurable terms was not. For accomplishments, only those articulated in repeating terms were associated with greater weight loss. Posts about one-time goals and accomplishments represent an opportunity to encourage planning for future behaviors. Future research should examine if stating goals and accomplishments in repeating terms signals habit formation.

Predicting Participant Engagement in a Social Media-Delivered Lifestyle Intervention Using Microlevel Conversational Data: Secondary Analysis of Data From a Pilot Randomized Controlled Trial

BACKGROUND

Social media-delivered lifestyle interventions have shown promising outcomes, often generating modest but significant weight loss. Participant engagement appears to be an important predictor of weight loss outcomes; however, engagement generally declines over time and is highly variable both within and across studies. Research on factors that influence participant engagement remains scant in the context of social media-delivered lifestyle interventions.

OBJECTIVE

This study aimed to identify predictors of participant engagement from the content generated during a social media-delivered lifestyle intervention, including characteristics of the posts, the conversation that followed the post, and participants' previous engagement patterns.

METHODS

We performed secondary analyses using data from a pilot randomized trial that delivered 2 lifestyle interventions via Facebook. We analyzed 80 participants' engagement data over a 16-week intervention period and linked them to predictors, including characteristics of the posts, conversations that followed the post, and participants' previous engagement, using a mixed-effects model. We also performed machine learning-based classification to confirm the importance of the significant predictors previously identified and explore how well these measures can predict whether participants will engage with a specific post.

RESULTS

The probability of participants' engagement with each post decreased by 0.28% each week (P<.001; 95% CI 0.16%-0.4%). The probability of participants engaging with posts generated by interventionists was 6.3% (P<.001; 95% CI 5.1%-7.5%) higher than posts generated by other participants. Participants also had a 6.5% (P<.001; 95% CI 4.9%-8.1%) and 6.1% (P<.001; 95% CI 4.1%-8.1%) higher probability of engaging with posts that directly mentioned weight and goals, respectively, than other types of posts. Participants were 44.8% (P<.001; 95% CI 42.8%-46.9%) and 46% (P<.001; 95% CI 44.1%-48.0%) more likely to engage with a post when they were replied to by other participants and by interventionists, respectively. A 1 SD decrease in the sentiment of the conversation on a specific post was associated with a 5.4% (P<.001; 95% CI 4.9%-5.9%) increase in the probability of participants' subsequent engagement with the post. Participants' engagement in previous posts was also a predictor of engagement in subsequent posts (P<.001; 95% CI 0.74%-0.79%). Moreover, using a machine learning approach, we confirmed the importance of the predictors previously identified and achieved an accuracy of 90.9% in terms of predicting participants' engagement using a balanced testing sample with 1600 observations.

CONCLUSIONS

Findings revealed several predictors of engagement derived from the content generated by interventionists and other participants. Results have implications for increasing engagement in asynchronous, remotely delivered lifestyle interventions, which could improve outcomes. Our results also point to the potential of data science and natural language processing to analyze microlevel conversational data and identify factors influencing participant engagement. Future studies should validate these results in larger trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02656680; https://clinicaltrials.gov/ct2/show/NCT02656680.

Naturopathic patient care during different life stages: an international observational study of naturopathic practitioners and their patients

BACKGROUND

An individual's health status varies with age, with most health problems increasing through different life stages. Yet, a key feature of the majority of conditions contributing burden to society globally, irrespective of life stage, is the predominance of chronic, non-communicable diseases (NCDs). An important response to this growing burden is the increasing recognition of addressing NCD prevention through a life-course perspective through primary care and public health. Naturopathy is a traditional medicine system originating from Europe, and its practitioners commonly provide primary care and focus on prevention and wellness. However, little is known about naturopathic practitioners (NPs) contribution to health care across different life stages.

METHODS

This secondary analysis of a cross-sectional study aimed to describe the approach to the care of NPs based on the life stage of their patients. The primary study recruited NPs from 14 regions or countries, who were invited to complete a short survey about 20 consecutive patients. The multilingual survey included the following domains: patient demographics, reason for visit, prescribed or recommended treatments, and naturopathic interpretation of the health conditions. Descriptive statistics were tabulated as frequencies and percentages and chi square tests were used to test associations and compare groups. Effect size was determined by Cramer's V.

