Efficacy and External Validity of Electronic and Mobile Phone-Based Interventions Promoting Vegetable Intake in Young Adults: Systematic Review and Meta-Analysis

Adherence to the Eatwell Guide and population and planetary health: A Rank Prize Forum report

This report summarises a Forum conducted in June 2023 to explore the current state of the knowledge around the Eatwell Guide, which is the UK government's healthy eating tool, in relation to population and planetary health. The 1.5-day Forum highlighted the limited, albeit promising evidence linking higher adherence to the Eatwell Guide with favourable health outcomes, including reduced overall mortality risk, lower abdominal obesity in post-menopausal women and improved cardiometabolic health markers. Similarly, evidence was presented to suggest that higher adherence to the Eatwell Guide is associated with reduced greenhouse gas emissions. Presentations were given around cultural adaptations of the Eatwell Guide, including African Heritage and South Asian versions, which are designed to increase the acceptability and uptake of the Eatwell Guide in these communities in the United Kingdom. Presentations highlighted ongoing work relevant to the applications of the Eatwell Guide in randomised controlled trials and public health settings, including the development of a screening tool to quantify Eatwell Guide adherence. The Forum ended with a World Café-style event, in which the strengths and limitations of the Eatwell Guide were discussed, and directions for future research were identified. This Forum report serves as a primer on the current state of the knowledge on the Eatwell Guide and population and planetary health and will be of interest to researchers, healthcare professionals and public health officials.

Telessaúde no consumo e comportamento alimentar em adultos: uma revisão rápida de revisões sistemáticas

Objetivo.

Sintetizar as evidências sobre os efeitos de intervenções de telessaúde oferecidas por meio de aplicativos de celular e de mensagens de texto no comportamento de adultos com vistas à alimentação saudável.

Métodos.

Foi realizada uma revisão rápida por meio de buscas em nove bases eletrônicas da literatura para identificar revisões sistemáticas publicadas em inglês, português e espanhol que avaliassem estratégias de telessaúde comparadas a atendimento presencial para melhoria da alimentação na população adulta (18 a 59 anos). As buscas foram realizadas em novembro de 2020 e atualizadas em abril de 2022. As revisões sistemáticas incluídas foram avaliadas quanto à qualidade metodológica com a ferramenta AMSTAR 2.

Resultados.

Cinco revisões sistemáticas foram incluídas, sendo uma com avaliação de confiança moderada e as demais com confiança criticamente baixa. Verificou-se uma escassez de estudos comparando o uso de estratégias de telessaúde com o atendimento presencial para a promoção da alimentação saudável em adultos. Os resultados mais consistentes referem-se ao aumento no consumo de frutas e vegetais com o uso de aplicativo ou mensagens de texto, além de melhoria do padrão alimentar de pessoas com diabetes ou intolerância à glicose com o uso de mensagens de texto.

Conclusão.

A maioria das análises de intervenções utilizando aplicativos de celular ou mensagens de texto mostrou efeitos positivos nos desfechos de alimentação saudável. No entanto, esses achados se referem aos poucos ensaios clínicos com amostras pequenas de participantes incluídos nas revisões sistemáticas da presente revisão rápida, a maioria de baixa qualidade metodológica. Conclui-se que há uma lacuna no conhecimento, sendo importante a realização de estudos metodologicamente mais robustos.

Digital behaviour change interventions to increase vegetable intake in adults: a systematic review

BACKGROUND

Digital interventions may help address low vegetable intake in adults, however there is limited understanding of the features that make them effective. We systematically reviewed digital interventions to increase vegetable intake to 1) describe the effectiveness of the interventions; 2) examine links between effectiveness and use of co-design, personalisation, behavioural theories, and/or a policy framework; and 3) identify other features that contribute to effectiveness.

METHODS

A systematic search strategy was used to identify eligible studies from MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Library, INFORMIT, IEEE Xplore and Clinical Trial Registries, published between January 2000 and August 2022. Digital interventions to increase vegetable intake were included, with effective interventions identified based on statistically significant improvement in vegetable intake. To identify policy-action gaps, studies were mapped across the three domains of the NOURISHING framework (i.e., behaviour change communication, food environment, and food system). Risk of bias was assessed using Cochrane tools for randomized, cluster randomized and non-randomized trials.

RESULTS

Of the 1,347 records identified, 30 studies were included. Risk of bias was high or serious in most studies (n = 25/30; 83%). Approximately one quarter of the included interventions (n = 8) were effective at improving vegetable intake. While the features of effective and ineffective interventions were similar, embedding of behaviour change theories (89% vs 61%) and inclusion of stakeholders in the design of the intervention (50% vs 38%) were more common among effective interventions. Only one (ineffective) intervention used true co-design. Although fewer effective interventions included personalisation (67% vs 81%), the degree of personalisation varied considerably between studies. All interventions mapped across the NOURISHING framework behaviour change communication domain, with one ineffective intervention also mapping across the food environment domain.

CONCLUSION

Few digital interventions identified in this review were effective for increasing vegetable intake. Embedding behaviour change theories and involving stakeholders in intervention design may increase the likelihood of success. The under-utilisation of comprehensive co-design methods presents an opportunity to ensure that personalisation approaches better meet the needs of target populations. Moreover, future digital interventions should address both behaviour change and food environment influences on vegetable intake.

Assessing the effectiveness of a 4-week online intervention on food literacy and fruit and vegetable consumption in Australian adults: The online MedDiet challenge

Australians fail to meet the daily recommended two and five serves of fruit and vegetable respectively, which increases mortality risk for non-communicable diseases such as cardiovascular disease and type 2 diabetes. This study aimed to evaluate the effectiveness of an online intervention delivered through social media on food literacy and fruit and vegetable consumption in Australian adults. In a pre-post single group experimental study, 29 participants completed the "online MedDiet challenge", a four-week intervention delivered via Facebook. Infographics, recipes and informational videos aligned with food literacy concepts related to the Mediterranean Diet were shared with participants. Outcome measures included a validated food literacy questionnaire with two questions from the National Nutrition Survey to record fruit and vegetable consumption. The mean age of participants was 52 years (range: 25-67 years). Post intervention, food literacy improved between 21%-45% across each survey component. Participants also reported an increase in fruit and vegetable consumption by 0.6 and 1.3 serves per day (p < 0.05) respectively. Social media holds potential for increasing fruit and vegetable consumption in adults through food literacy. Future research should focus on longer studies and larger cohorts to confirm that food literacy plays a key component to maintain sustainability of such interventions.

Hosting an Online World Café to Develop an Understanding of Digital Health Promoting Settings from a Citizen's Perspective-Methodological Potentials and Challenges

Brown and Isaacs' World Café is a participatory research method to make connections to the ideas of others. During the SARS-CoV-2 pandemic and the corresponding contact restrictions, only digital hostings of World Cafés were possible. This article aims to present and reflect on the potentials and challenges of hosting online World Cafés and to derive recommendations for other researchers. Via Zoom and Conceptboard, three online World Cafés were conducted in August 2021. In the World Cafés, the main focus was on the increasing digitization in settings in the context of health promotion and prevention from the perspective of setting members of educational institutions, leisure clubs, and communities. Between 9 and 13 participants participated in three World Cafés. Hosting comprises the phases of design and preparation, realisation, and evaluation. Generally, hosting an online World Café is a suitable method for participatory engagement, but particular challenges have to be overcome. Overall café hosts must create an equal participation environment by ensuring the availability of digital devices and stable internet access. The event schedule must react flexibly to technical disruptions and varying participation numbers. Further, compensatory measures such as support in the form of technical training must be implemented before the event. Finally, due to the higher complexity of digitalisation, roles of participants and staff need to be distributed and coordinated.

Methods and Lessons From Costing a Large mHealth Intervention at Scale in India

The use of mobile devices to deliver public health interventions is rapidly increasing, particularly in low resource settings. Despite their proliferation, several mHealth interventions in developing countries fail to reach geographical scale, and long-term sustainability for most remains uncertain. There is a need to cost for such programs, to enable better planning and budgeting and tailor programs as required. Cost estimates can contribute to a more informed debate on resource allocation priorities and help make choices clearer for policymakers. This paper has two main objectives: (1) present a detailed protocol on determining the costs of a large national mHealth job aid and behavior change communication tool known as Integrated Child Development Services - Common Application Software (ICDS-CAS) in India, and (2) to present lessons for policymakers on how to ensure financial planning for scaling mHealth interventions. The study uses the Activity Based Costing—Ingredients (ABC-I) method. The major advantage of the ABC-I method is the clarity it brings to costs for each input and activity, across levels and geographies. It also accounts for indirect costs. There are five key lessons while costing for mHealth programs. First, that there are many activities and ingredients that must be budgeted for and discussed while planning and implementing mHealth programs. Second, the ABC-I method described in this paper provides great clarity on costs, yet its major limitation is the availability of data, which must be mitigated with the careful use of assumptions. Third, mHealth technology life cycles have financial implications which must be accounted for. Fourth, determining cost locations and all sources of funding including non-government sources is crucial. Fifth, since costing estimates are subject to a set of assumptions, a disaggregation of costs allows for scenario-building, which is useful while planning ahead and accounting for program changes. The evidence generated can be used for more informed debate on resource allocation priorities, given competing priorities in low- and middle-income countries.

