Improving physical activity and dietary behaviours with single or multiple health behaviour interventions? A synthesis of meta-analyses and reviews

Effectiveness of Interventions for Changing More Than One Behavior at a Time to Manage Chronic Conditions: A Systematic Review and Meta-analysis

BACKGROUND

Health behaviors play a significant role in chronic disease management. Rather than being independent of one another, health behaviors often co-occur, suggesting that targeting more than one health behavior in an intervention has the potential to be more effective in promoting better health outcomes.

PURPOSE

We aimed to conduct a systematic review and meta-analysis of randomized trials of interventions that target more than one behavior to examine the effectiveness of multiple health behavior change interventions in patients with chronic conditions.

METHODS

Five electronic databases (Web of Science, PubMed, CINAHL, EMBASE, and Cochrane) were systematically searched in November 2023, and studies included in previous reviews were also consulted. We included randomized trials of interventions aiming to change more than one health behavior in individuals with chronic conditions. Two independent reviewers screened and extracted data, and used Cochrane's Risk of Bias 2 tool. Meta-analyses were conducted to estimate the effects of interventions on change in health behaviors. Results were presented as Cohen's d for continuous data, and risk ratio for dichotomous data.

RESULTS

Sixty-one studies were included spanning a range of chronic diseases: cardiovascular (k = 25), type 2 diabetes (k = 15), hypertension (k = 10), cancer (k = 7), one or more chronic conditions (k = 3), and multiple conditions (k = 1). Most interventions aimed to change more than one behavior simultaneously (rather than in sequence) and most targeted three particular behaviors at once: "physical activity, diet and smoking" (k = 20). Meta-analysis of 43 eligible studies showed for continuous data (k = 29) a small to substantial positive effect on behavior change for all health behaviors (d = 0.081-2.003) except for smoking (d = -0.019). For dichotomous data (k = 23) all analyses showed positive effects of targeting more than one behavior on all behaviors (RR = 1.026-2.247).

CONCLUSIONS

Targeting more than one behavior at a time is effective in chronic disease management and more research should be directed into developing the science of multiple behavior change.

Utilizing the arts to improve health, resilience, and well-being (HeRe We Arts®): a randomized controlled trial in community-dwelling individuals with chronic medical conditions

Background

Healthcare workers are concerned with promoting behavior changes that enhance patients' health, wellness, coping skills, and well-being and lead to improved public health. The purpose of this randomized controlled trial was to determine if participation in an 8-week arts-based program leads to improved mood, health, resilience, and well-being in individuals with chronic health conditions as compared to a wait list control group.

Methods

Self-report questionnaires for well-being, mental health, physical health, overall health, social health, mood, coping, and resilience were administered at baseline, Week 8 (end of program), and Week 16 (8-week follow-up).

Results

Statistically significant improvements were noted in all outcome measures for the treatment group, as well as in most areas compared to the control group. Many of the positive results at Week 8 were either maintained or further improved at Week 16.

Discussion

These results suggest that arts-based programming can have a positive effect on the mood, health, resilience, and well-being of individuals with chronic health conditions. Therefore, arts-based programming should be utilized more frequently in the management of chronic conditions in community-dwelling individuals. These benefits should be further assessed in larger clinical trials.

The prevalence and clustering of alcohol consumption, gambling, smoking, and excess weight in an English adult population

BACKGROUND

The aim of this study was to examine the prevalence and clustering of four health risks (increasing-/higher-risk drinking, current smoking, overweight/obesity, and at-risk gambling), and to examine variation across sociodemographic groups in the English adult population.

METHODS

We analysed data from the 2012, 2015, 2016, and 2018 Health Survey for England (n = 20,698). Prevalence odds ratios (POR) were calculated to examine the clustering of risks. We undertook a multinomial multilevel regression model to examine sociodemographic variation in the clustering of health risks.

RESULTS

Overall, 23.8% of the adult English population had two or more co-occurring health risks. The most prevalent was increasing-/higher-risk drinking and overweight/obesity (17.2%). Alcohol consumption and smoking were strongly clustered, particularly higher-risk drinking and smoking (POR = 2.68; 95% CI = 2.31, 3.11; prevalence = 1.7%). Higher-risk drinking and at-risk gambling were also clustered (POR = 2.66; 95% CI = 1.76, 4.01), albeit with a very low prevalence (0.2%). Prevalence of multiple risks was higher among men for all risk combinations except smoking and obesity. The odds of multiple risks were highest for men and women aged 35-64 years. Unemployed men and women with lower educational qualifications had a higher odds of multiple risks. The relationship between deprivation and multiple risks depended on the definition of multiple risks, with the clearest socioeconomic gradients seen for the highest risk health behaviours.