RESULTS

Participant NPs (n = 56) provided consultation details for 854 patients encounters. There were differences in the patient's primary reason for visiting, the additional physiological systems the NP considered important in the management of the patient's health, and the treatments prescribed across all life stages. However, diet (45.1-70.0%) and lifestyle (14.3-60.0%) prescription were the most common categories of treatments across all patient groups.

CONCLUSION

NPs provide care to patients across all life stages, and diverse conditions pertinent to those life stages while also demonstrating a holistic approach that considers broader health concerns and long term treatment practices. While there may be emerging evidence supporting and informing NP clinical outcomes, the breadth and diversity of health conditions, populations and treatments within the scope of naturopathic practice underscores a need for urgent and widescale research investigating naturopathic care across the life course.

A Facebook-Delivered Weight Loss Intervention Using Open Enrollment: Randomized Pilot Feasibility Trial

BACKGROUND

Behavioral weight loss programs typically enroll 12-40 people into groups that then suffer from declining engagement over time. Web-based patient communities, on the other hand, typically offer no limits on capacity and membership is fluid. This model may be useful for boosting engagement in behavioral weight loss interventions, which could lead to better outcomes.

OBJECTIVE

In this study, we aimed to examine the feasibility and acceptability of continuously enrolling participants into a Facebook-delivered weight loss intervention for the first 8 of 16 weeks relative to the same intervention where no new participants were enrolled after randomization.

METHODS

We conducted a randomized pilot trial to compare a Facebook weight loss group that used open enrollment with a group that used closed enrollment on feasibility and acceptability in adults with BMI 27-45 kg/m2. The feasibility outcomes included retention, engagement, and diet tracking adherence. We described the percentage loss of ≥5% weight in both groups as an exploratory outcome. We also explored the relationship between total volume of activity in the group and weight loss. The participants provided feedback via web-based surveys and focus groups.

RESULTS

Randomized participants (68/80, 85% women) were on average, aged 40.2 (SD 11.2) years with a mean BMI of 34.4 (SD 4.98) kg/m2. We enrolled an additional 54 participants (50/54, 93% female) in the open enrollment condition between weeks 1 and 8, resulting in a total group size of 94. Retention was 88% and 98% under the open and closed conditions, respectively. Randomized participants across conditions did not differ in engagement (P=.72), or diet tracking adherence (P=.42). Participant feedback in both conditions revealed that sense of community was what they liked most about the program and not enough individualized feedback was what they liked the least. Weight loss of ≥5% was achieved by 30% (12/40) of the participants randomized to the open enrollment condition and 18% (7/40) of the participants in the closed enrollment condition. Exploratory analyses revealed that the open condition (median 385, IQR 228-536.5) had a greater volume of engagement than the closed condition (median 215, IQR 145.5-292; P=.007). Furthermore, an increase of 100 in the total volume of engagement in the Facebook group each week was associated with an additional 0.1% weekly weight loss among the randomized participants (P=.02), which was independent of time, individual participant engagement, and sociodemographic characteristics.

CONCLUSIONS

Open enrollment was as feasible and acceptable as closed enrollment. A greater volume of engagement in the Facebook group was associated with weight loss, suggesting that larger groups that produce more engagement overall may be beneficial. Future research should examine the efficacy of the open enrollment approach for weight loss in a fully powered randomized trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02656680; https://clinicaltrials.gov/ct2/show/NCT02656680.

Organization leaders' decisions to sustain a peer-led healthy lifestyle intervention for people with serious mental illness in supportive housing

Healthy lifestyle interventions that increase physical activity and healthy dietary habits can help improve the physical health of people with serious mental illness (SMI). Yet, these interventions are not implemented in routine practice settings. This mixed methods study examined the decisions that leaders from three supportive housing agencies made as they planned to sustain a peer-led healthy lifestyle intervention for people with SMI at the end of a clinical trial. A combination of implementation strategies that addressed cost concerns, generated local evidence of the intervention's benefits, and provided ongoing training was identified as important for sustainability. A sustainability model illustrating implementation strategies and mechanisms for supporting three sustainability domains (funding, organizational capacity, and adaptation) was prioritized by participants. Study findings can inform future studies testing strategies and mechanisms to support the sustainability of interventions in routine practice settings to improve the physical health of people with SMI.