Examination of influence of social media education through mobile phones on the change in physical activity and sedentary behavior in pregnant women: a randomized controlled trial

Background

Nowadays because of some necessities and demands for virtual and remote education, a new model of health approach through mobile-phones is widely used to deal with improving physical activity and its beneficial effect on pregnancy. There are a small number of studies for showing this importance and the efficacy of such methods, so this study was aimed to determine the influence of social networking through mobile phones on changing the physical activity behavior in pregnant women.

Methods

This randomized controlled trial was conducted with parallel groups on 90 pregnant women referring to Urmia health centers in 2018–2019. The participants from various social and economic backgrounds were included. The participants were randomly assigned to a control and a treatment group. Demographic and Pregnancy Physical Activity Questionnaire (PPAQ) questionnaires were filled. In addition to routine cares, the treatment group received educational intervention through social network within 16 training sessions related to physical activity and nutrition in 8 weeks.

Results

The mean weight in both control and treatment groups changed significantly during the study, but in different trends (P < 0.001, Mean Difference (MD) = 4.43). At the beginning of the study, control and treatment groups were not different in terms of daily physical activity level (P = 0.17, MD = 0.62), meanwhile, there was a statistically significant difference at the end of intervention in the level of daily physical activity (P < 0.001, MD = 0.69). Comparison of both groups, based on different categories of activity level at the end of the treatment, showed a non-significant difference in sedentary activities (P = 0.89, MD = 0.46), but the intervention led to a significant difference based on the other level of activities; light (P < 0.001, MD = 51.94), moderate (P < 0.001, MD = 46.87), and sever (P = 0.05, MD = 1.07).

Conclusion

Educational intervention based on social networks through mobile phones had an effective role in behavior change in physical activity during pregnancy.

Trial registration

IRCT20151004024340N15, Registration date05/06/2020.

Investigating Web-Based Nutrition Education Interventions for Promoting Sustainable and Healthy Diets in Young Adults: A Systematic Literature Review

Background: Our current rapidly growing food systems are imposing a heavy burden on both environmental sustainability and human health. Sustainable and healthy diets aim to promote optimal health and have a minimal environmental impact. This study aimed to critically review and synthesise the evidence on the effectiveness of web-based nutrition education interventions aiming to promote sustainable and healthy diets among young adults. Methods: A systematic search of four databases (Medline, PsycINFO, Scopus, and Embase) was conducted in March 2021. Studies were included if they used an online platform to deliver the intervention to young adults and measured at least one aspect of sustainable and healthy diets, such as plant-based food intake, food waste, and local and seasonal produce. Of the 2991 studies, a total of 221 full-text articles were assessed for eligibility of which 22 were included in the final review. Results: A majority of the studies (82%) targeted fruit and vegetable consumption, and close to a quarter of studies (23%) targeted other aspects of a sustainable and healthy diet, such as red meat intake. Only one study included multiple aspects of a sustainable and healthy diet. Program delivery outcomes reported overall positive feedback and engagement. Conclusion: This review suggests that web-based interventions may be effective in promoting some sustainable diet-related outcomes in young adults. However, there is a need for developing and evaluating future programs to promote sustainable diets more comprehensively in order to help young adults make healthy and sustainable food choices.

Digital Health Promotion and Prevention in Settings: Scoping Review

BACKGROUND

Digital technologies are increasingly integrating into people's daily living environments such as schools, sport clubs, and health care facilities. These settings play a crucial role for health promotion and prevention because they affect the health of their members, as the World Health Organization has declared. Implementing digital health promotion and prevention in settings offers the opportunity to reach specific target groups, lower the costs of implementation, and improve the health of the population. Currently, there is a lack of scientific evidence that reviews the research on digital health promotion and prevention in settings.

OBJECTIVE

This scoping review aims to provide an overview of research targeting digital health promotion and primary prevention in settings. It assesses the range of scientific literature regarding outcomes such as applied technology, targeted setting, and area of health promotion or prevention, as well as identifies research gaps.

METHODS

The scoping review was conducted following the Levac, Colquhoun, and O'Brien framework. We searched scientific databases and gray literature for articles on digital setting-based health promotion and prevention published from 2010 to January 2020. We included empirical and nonempirical publications in English or German and excluded secondary or tertiary prevention and health promotion at the workplace.

RESULTS

From 8888 records, the search resulted in 200 (2.25%) included publications. We identified a huge diversity of literature regarding digital setting-based health promotion and prevention. The variety of technology types extends from computer- and web-based programs to mobile devices (eg, smartphone apps) and telemonitoring devices (sensors). We found analog, digital, and blended settings in which digital health promotion and prevention takes place. The most frequent analog settings were schools (39/200, 19.5%) and neighborhoods or communities (24/200, 12%). Social media apps were also included because in some studies they were defined as a (digital) setting. They accounted for 31.5% (63/200) of the identified settings. The most commonly focused areas of health promotion and prevention were physical activity (81/200, 40.5%), nutrition (45/200, 22.5%), and sexual health (34/200, 17%). Most of the interventions combined several health promotion or prevention methods, including environmental change; providing information, social support, training, or incentives; and monitoring. Finally, we found that the articles mostly reported on behavioral rather than structural health promotion and prevention.

CONCLUSIONS

The research field of digital health promotion and prevention in settings is heterogeneous. At the same time, we identified research gaps regarding the absence of valid definitions of relevant terms (eg, digital settings) and the lack of literature on structural health promotion and prevention in settings. Therefore, it remains unclear how digital technologies can contribute to structural (or organizational) changes in settings. More research is needed to successfully implement digital technologies to achieve health promotion and prevention in settings.

The association of social and food preparation location context with the quality of meals and snacks consumed by young adults: findings from the MYMeals wearable camera study

PURPOSE

This study examined the association of social contexts and food preparation location with the quality of meals and snacks (predominately from the five food groups (FFG) versus discretionary foods) in a sample of young Australian adults (18-30 years old) using wearable camera technology.

METHODS

A sub-sample from the cross-sectional MYMeals study wore a wearable camera that captured images every 30 s for three consecutive days. Eating episodes from 133 participants (55% female) were classified across 4 domains: food quality (observed proportion of FFG and discretionary items), preparation location, social interaction, and screen use. Socio-economic status (SES) was assigned using residential postcode and gender self-reported. Associations of contexts and demographic factors with food quality stratified by meal type were determined using mixed binary logistic regression models.

RESULTS

Of the 1840 eating episodes identified, 1775 were included in analysis (n = 8 preparation location and n = 57 food components that could not be identified were excluded). Food prepared at home was more likely to be from the FFG at lunch (OR = 4.8 95% CI 2.7-8.6), dinner (OR = 14.8 95% CI 7.6-28.6), and snacks (OR = 3.2 95% CI 2.2-4.8). Participants from higher SES areas were more likely to consume breakfasts (OR = 3.2 95% CI 1.4-7.4) and lunches (OR = 1.9 95% CI 1.0-3.7) predominately from the FFG. Females were more likely to consume lunches (OR = 2.0 95% CI 1.1-3.8) that was largely from the FFG. Social interaction and screen use were not associated with meal or snack quality.

CONCLUSION

Wearable cameras have verified the importance of addressing meals and snacks prepared outside of home as an important contributor of discretionary food.

Perceptions of Factors Influencing Engagement With Health and Well-being Apps in the United Kingdom: Qualitative Interview Study

BACKGROUND

Digital health devices, such as health and well-being smartphone apps, could offer an accessible and cost-effective way to deliver health and well-being interventions. A key component of the effectiveness of health and well-being apps is user engagement. However, engagement with health and well-being apps is typically poor. Previous studies have identified a list of factors that could influence engagement; however, most of these studies were conducted on a particular population or for an app targeting a particular behavior. An understanding of the factors that influence engagement with a wide range of health and well-being apps can inform the design and the development of more engaging apps in general.

OBJECTIVE

The aim of this study is to explore user experiences of and reasons for engaging and not engaging with a wide range of health and well-being apps.

METHODS

A sample of adults in the United Kingdom (N=17) interested in using a health or well-being app participated in a semistructured interview to explore experiences of engaging and not engaging with these apps. Participants were recruited via social media platforms. Data were analyzed with the framework approach, informed by the Capability, Opportunity, Motivation-Behaviour (COM-B) model and the Theoretical Domains Framework, which are 2 widely used frameworks that incorporate a comprehensive set of behavioral influences.

RESULTS

Factors that influence the capability of participants included available user guidance, statistical and health information, reduced cognitive load, well-designed reminders, self-monitoring features, features that help establish a routine, features that offer a safety net, and stepping-stone app characteristics. Tailoring, peer support, and embedded professional support were identified as important factors that enhance user opportunities for engagement with health and well-being apps. Feedback, rewards, encouragement, goal setting, action planning, self-confidence, and commitment were judged to be the motivation factors that affect engagement with health and well-being apps.