CONCLUSION

An understanding of the prevalence, clustering, and risk factors for multiple health risks can help inform effective prevention and treatment approaches and may support the design and use of multiple behaviour change interventions.

School health programs of physical education and/or diet among pupils of primary and secondary school levels I and II linked to body mass index: A systematic review protocol within the project From Science 2 School

The most common causes of death in Western countries today are preventable diseases mainly attributed to daily behavior. It has been well documented that genetics are influential but not the deciding factor for developing non-communicable diseases. Ideally, the public should be educated to perform methods of optimal health and wellbeing independently, meaning that individuals should be in control of their health without relying on others. As behavior is known to be consistent over time, good or poor health behavior will track from childhood into adulthood. Physical activity and diet are permanently linked to the individual's state of health, and when properly balanced, the effects on personal health summate, resulting in greater benefits from this dual-approach for public health. The objective is to highlight the different approaches (physical intervention, nutritional intervention, and dual-approach of diet and exercise) and identify effective interventions for sustainable body weight and healthy body mass index in school children. A systematic review will be conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The review will assess school-based diet and exercise interventions on children in primary and secondary school levels I and II. Overweight and obesity develop as a result of a prolonged imbalance in the energy balance model, with both physical activity and diet being influential in the fluctuation of body weight. A dual-approach including physical activity and diet could therefore be a very promising method to promote sustainable healthy body weight in school children.

Study protocol of "From Science 2 School"-prevalence of sports and physical exercise linked to omnivorous, vegetarian and vegan, diets among Austrian secondary schools

The increasing prevalence of unhealthy lifestyle choices contribute to almost all chronic conditions negatively affecting individual and public health. As the most beneficial preventative solution, a healthy lifestyle focusing on the dual approach of physical activity (PA) and a healthful diet is highly recommended. Considering the growing number of people interested in sustainable, plant-based diets, it seems crucial to analyze lifestyle behaviors with a special focus on diet type to delve deeper into the unenthusiastic health status among young populations. Therefore, this multidisciplinary study aims to survey and scale health behaviors with a special focus on the prevalence of traditional and vegetarian diets in connection with PA levels among Austrian pupils (10-19 years), teachers and principals in secondary education levels I and II. Following a cross-sectional design, sociodemographic and school-related data along with a complete profile of lifestyle behaviors, including detailed information regarding diet, PA, sports & exercise, and other health-related behaviors, were collected using online-based questionnaires. A total number of 8,845 children/adolescents (~1.2% of the eligible 771,525 Austrian secondary school pupils) and 1,350 adults (~1.5% of total eligible 89,243 Austrian teachers/principals) participated in the study. As this is the first investigation to explore the prevalence of veganism/vegetarianism amongst a large group of pupils, the present study will add an important contribution to overcome the lack of knowledge on PA, sports & exercise linked to healthy alternative diets. With a sustainable healthy lifestyle, a healthy transition from childhood to adulthood occurs, which can result in growing healthier functioning generations at all social levels. As a study protocol, the present article is intended to present comprehensive details of the study design, objectives, and the associated analytical procedures of the "From Science 2 School" study.

Feasibility, Usability, and Effectiveness of a Machine Learning-Based Physical Activity Chatbot: Quasi-Experimental Study

BACKGROUND

Behavioral eHealth and mobile health interventions have been moderately successful in increasing physical activity, although opportunities for further improvement remain to be discussed. Chatbots equipped with natural language processing can interact and engage with users and help continuously monitor physical activity by using data from wearable sensors and smartphones. However, a limited number of studies have evaluated the effectiveness of chatbot interventions on physical activity.

OBJECTIVE

This study aims to investigate the feasibility, usability, and effectiveness of a machine learning-based physical activity chatbot.

METHODS

A quasi-experimental design without a control group was conducted with outcomes evaluated at baseline and 6 weeks. Participants wore a Fitbit Flex 1 (Fitbit LLC) and connected to the chatbot via the Messenger app. The chatbot provided daily updates on the physical activity level for self-monitoring, sent out daily motivational messages in relation to goal achievement, and automatically adjusted the daily goals based on physical activity levels in the last 7 days. When requested by the participants, the chatbot also provided sources of information on the benefits of physical activity, sent general motivational messages, and checked participants' activity history (ie, the step counts/min that were achieved on any day). Information about usability and acceptability was self-reported. The main outcomes were daily step counts recorded by the Fitbit and self-reported physical activity.