Effect of a Smartphone App on Weight Change and Metabolic Outcomes in Asian Adults With Type 2 Diabetes: A Randomized Clinical Trial

IMPORTANCE

Lifestyle interventions are effective in diabetes management, with smartphone apps that manage health data and dietary and exercise schedules gaining popularity. However, limited evidence from randomized clinical trials exists regarding the effectiveness of smartphone-based interventions among Asian adults with type 2 diabetes.

OBJECTIVE

To compare the effects of a culturally contextualized smartphone-based intervention with usual care on weight and metabolic outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial conducted at multiple primary care centers in Singapore included 305 adults with type 2 diabetes and body mass index (BMI) of 23 or greater who had literacy in English and smartphone access. Participants were recruited between October 3, 2017, and September 9, 2019, and were randomly assigned (1:1; stratified by gender, age, and BMI) to intervention (99 participants) or control (105 participants) groups. Participants' data were analyzed using intention-to-treat analysis.

INTERVENTIONS

Both control and intervention participants received diet and physical activity advice from a dietitian at a baseline face-to-face visit. Intervention participants additionally used a smartphone app to track weight, diet, physical activity, and blood glucose and then communicated with dietitians for 6 months.

MAIN OUTCOMES AND MEASURES

Primary outcome was change in body weight, while secondary outcomes were changes in hemoglobin A1c (HbA1c), fasting blood glucose, blood pressure, lipids, and diet. Post hoc analyses included glycemic changes in the subgroup with HbA1c levels of 8% or greater and diabetes medication changes.

RESULTS

Among the 204 randomized participants (mean [SD] age, 51.2 [9.7] years; 132 [64.7%] men), baseline mean (SD) BMI was 30.6 (4.3). Compared with the control group, intervention participants achieved significantly greater reductions in weight (mean [SD] change, -3.6 [4.7] kg vs -1.2 [3.6] kg) and HbA1c levels (mean [SD] change, -0.7% [1.2] vs -0.3% [1.0]), with a greater proportion having a reduction in diabetes medications (17 participants [23.3%] vs 4 participants [5.4%]) at 6 months. The intervention led to a greater HbA1c reduction among participants with HbA1c levels of 8% or higher (mean [SD] change, -1.8% [1.4] vs -1.0% [1.4]; P = .001). Intergroup differences favoring the intervention were also noted for fasting blood glucose, diastolic blood pressure, and dietary changes.

CONCLUSIONS AND RELEVANCE

In this study, a smartphone-based lifestyle intervention was more effective in achieving weight and glycemic reductions among Asian adults with type 2 diabetes compared with usual care, supporting the use of apps in lifestyle intervention delivery.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12617001112358.

Interest in and barriers to participation in a Facebook-delivered weight loss program among female cancer survivors with overweight or obesity

BACKGROUND

Although excess body weight is linked to post-treatment complications for cancer survivors, obesity rates have increased rapidly among adult cancer survivors. Innovative approaches to weight loss programs, such as via social media, are needed to engage female cancer survivors. The purpose of this study is to explore important components of a Facebook-delivered weight loss program for female cancer survivors.

METHODS

Female cancer survivors who are overweight or obese and finished active treatment completed a web-based, mixed-methods survey.

RESULTS

Participants (N=96) were on average 54.3±9.6 years old, 89% white, 66% obese, and 87% tried to lose weight in the last year. Health concerns were the most important reason (88%) for wanting to lose weight. Barriers to weight loss included other health issues (52%) and perceived sacrifice/burden of weight loss process (35%). Qualitative themes for barriers included inability to make dietary changes (19%), lack of motivation (18%), and physical limitations (13%). Participants were most interested in a weight loss program delivered via Facebook (81%), led by a weight loss counselor (78%), provided healthy recipes (73%) and exercise videos (72%). Qualitative themes included information on cancer treatment effects (25%), calorie tracker (21%), and exercise modifications (17%). Qualitatively, concerns about weight loss included fear of cancer recurrence (20%) and lack of confidence in weight loss efforts (17%).

CONCLUSIONS

While female cancer survivors are interested in a Facebook-delivered weight loss program, additional research needs to address customization and delivery to address specific barriers experienced by cancer survivors.

Implementation of public health policies for healthy lifestyles promotion: what Brazil should tell us?