CONCLUSIONS

Multiple factors were identified across all components of the COM-B model that may be valuable for the development of more engaging health and well-being apps. Engagement appears to be influenced primarily by features that provide user guidance, promote minimal cognitive load, support self-monitoring (capability), provide embedded social support (opportunity), and provide goal setting with action planning (motivation). This research provides recommendations for policy makers, industry, health care providers, and app developers for increasing effective engagement.

eHealth interventions targeting nutrition, physical activity, sedentary behavior, or obesity in adults: A scoping review of systematic reviews

A vast body of evidence regarding eHealth interventions for nutrition, physical activity, sedentary behavior, and obesity exists. This scoping review of systematic reviews aimed to evaluate the current level of evidence in this growing field. Seven electronic databases were searched for systematic reviews published until October 27, 2019. The systematic reviews must have included adult participants only and have evaluated eHealth behavioral interventions with the primary aim of changing nutrition, physical activity, and sedentary behavior or treating or preventing overweight and obesity. One hundred and six systematic reviews, published from 2006 to 2019, were included. Almost all (n = 98) reviews evaluated the efficacy of interventions. Over half (n = 61) included interventions focused on physical activity, followed by treatment of obesity (n = 28), nutrition (n = 22), prevention of obesity (n = 18), and sedentary behavior (n = 6). Many reviews (n = 46) evaluated one type of eHealth intervention only, while 60 included two or more types. Most reviews (n = 67) were rated as being of critically low methodological quality. This scoping review identified an increasing volume of systematic reviews evaluating eHealth interventions. It highlights several evidence gaps (e.g., evaluation of other outcomes, such as reach, engagement, or cost effectiveness), guiding future research efforts in this area.

Influences on the Uptake of Health and Well-being Apps and Curated App Portals: Think-Aloud and Interview Study

BACKGROUND

Health and well-being smartphone apps can provide a cost-effective solution to addressing unhealthy behaviors. The selection of these apps tends to occur in commercial app stores, where thousands of health apps are available. Their uptake is often influenced by popularity indicators. However, these indicators are not necessarily associated with app effectiveness or evidence-based content. Alternative routes to app selection are increasingly available, such as via curated app portals, but little is known about people's experiences of them.

OBJECTIVE

The aim of this study is to explore how people select health apps on the internet and their views on curated app portals.

METHODS

A total of 18 UK-based adults were recruited through social media and asked during an in-person meeting to verbalize their thoughts while searching for a health or well-being app on the internet on a platform of their choice. The search was then repeated on 2 curated health app portals: the National Health Service Apps Library and the Public Health England One You App portal. This was followed by semistructured interviews. Data were analyzed using framework analysis, informed by the Capability, Opportunity, Motivation-Behavior model and the Theoretical Domains Framework.

RESULTS

Searching for health and well-being apps on the internet was described as a minefield. App uptake appeared to be influenced by participants' capabilities such as app literacy skills and health and app awareness, and opportunities including the availability of apps, app esthetics, the price of an app, and social influences. Motivation factors that seemed to affect the uptake were perceived competence, time efficiency, perceived utility and accuracy of an app, transparency about data protection, commitment and social identity, and a wide range of emotions. Social influences and the perceived utility of an app were highlighted as particularly important. Participants were not previously aware of curated portals but found the concept appealing. Curated health app portals appeared to engender trust and alleviate data protection concerns. Although apps listed on these were perceived as more trustworthy, their presentation was considered disappointing. This disappointment seemed to stem from the functionality of the portals, lack of user guidance, and lack of tailored content to an individual's needs.

CONCLUSIONS

The uptake of health and well-being apps appears to be primarily affected by social influences and the perceived utility of an app. App uptake via curated health app portals perceived as credible may mitigate concerns related to data protection and accuracy, but their implementation must better meet user needs and expectations.

A Systematic Review of Psychosocial Nutrition Interventions for Young Adults

INTRODUCTION

Few have examined the effects of psychosocial nutrition interventions targeting young adults, a population with low fruit and vegetable (FV) consumption. This study investigated the impact of nutrition interventions with psychosocial content on improving young adult FV intake.

METHOD

This registered systematic review was guided by the Preferred Reported Items for Systematic Reviews and Meta-Analyses.

RESULTS

Searches on CINAHL, Embase, Medline PubMed, Ovid-Medline, PsychInfo, and Web of Science identified 4,113 records. Twenty-four randomized controlled trials were extracted. Eighteen studies found significant between-group differences in fruit and/or vegetable intake. Young adults with low income and racial-ethnic subgroups were underrepresented. A typology emerged as an organizing framework from the psychosocial intervention content. Interventions were anticipatory, socially engaged, a hybrid (anticipatory and socially engaged), or exposure-based. Studies also reported unintended consequences.

DISCUSSION

Significant between-group differences were mostly reported by anticipatory, socially engaged, or hybrid interventions, aligning with young adult developmental needs through detailed planning, goal-setting tasks, and/or addressing social norms. Interventions with insignificant differences lacked engagement and adequate exposure.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Demographically inclusive studies are imperative in addressing dietary disparities by socioeconomic status. A typology of interventions emphasizing content rather than theories or treatment strategies widens opportunities for interdisciplinary collaboration. More research is needed to mitigate unintended consequences (boomerang effects) in which FV intake decreased postintervention or participants disengaged in activities intended to increase FV intake.

Exploring Sports Nutrition Knowledge in Elite Gaelic Footballers

Nutrition intake plays a crucial role in improving athletic performance, enhancing adaptations to training, and augmenting recovery from exercise. However, research has reported that Gaelic footballers consistently fail to meet energy and carbohydrate recommendations. Sports nutrition knowledge (SNK) can influence the dietary intake of athletes, and therefore has the potential to have a significant impact on athletic performance. The aim of this study was to investigate the current level of SNK in elite Gaelic footballers (n = 100). An online version of the Nutrition for Sport Knowledge Questionnaire (NSKQ) was used to assess sports SNK. The overall mean SNK scores for Gaelic footballers and practitioners were 47.6 ± 12.3% and 78.1 ± 8.3%, respectively. There were no differences in knowledge between age groups, education level or divisional status. The top three sources of nutrition information identified by participants were team dietitian/nutritionists (84.0%), athletic trainers/strength and conditioning coaches (73%), and social media (37%). The results show that there is a major gap in the SNK of Gaelic footballers, while practitioners demonstrated a promising SNK, that could support Gaelic footballers. There is a need for development of interventions and knowledge transfer partnerships, including more effective methods of educating Gaelic footballers and translating sports nutrition principles to players. Developing appropriate nutritional education strategies using online resources and mobile applications could help to improve nutritional knowledge and practice of Gaelic footballers.

Recruiting and retaining young adults: what can we learn from behavioural interventions targeting nutrition, physical activity and/or obesity? A systematic review of the literature

OBJECTIVE

To describe strategies used to recruit and retain young adults in nutrition, physical activity and/or obesity intervention studies, and quantify the success and efficiency of these strategies.

DESIGN

A systematic review was conducted. The search included six electronic databases to identify randomised controlled trials (RCT) published up to 6 December 2019 that evaluated nutrition, physical activity and/or obesity interventions in young adults (17-35 years). Recruitment was considered successful if the pre-determined sample size goal was met. Retention was considered acceptable if ≥80 % retained for ≤6-month follow-up or ≥70 % for >6-month follow-up.

RESULTS

From 21 582 manuscripts identified, 107 RCT were included. Universities were the most common recruitment setting used in eighty-four studies (79 %). Less than half (46 %) of the studies provided sufficient information to evaluate whether individual recruitment strategies met sample size goals, with 77 % successfully achieving recruitment targets. Reporting for retention was slightly better with 69 % of studies providing sufficient information to determine whether individual retention strategies achieved adequate retention rates. Of these, 65 % had adequate retention.

CONCLUSIONS

This review highlights poor reporting of recruitment and retention information across trials. Findings may not be applicable outside a university setting. Guidance on how to improve reporting practices to optimise recruitment and retention strategies within young adults could assist researchers in improving outcomes.

Pilot Study of a Farm-to-Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Intervention Promoting Vegetable Consumption

BACKGROUND

Vegetable intake is below recommended levels among adults served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

OBJECTIVE

The aim of this study was to determine whether a novel, theory-driven, farm-to-WIC intervention to promote vegetable intake showed promise of being successful and is therefore appropriate for efficacy testing.

DESIGN

From June 2019 to January 2020, the intervention was piloted in three WIC agency sites (one randomized to the intervention study group and two to the control group) selected based on similarity in size and the demographics of participants served.

PARTICIPANTS/SETTING

Recruited between June 3, 2019 and August 1, 2019, participants were 297 primarily Hispanic adults served by a large WIC agency located in a densely populated urban area in New Jersey (160 were enrolled at the intervention site and 137 at control sites).

INTERVENTION

The intervention combined behaviorally focused instruction and handouts with the introduction of a WIC-based farmers' market, field trips to an area farmers' market, telephone coaching and support before and after trips, and recipe demonstrations and tastings.

MAIN OUTCOME MEASURES

The primary outcomes were vegetable intake (measured objectively using dermal carotenoids as a biomarker of intake and via self-report) and the redemption of vouchers provided through the WIC Farmers' Market Nutrition Program (FMNP) for fruit and vegetable purchases at farmers' markets (objectively assessed using data provided by WIC).

STATISTICAL ANALYSES PERFORMED

Between-group differences in vegetable intake were examined at mid- and post-intervention (3 and 6 months post-baseline, respectively) with linear mixed-effects models adjusted for baseline vegetable intake and covariates. Logistic regression analysis was used to relate FMNP voucher redemption to study group and covariates.