The objective of this work was to update Brazilian experiences on implementation research (IR)regarding promotion of healthy lifestyles to decrease the risk of chronic non-communicable diseases (CNCD). Some Brazilian governmental activities for promotion of healthy lifestyles have been adopted around the world such as the case of the "World Physical Activity Day" and the"Walking for health program". Following the example of many other developing and developed countries, Brazilian government has been sponsored leisure-time physical activity and healthy eating programs which still were not capable of promoting massive participation, especially from workers, elderly and people from the less privileged socioeconomic classes. Although successful exercise promotion strategies have been done in Brazil, the implementation science on promotion of healthy lifestyles is still rising and more research is necessary to identify the settings, circumstances, and processes for effective and sustainable adoption of healthy dietary and exercise practices. Understanding problems, concerns and barriers for implementation of health promotion (HP) policies in Brazil could be useful for many other developing nations.

How can clinical practices pragmatically increase physical activity for patients with type 2 diabetes? A systematic review

Although regular physical activity (PA) is a cornerstone of treatment for type 2 diabetes (T2D), most adults with T2D are sedentary. Randomized controlled trials (RCTs) have proven the effectiveness of PA behavioral interventions for adults with T2D but have rarely been conducted in healthcare settings. We sought to identify PA interventions that are effective and practical to implement in clinical practice settings. Our first aim was to use the valid Pragmatic-Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool to assess the potential for future implementation of PA interventions in clinical practice settings. Our second aim was to identify interventions that effectively increased PA and glycemic control among the interventions in the top tertile of PRECIS-2 scores. We searched PubMed MEDLINE from January 1980 through May 2015 for RCTs of behavioral PA interventions coordinated by clinical practices for patients with T2D. Dual investigators assessed pragmatism by PRECIS-2 scores, and study effectiveness was extracted from original RCT publications. The PRECIS-2 scores of the 46 behavioral interventions (n = 13,575 participants) ranged from 3.0 to 4.8, where 5 is the most pragmatic score. In the most pragmatic tertile of interventions (n = 16) by PRECIS-2 scores, 30.8 and 31.3% of interventions improved PA outcomes and hemoglobin A1c, respectively. A minority of published evidence-based PA interventions for adults with T2D were both effective and pragmatic for clinical implementation. These should be tested for dissemination using implementation trial designs.

Clinic Versus Online Social Network-Delivered Lifestyle Interventions: Protocol for the Get Social Noninferiority Randomized Controlled Trial

Background

Online social networks may be a promising modality to deliver lifestyle interventions by reducing cost and burden. Although online social networks have been integrated as one component of multimodality lifestyle interventions, no randomized trials to date have compared a lifestyle intervention delivered entirely via online social network with a traditional clinic-delivered intervention.

Objective

This paper describes the design and methods of a noninferiority randomized controlled trial, testing (1) whether a lifestyle intervention delivered entirely through an online social network would produce weight loss that would not be appreciably worse than that induced by a traditional clinic-based lifestyle intervention among overweight and obese adults and (2) whether the former would do so at a lower cost.

Methods

Adults with body mass index (BMI) between 27 and 45 kg/m² (N=328) will be recruited from the communities in central Massachusetts. These overweight or obese adults will be randomized to two conditions: a lifestyle intervention delivered entirely via the online social network Twitter (Get Social condition) and an in-person group-based lifestyle intervention (Traditional condition) among overweight and obese adults. Measures will be obtained at baseline, 6 months, and 12 months after randomization. The primary noninferiority outcome is percentage weight loss at 12 months. Secondary noninferiority outcomes include dietary intake and moderate intensity physical activity at 12 months. Our secondary aim is to compare the conditions on cost. Exploratory outcomes include treatment retention, acceptability, and burden. Finally, we will explore predictors of weight loss in the online social network condition.

Results

The final wave of data collection is expected to conclude in June 2019. Data analysis will take place in the months following and is expected to be complete in September 2019.

Conclusions

Findings will extend the literature by revealing whether delivering a lifestyle intervention via an online social network is an effective alternative to the traditional modality of clinic visits, given the former might be more scalable and feasible to implement in settings that cannot support clinic-based models.

Trial Registration

ClinicalTrials.gov NCT02646618; https://clinicaltrials.gov/ct2/show/NCT02646618 (Archived by WebCite at http://www.webcitation.org/6v20waTFW)

Interest in a Twitter-delivered weight loss program among women of childbearing age

Weight management through the childbearing years is important, yet few women have access to efficacious weight loss programs. Online social network-delivered programs may increase reach and thus impact. The aim of this study was to gauge interest in a Twitter-based weight loss intervention among women of childbearing age and the feasibility of recruitment via Twitter. We recruited English-speaking women aged 18-45 years (N = 63) from Twitter to complete an anonymous online survey including open-ended questions about program advantages and concerns. Forty percent of participants were obese and 83 % were trying to lose weight. Eighty-one percent were interested in a Twitter-delivered weight loss program. Interest was high in all subgroups (62-100 %). Participants (59 %) cited program advantages, including convenience, support/accountability, and privacy. Concerns (59 %) included questions about privacy, support/accountability, engagement, efficacy, and technology barriers. Research is needed to develop and evaluate social media-delivered interventions, and to develop methods for recruiting participants directly from Twitter.

Interventions to improve physical activity during pregnancy: a systematic review on issues of internal and external validity using the RE-AIM framework

BACKGROUND

Physical activity (PA) during pregnancy has significant health benefits for the mother and her child; however, many women reduce their activity levels during pregnancy and most are not sufficiently active. Given the important health benefits of PA during pregnancy, evidence that supports research translation is vital.

OBJECTIVES

To determine the extent to which physical activity interventions for pregnant women report on internal and external validity factors using the RE-AIM framework (reach, efficacy/effectiveness, adoption, implementation, and maintenance).

SEARCH STRATEGY

Ten databases were searched up to 1 June 2015. Eligible published papers and unpublished/grey literature were identified using relevant search terms.

SELECTION CRITERIA

Studies had to report on physical activity interventions during pregnancy, including measures of physical activity during pregnancy at baseline and at least one point post-intervention. Randomised controlled trials and quasi-experimental studies that had a comparator group were included.

DATA COLLECTION AND ANALYSIS

Reporting of RE-AIM dimensions were summarised and synthesised across studies.

MAIN RESULTS

The reach (72.1%) and efficacy/effectiveness (71.8%) dimensions were commonly reported; however, the implementation (28.9%) and adoption (23.2%) dimensions were less commonly reported and no studies reported on maintenance.

CONCLUSIONS

This review highlights the under-reporting of issues of contextual factors in studies of physical activity during pregnancy. The translation of physical activity interventions during pregnancy could be improved through reporting of representativeness of participants, clearer reporting of outcomes, more detail on the setting and staff who deliver interventions, costing of interventions and the inclusion of process evaluations and qualitative data.

TWEETABLE ABSTRACT

The systematic review highlights the under-reporting of contextual factors in studies of physical activity during pregnancy.

The Effect of Changes in Health Beliefs Among African-American and Rural White Church Congregants Enrolled in an Obesity Intervention: A Qualitative Evaluation

Church interventions can reduce obesity disparities by empowering participants with knowledge and skills within an established community. The purpose of this study was to evaluate the Biomedical/Obesity Reduction Trial (BMORe) and investigate changes in health beliefs among obese adult participants. Ten pre-/post-intervention focus groups applying the Health Belief Model conducted in two African-American churches in Tennessee (n = 20) and South Carolina (n = 20), and one rural Appalachian church in Kentucky (n = 21). Two independent coders using NVivo analyzed transcribed audio data and notes. Participants' health status of being overweight/obese and having comorbidities of diabetes and high blood pressure motivated enrollment in BMORe. Initially participants voiced low self-efficacy in cooking healthy and reading food labels. BMORe made participants feel "empowered" after 12 weeks compared to initially feeling "out of control" with their weight. Participants reported improvements in emotional health, quality of life, and fewer medications. During post-intervention focus groups, participants reported increased self-efficacy through family support, sharing healthy eating strategies, and having accountability partners. Solidarity and common understanding among BMORe participants led focus group attendees to comment how their peers motivated them to stay in the program for 12 weeks. Long-term barriers include keeping the weight off by maintaining habits of exercise and healthy eating. Implementation of pre-/post-intervention focus groups is an innovative approach to evaluate an obesity intervention and track how changes in health beliefs facilitated behavior change. This novel approach shows promise for behavioral interventions that rely on participant engagement for sustained effectiveness.