RESULTS

At mid-intervention, objectively measured vegetable intake was higher among participants in the control group as compared with the intervention group; self-reported intake did not differ by group. Post-intervention, objectively measured and self-reported vegetable intake were higher among participants in the intervention group as compared with the control group. Receipt of the intervention was associated with a greater likelihood of FMNP voucher redemption. Voucher redemption rates were 87% in the intervention group and 28% in the control group (odds ratio = 17.39, 95% confidence interval [8.64, 35.02]).

CONCLUSIONS

Meaningful associations found between the intervention, vegetable intake, and FMNP voucher redemption suggest that the program is appropriate for efficacy testing.

A Randomized mHealth Trial to Promote Vegetable Intake Through Counting and Goal Setting

OBJECTIVE

To determine if counting and goal setting can increase red/orange vegetable intake.

DESIGN

Pre-posttest experimental.

SETTING

Midwestern university.

PARTICIPANTS

Undergraduate students (n = 165).

INTERVENTION

Those in the intervention group (n = 85) were asked to count the number of times they ate red/orange vegetables and set a goal to eat 1 more time.

MAIN OUTCOME MEASURE

An estimate (number of times/d) of vegetable intake based on an independent review of uploaded photographs and descriptions of meals from smartphones.

ANALYSIS

Generalized estimating equations.

RESULTS

For the intervention group, mean frequency intake increased from 0.9 times/d on Monday to 1.6 times/d on Tuesday and to 1.3 times/d on Wednesday, whereas mean intakes for the control group were 1.0, 0.8, and 0.8 times/d, respectively. There were significant group × time interactions for Tuesday (β = 0.8; P < 0.001) and Wednesday (β = 0.5; P = 0.006).

CONCLUSIONS AND IMPLICATIONS

A mobile method that helped people count their daily red/orange vegetable intake and set a goal appeared to increase consumption. This finding suggests that nutrition education programs that provide people with easy ways to track specific dietary behaviors might be effective at helping them attain goals.

Key facets to build up eHealth and mHealth interventions to enhance physical activity, sedentary behavior and nutrition in healthy subjects - an umbrella review

BACKGROUND

Electronic (eHealth) and mobile (mHealth) health interventions can provide a large coverage, and are promising tools to change health behavior (i.e. physical activity, sedentary behavior and healthy eating). However, the determinants of intervention effectiveness in primary prevention has not been explored yet. Therefore, the objectives of this umbrella review were to evaluate intervention effectiveness, to explore the impact of pre-defined determinants of effectiveness (i.e. theoretical foundations, behavior change techniques, social contexts or just-in-time adaptive interventions), and to provide recommendations for future research and practice in the field of primary prevention delivered via e/mHealth technology.

METHODS

PubMed, Scopus, Web of Science and the Cochrane Library were searched for systematic reviews and meta-analyses (reviews) published between January 1990 and May 2020. Reviews reporting on e/mHealth behavior change interventions in physical activity, sedentary behavior and/or healthy eating for healthy subjects (i.e. subjects without physical or physiological morbidities which would influence the realization of behaviors targeted by the respective interventions) were included if they also investigated respective theoretical foundations, behavior change techniques, social contexts or just-in-time adaptive interventions. Included studies were ranked concerning their methodological quality and qualitatively synthesized.

RESULTS

The systematic search revealed 11 systematic reviews and meta-analyses of moderate quality. The majority of original research studies within the reviews found e/mHealth interventions to be effective, but the results showed a high heterogeneity concerning assessment methods and outcomes, making them difficult to compare. Whereas theoretical foundation and behavior change techniques were suggested to be potential positive determinants of effective interventions, the impact of social context remains unclear. None of the reviews included just-in-time adaptive interventions.

CONCLUSION

Findings of this umbrella review support the use of e/mHealth to enhance physical activity and healthy eating and reduce sedentary behavior. The general lack of precise reporting and comparison of confounding variables in reviews and original research studies as well as the limited number of reviews for each health behavior constrains the generalization and interpretation of results. Further research is needed on study-level to investigate effects of versatile determinants of e/mHealth efficiency, using a theoretical foundation and additionally explore the impact of social contexts and more sophisticated approaches like just-in-time adaptive interventions.

TRIAL REGISTRATION

The protocol for this umbrella review was a priori registered with PROSPERO: CRD42020147902 .

Dietitians Australia position statement on telehealth

It is the position of Dietitians Australia that clients can receive high‐quality and effective dietetic services such as Medical Nutrition Therapy (MNT) delivered via telehealth. Outcomes of telehealth‐delivered dietetic consultations are comparable to those delivered in‐person, without requiring higher levels of additional training nor compromising quality of service provision. Dietitians Australia recommends that policy makers and healthcare funders broaden the recognition for telehealth‐delivered dietetic consultations as a responsive and cost‐effective alternative or complement to traditional in‐person delivery of dietetic services. The successful implementation of telehealth can help to address health and service inequalities, improve access to effective nutrition services, and support people with chronic disease to optimise their diet‐related health and well‐being, regardless of their location, income or literacy level, thereby addressing current inequities.

Promoting healthy lifestyle in Chinese college students: evaluation of a social media-based intervention applying the RE-AIM framework

BACKGROUND

A health program aiming at college students is pressingly needed to improve their lifestyle and prevent diseases. However, a health intervention often requires health facilities and the many efforts of health workers. This project attempts to evolve traditional health intervention by using integrated methods based on social media and multiple mobile tools.

METHODS

A total of 110 undergraduates from Zhejiang University were recruited. In all, 87 participants volunteered to enroll in the intervention group, whereas 23 stayed in a control group. Fifteen staff (dietitians, health assistants and a sports coach) used the WeChat app and its plugin Zhishi mini-program for health education, diet and physical activity (PA) supervision during 21 days. Pre-to-post changes of eating habits, physical fitness tests and anthropometry data were measured. The RE-AIM framework was employed to evaluate the intervention, dimensions of which were Reach, Effectiveness, Adoption, Implementation, and Maintenance.

RESULTS

The recruitment rate of students was 79.1%. The intervention group showed significant progress in terms of healthy food intake (all P < 0.05), and an improvement in PA level (P = 0.004) over 21 days. About 60.9% subjects were satisfied with the whole program and 64.4% would like to join the program again.

CONCLUSIONS

This intervention showed a great improvement in healthy behavior with great feasibility for further dissemination.

The Mobile Health Multiple Lifestyle Behavior Interventions Across the Lifespan (MoBILE) Research Program: Protocol for Development, Evaluation, and Implementation

BACKGROUND

Clustering of multiple lifestyle risk behaviors has been associated with a greater risk of noncommunicable diseases and mortality than one lifestyle risk behavior or no lifestyle risk behaviors. The National Board of Health and Welfare in Sweden reported in 2018 that it is important to provide additional support to individuals with multiple lifestyle risk behaviors, as risks from these behaviors are multiplicative rather than additive. However, the same report emphasized that there is a lack of knowledge regarding interventions that support changes to unhealthy lifestyle behaviors.

OBJECTIVE

The MoBILE (Mobile health Multiple lifestyle Behavior Interventions across the LifEspan) research program has brought together two Swedish research groups supported by international collaborators. Through this collaboration, we aim to design and evaluate a number of novel and tailored mobile health (mHealth) multiple lifestyle behavior interventions across the life span of different health care populations. In addition, the MoBILE research program will extend ongoing research to include mHealth interventions for migrant pregnant women and children.

METHODS

Each project within the MoBILE program will focus on a specific group: pregnant women, preschool children, high school and university students, and adults in primary and clinical care. All the projects will follow the same 4 phases: requirements, development, evaluation, and implementation. During the requirements phase, implementers and end users will aid the design of content and functionality of the interventions. In the development phase, findings from the first phase will be synthesized with expert domain knowledge and theoretical constructs to create interventions tailored to the target groups. The third phase, evaluation, will comprise randomized controlled trials conducted to estimate the effects of the interventions on multiple lifestyle risk behaviors (eg, alcohol, nutrition, physical activity, and smoking). The final phase will investigate how the interventions, if found effective, can be disseminated into different health care contexts.

RESULTS

The research program commenced in 2019, and the first results will be available in 2020. Projects involving pregnant women, preschool children, and high school and university students will be completed in the first 3 years, with the remaining projects being planned for the program's final 3 years.

CONCLUSIONS

The development of evidence-based digital tools is complex, as they should be guided by theoretical frameworks, and requires large interdisciplinary teams with competence in technology, behavioral science, and lifestyle-specific areas. Individual researchers or smaller research groups developing their own tools is not the way forward, as it means reinventing the wheel over and over again. The MoBILE research program therefore aims to join forces and learn from the past 10 years of mHealth research to maximize scientific outcomes, as well as the use of financial resources to expand the growing body of evidence for mHealth lifestyle behavior interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/14894.

Impact of a Mobile Phone App to Increase Vegetable Consumption and Variety in Adults: Large-Scale Community Cohort Study

Background

Large-scale initiatives to improve diet quality through increased vegetable consumption have had small to moderate success. Digital technologies have features that are appealing for health-related behavior change interventions.

Objective

This study aimed to describe the implementation and evaluation of a mobile phone app called VegEze, which aims to increase vegetable intake among Australian adults.

Methods

To capture the impact of this app in a real-world setting, the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was utilized. An uncontrolled, quantitative cohort study was conducted, with evaluations after 21 and 90 days. The app was available in the Apple App Store and was accompanied by television, radio, and social media promotion. Evaluation surveys were embedded into the app using ResearchKit. The primary outcomes were vegetable intake (servings per day) and vegetable variety (types per day). Psychological variables (attitudes, intentions, self-efficacy, and action planning) and app usage were also assessed. Descriptive statistics and multiple linear regression were used to describe the impact of the app on vegetable intake and to determine the characteristics associated with the increased intake.

Results

Data were available from 5062 participants who completed the baseline survey; 1224 participants completed the 21-day survey, and 273 completed the 90-day survey. The participants resided across Australia and were mostly women (4265/5062, 84.3%) with a mean age of 48.2 years (SD 14.1). The mean increase in intake was 0.48 servings, from 3.06 servings at baseline to 3.54 servings at the end of the 21-day challenge (t₁₂₂₃=8.71; P<.001). The variety of vegetables consumed also increased by 0.35 types per day (t₁₁₂₃=9.59; P<.001). No changes in intake and variety were found from day 21 to the 90-day follow-up. Participants with the highest app usage increased their vegetable intake by 0.63 (SD 2.02) servings per day compared with 0.32 (SD 1.69) servings per day for those with the lowest app usage. On the basis of multiple linear regression, gender; age; BMI; psychological variables of self-efficacy, attitudes, intentions, and action planning specific to vegetable intake; baseline vegetable intake; and active days of app usage accounted for 23.3% of the variance associated with the change in intake (F_9,1208=42.09; P<.001). Baseline vegetable intake was the strongest predictor of change in intake (beta=−.495; P<.001), with lower baseline intake associated with a greater change in intake. Self-efficacy (beta=.116; P<.001), action planning (beta=.066; P=.02), BMI (beta=.070; P=.01), and app usage (beta=.081; P=.002) were all significant predictors of the change in intake.

Conclusions

The VegEze app was able to increase intake by half a serving in a large sample of Australian adults. Testing the app in a real-world setting and embedding the consent process allowed for greater reach and an efficient, robust evaluation. Further work to improve engagement is warranted.

Educational interventions on nutrition among older adults: A systematic review and meta-analysis of randomized clinical trials

Poor nutrition is a major risk factor for non-communicable diseases and nutritional deficiencies. Dietary interventions have been proposed to improve eating habits. The aim of this systematic review is to evaluate the efficacy of randomized clinical trials of nutritional interventions in food habits among older people. A systematic literature review using the MEDLINE, LILACS, Scopus, Cochrane Library, Web of Science and Google Scholar databases was conducted, according to PRISMA guidelines. The keywords were: food and nutrition education OR educación alimentaria y nutricional OR educação alimentar e nutricional AND clinical trial OR ensayo clínico OR ensaio clínico AND elderly OR aged OR anciano OR idoso AND human OR seres humanos. The pooled standardized mean differences (SMD) and 95 % confidence intervals (CIs) were estimated using a random-effects model. Heterogeneity among studies was assessed using I² tests. After screening based on the title and abstract, and a full-text assessment, 11 studies remained. Results of pooling eleven studies were as follows: SMD = 0.25 (95 % CI = 0.15 - 0.34; I² = 0,0%) for vegetable, SMD = 0.18 (95 % CI = 0.08 - 0.27; I² = 0,0%) for fruit and SMD = 0.27 (95 % CI = 0.18 - 0.36; I² = 58,3%) for fibre intake. Our results suggest that nutritional interventions were effective in increasing vegetable, fruit and fibre intake. However, these results should be analyzed carefully, due to the small number of studies included in the meta-analysis. Further studies should be encouraged due to the aging process.

Developing theory- and evidence-based counseling for a health promotion intervention: A discussion paper

Although the use of theories and evidence is often stressed in the development of health promotion interventions, this does not guarantee the success of an intervention. Thus, we need to reflect on intervention development processes that use different types of theories and evidence. In this paper, we provide a reflective discussion on how we identified evidence-based behavior change techniques and counseling themes for a health promotion intervention. In addition, we discuss the challenges that we encountered and what we learned during the process: a) a lack of previous research and meta-analyses, b) inconsistencies in evidence, c) integrating evidence and theories that have different starting points, and d) collaborating with researchers who represent different evidence and theories. During the process, we benefitted from having the clear goal of conducting evidence- and theory-based work. We solved the challenges by, for example, utilizing different types of evidence and being reflective about the reasons behind any inconsistencies in the evidence. In retrospect, we would have benefitted from closer collaboration between the teams that worked separately with different evidence. These kinds of reflective descriptions of development processes and the challenges encountered during them may help other researchers and professionals avoid encountering the same challenges.

Achieving Effective and Efficient Basal Insulin Optimal Management by Using Mobile Health Application (APP) for Type 2 Diabetes Patients in China

AIM

To evaluate the effectiveness of the mobile health application (APP) education in basal insulin optimal management program for insulin-naive type 2 diabetes (T2D) patients in China.

METHODS

The basal insulin optimal management program was launched in 297 hospitals in China, throughout the six main regions of China. A total of 17,208 insulin-naive patients with T2D who started to use basal insulin were screened. The mobile health APP was downloaded in each recruited patient's mobile phone and the doctor's mobile phone. Then, according to the instructions and education materials in the APP, these patients began their self-management of insulin dosage titrations and contacted their doctors by APP if they need help.

RESULTS

Overall, 12,530 patients with T2D were finally included in the analysis. The average age was 51.97±12.76 years, and 58% of them were males. The average body mass index is 24.46±3.83 kg/m², and the average HbA1c at baseline was 8.33±2.11% with 24% of the subjects reaching the target of HbA1c<7.0% at baseline. After 3 months of treatment and educations through the APP, HbA1c decreased significantly from baseline (-1.02±1.72%), with 59% of the patients reaching HbA1c<7.0%. After 6 months, the glycemic control of HbA1c also decreased from baseline significantly (-1.01±1.67%). Dosage of insulin daily was 0.23±0.09 IU/kg at baseline, and 0.23±0.23 IU/kg after 6 months of treatment. Regarding the profiles of hypoglycemia treatment, 3145 patients received basal insulin in combination with mono oral anti-diabetic drug (OAD), 1204 patients with dual OADs, 208 patients with triple OADs, and 17 patients with quarter OADs.

CONCLUSION

Patients could benefit from the basal insulin optimal management program in self-management by using mobile health APP educations. For T2D patients who are going to start insulin treatment, mobile health APP can help them to reach the target of glycemic control with appropriate dosage of insulin.

Performance Nutrition in the digital era - An exploratory study into the use of social media by sports nutritionists

This study aimed to explore how social media is being used by sports nutritionists as part of service provision, as well as practitioners' experiences and opinions of its use in practice. An exploratory sequential mixed methods approach was used during this research. Forty-four sports nutritionists completed an online survey detailing their personal and professional social media use. Semi-structured follow-up interviews were conducted with 16 participants who volunteered to do so. Survey responses were collated and reported as descriptive statistics. Interviews were thematically analysed. Social media was used by 89% of sports nutritionists to support practice, of which 97% perceived its use to be beneficial. Platforms were used to deliver information and resources, and support athletes online via pages, groups and 1-2-1 messaging. Social media facilitated improved communication between the practitioner and the athlete, as well as facilitating mobile and visual learning. Lack of digital intervention training and time were reported as challenges to social media use in practice. Sports nutritionists have embraced social media as an extension of service provision. Professional education should now consider supporting nutritionists' in developing digital professionalism.

Picture Yourself Healthy-How Users Select Mediated Images to Shape Health Intentions and Behaviors

Hypotheses on how selective viewing of mediated images may sustain eating habits and aid healthier eating were derived from the Selective Exposure Self- and Affect Management model. The model posits that individuals select to view media to manage their self-concepts-and that this exposure affects subsequent intentions and behaviors. Participants (N = 265) selectively viewed Instagram-like postings featuring healthy or unhealthy food imagery. Beforehand, participants reported habits and perceived expert recommendations regarding food intake. After viewing postings, participants chose gift cards representing healthy or unhealthy food purchases and indicated food intake intentions. Results show that existing eating behavior predicts selective exposure to healthy or unhealthy food imagery, which in turn shapes gift card choices and (both healthy and unhealthy) food intake intentions.

Young Adults' Engagement With a Self-Monitoring App for Vegetable Intake and the Impact of Social Media and Gamification: Feasibility Study

Background

Social media and gamification have been used in digital interventions for improving nutrition behaviors of young adults, but few studies measure engagement.

Objective

This feasibility study aimed to explore user engagement with a 4-week smartphone program for improving vegetable intake.

Methods

A goal setting and self-monitoring app was developed for feasibility testing. We assessed if additional components of gaming and/or social media support increased engagement. A 2 × 2 factorial study design was used with participants randomly allocated to each group. Engagement with the app (usage) was captured via inbuilt software, which recorded total days of app usage (duration) and the frequency of logging vegetable intake. Uptake of the social media (Facebook) content was measured by tracking views, likes, and comments on posts.