An Evidence-based Guide for Obesity Treatment in Primary Care

On behalf of the Society of Behavioral Medicine, we present a model of obesity management in primary care based on the 5As counseling framework (Assess, Advise, Agree, Assist, and Arrange). Primary care physicians can use the 5As framework to build and coordinate a multidisciplinary team that: 1) addresses patients' psychosocial issues and medical and psychiatric comorbidities associated with obesity treatment failure; 2) delivers intensive counseling that consists of goal setting, self-monitoring, and problem solving; and 3) connects patients with community resources to assist them in making healthy lifestyle changes. This paper outlines reimbursement guidelines and weight-management counseling strategies, and provides a framework for building a multidisciplinary team to maximize the patient's success at weight management.

Twitter-Delivered Behavioral Weight-Loss Interventions: A Pilot Series

BACKGROUND

Lifestyle interventions are efficacious at reducing risk for diabetes and cardiovascular disease but have not had a significant public health impact given high cost and patient and provider burden.

OBJECTIVE

Online social networks may reduce the burden of lifestyle interventions to the extent that they displace in-person visits and may enhance opportunities for social support for weight loss.

METHODS

We conducted an iterative series of pilot studies to evaluate the feasibility and acceptability of using online social networks to deliver a lifestyle intervention.

RESULTS

In Study 1 (n=10), obese participants with depression received lifestyle counseling via 12 weekly group visits and a private group formed using the online social network, Twitter. Mean weight loss was 2.3 pounds (SD 7.7; range -19.2 to 8.2) or 1.2% (SD 3.6) of baseline weight. A total of 67% (6/9) of participants completing exit interviews found the support of the Twitter group at least somewhat useful. In Study 2 (n=11), participants were not depressed and were required to be regular users of social media. Participants lost, on average, 5.6 pounds (SD 6.3; range -15 to 0) or 3.0% (SD 3.4) of baseline weight, and 100% (9/9) completing exit interviews found the support of the Twitter group at least somewhat useful. To explore the feasibility of eliminating in-person visits, in Study 3 (n=12), we delivered a 12-week lifestyle intervention almost entirely via Twitter by limiting the number of group visits to one, while using the same inclusion criteria as that used in Study 2. Participants lost, on average, 5.4 pounds (SD 6.4; range -14.2 to 3.9) or 3.0% (SD 3.1) of baseline weight, and 90% (9/10) completing exit interviews found the support of the Twitter group at least somewhat useful. Findings revealed that a private Twitter weight-loss group was both feasible and acceptable for many patients, particularly among regular users of social media.

CONCLUSIONS

Future research should evaluate the efficacy and cost-effectiveness of online social network-delivered lifestyle interventions relative to traditional modalities.

Commercial Smartphone-Based Devices and Smart Applications for Personalized Healthcare Monitoring and Management

Smartphone-based devices and applications (SBDAs) with cost effectiveness and remote sensing are the most promising and effective means of delivering mobile healthcare (mHealthcare). Several SBDAs have been commercialized for the personalized monitoring and/or management of basic physiological parameters, such as blood pressure, weight, body analysis, pulse rate, electrocardiograph, blood glucose, blood glucose saturation, sleeping and physical activity. With advances in Bluetooth technology, software, cloud computing and remote sensing, SBDAs provide real-time on-site analysis and telemedicine opportunities in remote areas. This scenario is of utmost importance for developing countries, where the number of smartphone users is about 70% of 6.8 billion cell phone subscribers worldwide with limited access to basic healthcare service. The technology platform facilitates patient-doctor communication and the patients to effectively manage and keep track of their medical conditions. Besides tremendous healthcare cost savings, SBDAs are very critical for the monitoring and effective management of emerging epidemics and food contamination outbreaks. The next decade will witness pioneering advances and increasing applications of SBDAs in this exponentially growing field of mHealthcare. This article provides a critical review of commercial SBDAs that are being widely used for personalized healthcare monitoring and management.