Results

Out of the 110 potential participants who completed the prescreening questionnaire online, 97 were eligible (mean age 24.8 [SD 3.4]). In total, 49% (47/97) of participants were retained at 4 weeks. Attrition within the first week was the highest among users of the gamified app without social support (Facebook; P<.001). Over the intervention period, 64% (62/97) of participants logged into their app, with vegetable intake recorded on average for 11 out of 28 days. The frequency of recording decreased each week (mean 4 [SD 2] days in week 1 versus mean 2 [SD 2] days in week 4). No effects of gaming or social support on the frequency of recording vegetables or the duration of app engagement were found. However, regardless of the app type, the duration of app engagement was significantly associated with vegetable intake post intervention (P<.001). In total, 60% of Facebook posts were viewed by participants but engagement was limited to likes, with no comments or peer-to-peer interaction observed.

Conclusions

As duration of usage was associated with vegetable intake, a deeper understanding of factors influencing engagement is needed. Dimensions such as personal attributes and the setting and context require further exploration in addition to content and delivery.

A validation study of questionnaire towards mobile based health applications in uncontrolled diabetic population of India (South)

BACKGROUND

Mobile applications have the potential to provide needed support for older adults with diabetes. The field of medical application is currently one of the most dynamic in application development and medicine.

OBJECTIVE

This study was designed to develop and validate a questionnaire to assess knowledge, attitude and practice of uncontrolled diabetic patients towards mobile based health applications.

METHODS

A Cross Sectional study was designed and enrolled 78 adult uncontrolled diabetic (≥18 years old DM type 2)patients and clinically validated questionnaire was examined for internal consistency, reproducibility, convergent and discriminant validity using Cronbach's alpha, intra class correlation and CITC scores respectively.

RESULTS

Cronbach's alpha coefficient was 0.97 for Assessment of Knowledge, 0.93 for Assessment of Attitude, and 0.90 for Assessment of Practice in uncontrolled diabetic population.

CONCLUSION

The final version of questionnaire was found to be statistically internally consistent, reproducible and reliable and could be used to assess the awareness and attitude of patients towards self-management of diabetes mellitus.

Effectiveness of Interventions and Behaviour Change Techniques for Improving Dietary Intake in Young Adults: A Systematic Review and Meta-Analysis of RCTs

Poor eating habits are common during young adulthood and influence chronic disease morbidity. This systematic review evaluates the effectiveness of interventions aiming to improve dietary intake among young adults and, identifies which behaviour change techniques (BCTs) are most effective. Six electronic databases were searched for RCTs published until October 2018, and evaluating behavioural interventions assessing change in dietary intake in young adults (17–35 years). Of the 18,779 articles identified, 54 were included. Forty studies focused on fruit and/or vegetable intake, of which 63% showed a significant between-group difference in favour of the intervention group. Meta-analysis (n = 17) demonstrated a significant increase in fruit and vegetable intake of +68.6 g/day after three months of intervention and +65.8 g/day for interventions >3 months when compared to control. A meta-analysis (n = 5) on total energy intake found no significant differences between groups. The BCTs with the highest effectiveness ratio were habit formation (100%), salience of consequences (83%) and adding objects to the environment (70%). The review highlights the potential of behavioural interventions to improve young adults’ fruit and vegetable intake but was less convincing for other dietary outcomes. Due to the lack of studies including each BCT, the BCTs imperative to success could not be identified.

The Development of VegEze: Smartphone App to Increase Vegetable Consumption in Australian Adults

Background

Poor-quality dietary patterns are often characterized by inadequate consumption of fruits and vegetables. Changing dietary behavior is difficult, and although it is often clear what needs to change, how to enact change is more difficult. Smartphones have characteristics that may support the complexity of changing dietary behavior.

Objective

This paper describes the iterative process of developing a theory-based smartphone app called VegEze that aimed to increase vegetable consumption.

Methods

To upscale, reach target users, and create a user-friendly end product, a collaborative research-industry partnership was formed to build the app over a 20-week period. The Integrate, Design, Assess, and Share framework was used as a scientific basis to guide the development. The behavior change wheel was also used as a theoretical grounding in combination with other theory-based strategies, such as self-monitoring, social comparison, and gamification—which have all been shown to be successful in dietary change or digital health interventions. We conducted 1 consumer survey (N=1068), 1 usability testing session (N=11), and a pilot effectiveness and usability trial (N=283) to inform the design of the app.

Results

The target behavior for the app was defined as having 3 different types of vegetables at dinner. The perceived achievability of this target behavior was high; 93% of respondents (993/1068 users) felt they were likely or very likely to be able to regularly achieve the behavior. App features that users wanted included the following: recipes and meal ideas (876/1068, 82% of users), functionality to track their intake (662/1068, 62%), and information on how to prepare vegetables (545/1068, 51%). On the basis of importance of self-monitoring as a behavior change technique (BCT) and its rating by users, the vegetable tracker was a core feature of the app and was designed to be quick and simple to use. Daily feedback messages for logging intake and communicating progress were designed to be engaging and fun, using friendly, positive language and emoji icons. Daily and weekly feedback on vegetable consumption was designed to be simple, informative, and reinforce monitoring. A creative team was engaged to assist in the branding of the app to ensure it had an identity that reflected the fun and simple nature of the underlying behavior. The app included 16 BCTs, most of which were from the goals and planning subsection of the BCT taxonomy.

Conclusions

Combining a theoretical framework with an industry perspective and input resulted in an app that was developed in a timely manner while retaining its evidence-base. VegEze is an iOS app currently available in the App Store, and the overall impact of the VegEze app will be evaluated in an uncontrolled, quantitative study.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000481279; http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=ACTRN12618000481279 (Archived by WebCite: at http://www.webcitation.org/769oG9EaA)

Mobile-Based Interventions for Dietary Behavior Change and Health Outcomes: Scoping Review

Background

Mobile apps are being widely used for delivering health interventions, with their ubiquitous access and sensing capabilities. One such use is the delivery of interventions for healthy eating behavior.

Objective

The aim of this study was to provide a comprehensive view of the literature on the use of mobile interventions for eating behavior change. We synthesized the studies with such interventions and mapped out their input methods, interventions, and outcomes.

Methods

We conducted a scoping literature search in PubMed/MEDLINE, Association for Computing Machinery Digital Library, and PsycINFO databases to identify relevant papers published between January 2013 and April 2018. We also hand-searched relevant themes of journals in the Journal of Medical Internet Research and registered protocols. Studies were included if they provided and assessed mobile-based interventions for dietary behavior changes and/or health outcomes.

Results

The search resulted in 30 studies that we classified by 3 main aspects: input methods, mobile-based interventions, and dietary behavior changes and health outcomes. First, regarding input methods, 5 studies allowed photo/voice/video inputs of diet information, whereas text input methods were used in the remaining studies. Other than diet information, the content of the input data in the mobile apps included user’s demographics, medication, health behaviors, and goals. Second, we identified 6 categories of intervention contents, that is, self-monitoring, feedback, gamification, goal reviews, social support, and educational information. Although all 30 studies included self-monitoring as a key component of their intervention, personalized feedback was a component in 18 studies, gamification was used in 10 studies, goal reviews in 5 studies, social support in 3 studies, and educational information in 2 studies. Finally, we found that 13 studies directly examined the effects of interventions on health outcomes and 12 studies examined the effects on dietary behavior changes, whereas only 5 studies observed the effects both on dietary behavior changes and health outcomes. Regarding the type of studies, although two-thirds of the included studies conducted diverse forms of randomized control trials, the other 10 studies used field studies, surveys, protocols, qualitative interviews, propensity score matching method, and test and reference method.

Conclusions

This scoping review identified and classified studies on mobile-based interventions for dietary behavior change as per the input methods, nature of intervention, and outcomes examined. Our findings indicated that dietary behavior changes, although playing a mediating role in improving health outcomes, have not been adequately examined in the literature. Dietary behavior change as a mechanism for the relationship between mobile-based intervention and health outcomes needs to be further investigated. Our review provides guidance for future research in this promising mobile health area.

The use of social media in nutrition interventions for adolescents and young adults-A systematic review

OBJECTIVE

Social media is a potentially engaging way to support adolescents and young adults in maintaining healthy diets and learning about nutrition. This review identifies interventions that use social media to promote nutrition, examines their content and features, and evaluates the evidence for the use of such platforms among these groups.

MATERIAL AND METHODS

We conducted a systematic search of 5 databases (PubMed, CINAHL, EMBASE, PsycINFO, and ACM Digital Library) for studies that included: 1) adolescents and/or young adults (ages 10-19; ages 18-25); 2) a nutrition education or behavior change intervention component, or outcomes related to nutrition knowledge or dietary changes; and 3) a social media component that allowed users to communicate or share information with peers.

RESULTS

16 articles were identified that included a social media component in a nutrition-related intervention for adolescents or young adults. Interventions included features in 7 categories: social media; communication; tracking health; education; tailoring; social support; and gamification. 11 out of the 16 studies had at least one significant nutrition-related clinical or behavioral outcome.

CONCLUSION

Social media is a promising feature for nutrition interventions for adolescents and young adults. A limited number of studies were identified that included social media. A majority of the identified studies had positive outcomes. We found that most studies utilized only basic social media features, did not evaluate the efficacy of social media components, and did not differentiate between the efficacy of social media compared to other delivery mechanisms.

Assessing the applicability of public health intervention evaluations from one setting to another: a methodological study of the usability and usefulness of assessment tools and frameworks

BACKGROUND

Public health interventions can be complicated, complex and context dependent, making the assessment of applicability challenging. Nevertheless, for them to be of use beyond the original study setting, they need to be generalisable to other settings and, crucially, research users need to be able to identify to which contexts it may be applicable. There are many tools with set criteria for assessing generalisability/applicability, yet few seem to be widely used and there is no consensus on which should be used, or when. This methodological study aimed to test these tools to assess how easy they were to use and how useful they appeared to be.

METHODS

We identified tools from an existing review and an update of its search. References were screened on pre-specified criteria. Included tools were tested by using them to assess the applicability of a Swedish weight management intervention to the English context. Researcher assessments and reflections on the usability and utility of the tools were gathered using a standard pro-forma.

RESULTS

Eleven tools were included. Their length, content, style and time required to complete varied. No tool was considered ideal for assessing applicability. Their limitations included unrealistic criteria (requiring unavailable information), a focus on implementation to the neglect of transferability (i.e. little focus on potential effectiveness in the new setting), overly broad criteria (associated with low reliability), and a lack of an explicit focus on how interventions worked (i.e. their mechanisms of action).

CONCLUSION

Tools presenting criteria ready to be used may not be the best method for applicability assessments. They are likely to be either too long or incomplete, too focused on differences and fail to address elements that matter for the specific topic of interest. It is time to progress from developing lists of set criteria that are not widely used in the literature, to creating a new approach to applicability assessment. Focusing on mechanisms of action, rather than solely on characteristics, could be a useful approach, and one that remains underutilised in current tools. New approaches to assessing generalisability that evolve away from checklist style assessments need to be developed, tested, reported and discussed.

Mobile health applications in self-management of patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of their efficacy

Background

Mobile health applications are increasingly used in patients with Chronic Obstructive Pulmonary Disease (COPD) to improve their self-management, nonetheless, without firm evidence of their efficacy. This meta-analysis was aimed to assess the efficacy of mobile health applications in supporting self-management as an intervention to reduce hospital admission rates and average days of hospitalization, etc.

Methods

PubMed, Web of Science (SCI), Cochrane Library, and Embase were searched for relevant articles published before November 14th, 2017. A total of 6 reports with randomized controlled trials (RCTs) were finally included in this meta-analysis.

Results

Patients using mobile phone applications may have a lower risk for hospital admissions than those in the usual care group (risk ratio (RR) = 0.73, 95% CI [0.52, 1.04]). However, there was no significant difference in reducing the average days of hospitalization.

Conclusion

Self-management with mobile phone applications could reduce hospital admissions of patients with COPD.

Memphis FitKids: implementing a mobile-friendly web-based application to enhance parents' participation in improving child health

Background

Child obesity is a major public health challenge, increasing the risk of chronic medical conditions such as type 2 diabetes, metabolic syndrome, and hypertension. Among U.S. states, Tennessee has one of the highest rates of child obesity. Emerging communication technologies can help to deliver highly disseminable population-level interventions to improve health behavior. The aim of this paper is to report the implementation and the evaluation of the reach of Memphis FitKids, a web-based application, intended to promote healthy behaviors for families and children.

Methods

A community-level demonstration project, Memphis FitKids, was developed and implemented in Tennessee’s Greater Memphis Area. This application (www.memphisfitkids.org) was designed for parents to assess their children’s obesity risk through determinants such as weight, diet, physical activity, screen time, and sleep adequacy. A built-in “FitCheck” tool used this collected information to create a report with tailored recommendations on how to make healthy changes. A Geographic Information Systems component was implemented to suggest low-cost neighborhood resources that support a healthy lifestyle. A social marketing framework was used to develop and implement FitKids, and a Community Advisory Board with representatives from community partners (e.g., the YMCA of Memphis, the Pink Palace Family of Museums, and the Memphis Public Library) supported the implementation of the project. Five kiosks distributed in the community served as public access points to provide a broad reach across socioeconomic strata. Presentations at community events and the use of Facebook facilitated the promotion of FitKids. Website traffic and Facebook usage were evaluated with Google Analytics and Facebook Insights, respectively.

Results

In Tennessee, 33,505 users completed 38,429 FitCheck sessions between July 2014 and December 2016. Among these, 6763 sessions were completed at the five kiosks in the community. FitKids was presented at 112 community events and the social media posts reached 23,767 unique Facebook users.

Conclusions

The Memphis FitKids demonstration project showed that web-based health tools may be a viable strategy to increase access to information about healthy weight and lifestyle options for families. Mobile-friendly web-based applications like Memphis FitKids may also serve health professionals in their efforts to support their clients in adopting healthy behaviors.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5968-6) contains supplementary material, which is available to authorized users.

Social media use for nutrition outcomes in young adults: a mixed-methods systematic review

BACKGROUND

Social media has been widely adopted by young adults, consequently health researchers are looking for ways to leverage this engagement with social media for the delivery of interventions and health promotion campaigns. Weight gain and sub-optimal dietary choices are common in young adults, and social media may be a potential tool to facilitate and support healthier choices.

METHODS

We conducted a mixed-methods systematic review of studies examining social media use for nutrition-related outcomes in young adults. Seven databases [EBscohost, ERIC, ProQuest Central, PubMed, Ovid, Scopus, and Emerald] were systematically searched; 1225 abstracts were screened, and 47 full-text articles were assessed for eligibility. Study designs included both quantitative, such as experimental and observational studies, and qualitative, such as focus groups and interviews, approaches. Quality was assessed using the Mixed Methods Appraisal Tool. Quantitative and qualitative results were examined separately, and then synthesized.

RESULTS

Twenty-one studies were included although their use of social media was highly variable. The main purpose of social media was to provide information and social support to participants. In the nine randomized controlled trials, social media was used as one aspect of a multi-faceted intervention. Interventions had a positive statistically significant impact on nutritional outcomes in 1/9 trials. Engagement with the social media component of interventions varied, from 3 to 69%. Young adults appear to be open to receiving healthy eating and recipe tips through social media, however, they are reluctant to share personal weight-related information on their online social networks.

CONCLUSIONS

Information-dissemination is now an acceptable use of social media by young adults. Using social media effectively for social support, either via private groups or public pages, requires careful evaluation as its effectiveness is yet to be demonstrated in experimental designs. Concerns about public social media use may be a contributing factor to poor engagement with social media in research intervention studies aimed at influencing weight. Future research should consider how to best engage with young adults using social media, how to more effectively use social media to support young adults and to facilitate social and peer-to-peer support in making healthier choices.

Utility of eButton images for identifying food preparation behaviors and meal-related tasks in adolescents

BACKGROUND

Food preparation skills may encourage healthy eating. Traditional assessment of child food preparation employs self- or parent proxy-reporting methods, which are prone to error. The eButton is a wearable all-day camera that has promise as an objective, passive method for measuring child food preparation practices.

PURPOSE

This paper explores the feasibility of the eButton to reliably capture home food preparation behaviors and practices in a sample of pre- and early adolescents (ages 9 to 13).

METHODS

This is a secondary analysis of two eButton pilot projects evaluating the dietary intake of pre- and early adolescents in or around Houston, Texas. Food preparation behaviors were coded into seven major categories including: browsing, altering food/adding seasoning, food media, meal related tasks, prep work, cooking and observing. Inter-coder reliability was measured using Cohen's kappa and percent agreement.

RESULTS

Analysis was completed on data for 31 participants. The most common activity was browsing in the pantry or fridge. Few participants demonstrated any food preparation work beyond unwrapping of food packages and combining two or more ingredients; actual cutting or measuring of foods were rare.

CONCLUSIONS

Although previous research suggests children who "help" prepare meals may obtain some dietary benefit, accurate assessment tools of food preparation behavior are lacking. The eButton offers a feasible approach to food preparation behavior measurement among pre- and early adolescents. Follow up research exploring the validity of this method in a larger sample, and comparisons between cooking behavior and dietary intake are needed.

Text Messaging, Teen Outreach Program, and Sexual Health Behavior: A Cluster Randomized Trial

OBJECTIVES

To consider whether Youth All Engaged! (a text message intervention) intensified the effects of the adolescent pregnancy prevention Teen Outreach Program (control) for youths.

METHODS

In this trial performed in Denver, Colorado, from 2011 to 2014, we randomized 8 Boys & Girls Clubs each of 4 years into 32 clubs per year combinations to ensure each club would serve as a treatment site for 2 years and a control site for 2 years. Control intervention consisted of the Teen Outreach Program only. We enrolled 852 youths (aged 14-18 years), and 632 were retained at follow-up, with analytic samples ranging from 50 to 624 across outcomes. We examined program costs, and whether the intervention increased condom and contraceptive use, access to care, and pregnancy prevention.

RESULTS

Control program costs were $1184 per participant, and intervention costs were an additional $126 per participant (+10.6%). There were no statistically significant differences in primary outcomes for the full sample. Hispanic participants in the intervention condition had fewer pregnancies at follow-up (1.79%) than did those in the control group (6.72%; P = .02).

CONCLUSIONS

Youth All Engaged is feasible, low cost, and could have potential benefits for Hispanic youths.