Can physical activity interventions for adults with type 2 diabetes be translated into practice settings? A systematic review using the RE-AIM framework

Despite the strong evidence base for the efficacy of physical activity in the management of type 2 diabetes, a limited number of physical activity interventions have been translated and evaluated in everyday practice. This systematic review aimed to report the findings of studies in which an intervention, containing physical activity promotion as a component, has been delivered within routine diabetes care. A comprehensive search was conducted for articles reporting process data relating to components of the RE-AIM (Reach, Effectiveness, Adoption, Implementation and/or Maintenance) framework. Twelve studies met the selection criteria. Of the nine studies which measured physical activity as an outcome, eight reported an increase in physical activity levels, five of which were significant. Tailoring recruitment, resources and intervention delivery to the target population played a positive role, in addition to the use of external organisations and staff training. Many interventions were of short duration and lacked long-term follow-up data. Findings revealed limited and inconsistent reporting of useful process data.

Evidence-based strategies in weight-loss mobile apps

BACKGROUND

Physicians have limited time for weight-loss counseling, and there is a lack of resources to which they can refer patients for assistance with weight loss. Weight-loss mobile applications (apps) have the potential to be a helpful tool, but the extent to which they include the behavioral strategies included in evidence-based interventions is unknown.

PURPOSE

The primary aims of the study were to determine the degree to which commercial weight-loss mobile apps include the behavioral strategies included in evidence-based weight-loss interventions, and to identify features that enhance behavioral strategies via technology.

METHODS

Thirty weight-loss mobile apps, available on iPhone and/or Android platforms, were coded for whether they included any of 20 behavioral strategies derived from an evidence-based weight-loss program (i.e., Diabetes Prevention Program). Data on available apps were collected in January 2012; data were analyzed in June 2012.

RESULTS

The apps included on average 18.83% (SD=13.24; range=0%-65%) of the 20 strategies. Seven of the strategies were not found in any app. The most common technology-enhanced features were barcode scanners (56.7%) and a social network (46.7%).

CONCLUSIONS

Weight-loss mobile apps typically included only a minority of the behavioral strategies found in evidence-based weight-loss interventions. Behavioral strategies that help improve motivation, reduce stress, and assist with problem solving were missing across apps. Inclusion of additional strategies could make apps more helpful to users who have motivational challenges.

Clinic-integrated behavioral intervention for families of youth with type 1 diabetes: randomized clinical trial

OBJECTIVE

To test the effect on diabetes management outcomes of a low-intensity, clinic-integrated behavioral intervention for families of youth with type 1 diabetes.

METHODS

Families (n = 390) obtaining care for type 1 diabetes participated in a 2-year randomized clinical trial of a clinic-integrated behavioral intervention designed to improve family diabetes management practices. Measurement of hemoglobin A1c, the primary outcome, was obtained at each clinic visit and analyzed centrally. Blood glucose meter data were downloaded at each visit. Adherence was assessed by using a semistructured interview at baseline, mid-study, and follow-up. Analyses included 2-sample t tests at predefined time intervals and mixed-effect linear-quadratic models to assess for difference in change in outcomes across the study duration.

RESULTS

A significant overall intervention effect on change in glycemic control from baseline was observed at the 24-month interval (P = .03). The mixed-effect model showed a significant intervention by age interaction (P < .001). Among participants aged 12 to 14, a significant effect on glycemic control was observed (P = .009 for change from baseline to 24-month interval; P = .035 for mixed-effect model across study duration), but there was no effect among those aged 9 to 11. There was no intervention effect on child or parent report of adherence; however, associations of change in adherence with change in glycemic control were weak.

CONCLUSIONS

This clinic-integrated behavioral intervention was effective in preventing the deterioration in glycemic control evident during adolescence, offering a potential model for integrating medical and behavioral sciences in clinical care.

Necessary components for lifestyle modification interventions to reduce diabetes risk

Several efficacy trials and subsequent dissemination studies indicate that behavioral lifestyle interventions for diabetes risk reduction require, at a minimum, provision of 4 to 6 months of frequent intervention contact to induce clinically meaningful weight losses of at least 5% of initial body weight. Weekly contact during the first several months of intervention, followed by less frequent but regular therapeutic contact for a longer time period, appears necessary for participants to adopt and enact behavioral self-regulatory skills such as the self-monitoring of diet, weight, and physical activity and the problem solving of common physical, social, and cognitive barriers that impede sustained weight loss. In-person contact is associated with the largest effect sizes but may not be a necessary component for clinically meaningful weight loss. Regardless of intervention mode, setting, or provider, the interactive process of feedback and social support is crucial for skill development and sustained weight loss.