Farmers' Market Utilization among Supplemental Nutrition Assistance Program Recipients in New Orleans, Louisiana: Preliminary Findings

Objective

Farmers' markets are increasingly being promoted as a means to provide fresh produce to poor and underserved communities. However, farmers' market (FM) use remains low among low-income patrons. The purpose of our study was to examine FM awareness and use, grocery shopping behaviors, and internet use among Supplemental Nutrition Assistance Program (SNAP) recipients.

Design

A descriptive analysis of preliminary data was performed to evaluate quantitative baseline data among SNAP recipients between June and August 2016 in New Orleans, Louisiana (N=51). Data were collected via a 42-item online survey that included demographics, internet use, FM awareness and use, health information seeking behaviors and fruit and vegetable purchasing behaviors.

Results

Less than half of the survey respondents (n=24) had ever been to a FM. Local grocery stores and Wal-Mart were most used for purchasing fruits and vegetables (88% and 84%, respectively). The most common sources of healthy eating information were Women, Infants and Children (WIC) and the internet, frequently accessed via smartphones. More than 80% of participants were not aware that local FMs accepted electronic benefit transfer payments as a form of payment.

Conclusion

These results support the incorporation of promotional methodology that combines internet-based mobile technology and existing services (eg, WIC) as a viable strategy to improve farmers' market use among low-income populations. As most participants were not aware that participating FMs accept electronic benefit transfer payments, this fact should be emphasized in promotional material.

Assessing the efficacy and external validity of interventions promoting calcium or dairy intake in young adults: A systematic review with meta-analysis

Calcium and dairy products have a role in the prevention of chronic diseases and attainment of peak bone mass, during adolescence to young adulthood. However, intakes are often suboptimal and interventions to improve consumption of food sources are needed. This systematic review aimed to investigate the efficacy and external validity of interventions promoting calcium or dairy foods among young adults. Eight databases were searched from inception to identify relevant studies. Inclusion criteria included those aged 18 to 35 years in an intervention promoting calcium or dairy food intake. The mean age of the participants was 19.9 ± 1.4 years. Of the 16 studies that met the selection criteria, five studies were included in the meta-analyses for calcium (pooled effect size 0.35, 95% CI 0.04 to 0.67) and three studies for dairy (pooled effect size 0.31, 95% CI 0.11 to 0.50). The quality of the body of evidence was determined using the GRADE system, and was of overall low quality with high risk of bias. Our review suggests young adults respond favorably to interventions but the effect size is small.

Digital health behaviour change interventions targeting physical activity and diet in cancer survivors: a systematic review and meta-analysis

Purpose

The number of cancer survivors has risen substantially due to improvements in early diagnosis and treatment. Health behaviours such as physical activity (PA) and diet can reduce recurrence and mortality, and alleviate negative consequences of cancer and treatments. Digital behaviour change interventions (DBCIs) have the potential to reach large numbers of cancer survivors.

Methods

We conducted a systematic review and meta-analyses of relevant studies identified by a search of Medline, EMBASE, PubMed and CINAHL. Studies which assessed a DBCI with measures of PA, diet and/or sedentary behaviour were included.

Results

Fifteen studies were identified. Random effects meta-analyses showed significant improvements in moderate-vigorous PA (seven studies; mean difference (MD) = 41 min per week; 95% CI 12, 71) and body mass index (BMI)/weight (standardised mean difference (SMD) = −0.23; 95% CI −0.41, −0.05). There was a trend towards significance for reduced fatigue and no significant change in cancer-specific measures of quality of life (QoL). Narrative synthesis revealed mixed evidence for effects on diet, generic QoL measures and self-efficacy and no evidence of an effect on mental health. Two studies suggested improved sleep quality.

Conclusions

DBCIs may improve PA and BMI among cancer survivors, and there is mixed evidence for diet. The number of included studies is small, and risk of bias and heterogeneity was high. Future research should address these limitations with large, high-quality RCTs, with objective measures of PA and sedentary time.

Implications for cancer survivors

Digital technologies offer a promising approach to encourage health behaviour change among cancer survivors.

Electronic supplementary material

The online version of this article (doi:10.1007/s11764-017-0632-1) contains supplementary material, which is available to authorized users.

Characteristics of Smartphone Applications for Nutrition Improvement in Community Settings: A Scoping Review

Smartphone applications are increasingly being used to support nutrition improvement in community settings. However, there is a scarcity of practical literature to support researchers and practitioners in choosing or developing health applications. This work maps the features, key content, theoretical approaches, and methods of consumer testing of applications intended for nutrition improvement in community settings. A systematic, scoping review methodology was used to map published, peer-reviewed literature reporting on applications with a specific nutrition-improvement focus intended for use in the community setting. After screening, articles were grouped into 4 categories: dietary self-monitoring trials, nutrition improvement trials, application description articles, and qualitative application development studies. For mapping, studies were also grouped into categories based on the target population and aim of the application or program. Of the 4818 titles identified from the database search, 64 articles were included. The broad categories of features found to be included in applications generally corresponded to different behavior change support strategies common to many classic behavioral change models. Key content of applications generally focused on food composition, with tailored feedback most commonly used to deliver educational content. Consumer testing before application deployment was reported in just over half of the studies. Collaboration between practitioners and application developers promotes an appropriate balance of evidence-based content and functionality. This work provides a unique resource for program development teams and practitioners seeking to use an application for nutrition improvement in community settings.

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

Background

Interventions to prevent osteoporosis by increasing dairy intake or physical activity in young women have been limited to increasing osteoporosis knowledge and awareness. However, findings have shown that this does not always lead to a change in behaviors. Self-monitoring using mobile devices in behavioral interventions has yielded significant and positive outcomes. Yet, to our knowledge, mobile self-monitoring has not been used as an intervention strategy to increase calcium intake, particularly in young women, for better bone health outcomes.

Objective

As development and testing of mobile app–based interventions requires a sequence of steps, our study focused on testing the acceptability and usability of Calci-app, a dietary app to self-monitor calcium consumption, before it is used in a behavioral change intervention in young women aged 18-25 years.

Methods

Calci-app development followed 4 steps: (1) conceptualization, (2) development and pretesting, (3) pilot testing, and (4) mixed methods evaluation.

Results

We present the development process of Calci-app and evaluation of the acceptability and usability of the app in young women. Overall, 78% (31/40) of study participants completed the 5-day food record with high compliance levels (defined as more than 3 days of full or partial completion). There was a significant reduction in the proportion of participants completing all meal entries over the 5 days (P=.01). Participants generally found Calci-app easy and convenient to use, but it was time-consuming and they expressed a lack of motivation to use the app.

Conclusions

We present a detailed description of the development process of Calci-app and an evaluation of its usability and acceptability to self-monitor dietary calcium intake. The findings from this preliminary study demonstrated acceptable use of Calci-app to self-monitor calcium consumption. However, for regular and long-term use the self-monitoring function in Calci-app could be expanded to allow participants to view their total daily calcium intake compared with the recommended daily intake. Additionally, to facilitate sustainable lifestyle behavior modifications, a combination of various behavior change techniques should be considered, such as education, goal setting, and advice to participants based on their stage of change. The feedback on barriers and facilitators from testing Calci-app will be used to design a bone health mHealth intervention to modify risky lifestyle behaviors in young women for better bone health outcomes.

T2DM Self-Management via Smartphone Applications: A Systematic Review and Meta-Analysis

BACKGROUND

Mobile health interventions (mHealth) based on smartphone applications (apps) are promising tools to help improve diabetes care and self-management; however, more evidence on the efficacy of mHealth in diabetes care is needed. The objective of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effect of mHealth apps on changes in hemoglobin A1c (HbA1c), blood glucose, blood pressure, serum lipids, and body weight in type 2 diabetes mellitus (T2DM) patients.

METHODS

Two independent reviewers searched three online databases (PubMed, the Cochrane Library, and EMBASE) to identify relevant studies published between January 2005 and June 2016. Of the 2,596 articles retrieved, 13 RCTs were included. We used random effects model to estimate the pooled results.

RESULTS

Thirteen studies were selected for the systematic review, six of which with data available containing 1,022 patients were included for the meta-analysis. There was a moderate effect on glycemic control after the mHealth app-based interventions. The overall effect on HbA1c shown as mean difference (MD) was -0.40% (-4.37 mmol/mol) (95% confidence interval [CI] -0.69 to -0.11% [-7.54 to -1.20 mmol/mol]; p = 0.007) and standardized mean differences (SMD) was -0.40% (-4.37 mmol/mol) (95% confidence interval [CI] -0.69 to -0.10% [-7.54 to -1.09 mmol/mol]; p = 0.008). A subgroup analysis showed a similar effect with -0.33% (-3.61 mmol/mol) (95% CI -0.59 to -0.06% [-6.45 to -0.66 mmol/mol]; p = 0.02) in MD and -0.38% (-4.15 mmol/mol) (95% CI -0.71 to -0.05% [-7.76 to -0.55 mmol/mol]; p = 0.02) in SMD in studies where patients' baseline HbA1c levels were less than 8.0%. No effects of mHealth app interventions were found on blood pressure, serum lipids, or weight. Assessment of overall study quality and publication bias demonstrated a low risk of bias among the six studies.

CONCLUSIONS

Smartphone apps offered moderate benefits for T2DM self-management. However, more research with valid study designs and longer follow-up is needed to evaluate the impact of mHealth apps for diabetes care and self-management.