RESULTS

Among 116 participants, 95 (81.9%) were female, 85 (73.3%) were in a relationship, 101 (87.1%) were White, and 82 (70.7%) were full-time workers. Their average age was 49.1 (SD 9.3) years with an average BMI of 32.5 (SD 8.0) kg/m2. Most experienced technical issues were due to an unexpected change in Facebook policy (93/113, 82.3%). Most of the participants scored the usability of the chatbot (101/113, 89.4%) and the Fitbit (99/113, 87.6%) as at least "OK." About one-third (40/113, 35.4%) would continue to use the chatbot in the future, and 53.1% (60/113) agreed that the chatbot helped them become more active. On average, 6.7 (SD 7.0) messages/week were sent to the chatbot and 5.1 (SD 7.4) min/day were spent using the chatbot. At follow-up, participants recorded more steps (increase of 627, 95% CI 219-1035 steps/day) and total physical activity (increase of 154.2 min/week; 3.58 times higher at follow-up; 95% CI 2.28-5.63). Participants were also more likely to meet the physical activity guidelines (odds ratio 6.37, 95% CI 3.31-12.27) at follow-up.

CONCLUSIONS

The machine learning-based physical activity chatbot was able to significantly increase participants' physical activity and was moderately accepted by the participants. However, the Facebook policy change undermined the chatbot functionality and indicated the need to use independent platforms for chatbot deployment to ensure successful delivery of this type of intervention.

Identifying active ingredients, working mechanisms and fidelity characteristics reported in smoking cessation interventions in Dutch primary care: a systematic review

Background

Evidence-based smoking cessation interventions provided by healthcare professionals can be successful in helping citizens to quit smoking. Yet, evidence is needed about the active ingredients of these interventions, how these ingredients work and how they are implemented in practice. Such knowledge is required to effectively support healthcare professionals to optimally put evidence-based smoking cessation interventions to (inter)national practice.

Objective

To identify active ingredients (including behavior change techniques), mechanisms of action and implementation fidelity reported in smoking cessation interventions in Dutch primary care settings and to relate these to intervention effectiveness.

Methods

A systematic review was conducted by searching nine national intervention or funding databases, five international scientific databases and consulting 17 national smoking cessation experts. Out of 1066 identified manuscripts, 40 interventions were eligible for this review. Based on published protocols, information regarding behavior change techniques and mechanisms of action was systematically abstracted. Additionally, information regarding study characteristics and other active ingredients, effects on smoking behavior and implementation fidelity was abstracted. Comparative effectiveness concerning abstracted intervention characteristics was qualitatively explored.

Results

Active ingredients, mechanisms of action and implementation fidelity were moderately to poorly reported. Interventions applying behavior change techniques and interventions with a single behavioral target (i.e. smoking-only versus multiple behaviors) seemed to provide stronger evidence for successfully changing smoking behavior.

Conclusion

Attention to and reporting on interventions’ active ingredients (e.g. behavior change techniques), mechanisms of action and implementation fidelity are prerequisites for developing more effective evidence-based smoking cessation interventions to be successfully implemented in primary healthcare.

Implications

This systematic review provides an overview of smoking cessation interventions in Dutch primary care settings, identified since the year 2000. Smoking cessation support is offered in various forms, but our qualitative findings show that interventions including more behavior change techniques and interventions targeting only smoking cessation (compared to multiple behaviors) might be more effective. Results also show that—based on available intervention reports—it is difficult to distinguish patterns of active ingredients (such as behavior change techniques), mechanisms of action and fidelity of implementation in relation to interventions’ effectiveness. This means (quality of) reporting on these intervention characteristics should improve.

Food and health promotion literacy among employees with a low and medium level of education in the Netherlands

BACKGROUND

Prior research indicates a positive association between socioeconomic position and health literacy levels. We hypothesize comparable socioeconomic gradients for food literacy. This study aims to determine the level of self-perceived food literacy and health promotion literacy among adults with a low and medium level of education and from various subgroups, as well as the association between these food and health literacy levels. Furthermore, this study aims to explore the associations of self-perceived food literacy (SPFL) and health promotion literacy (HPL) in BMI.

METHODS

A cross-sectional study was conducted among employees with a low and medium level of education. Descriptive analyses were performed to compute SPFL and HPL levels. Analyses of variance were performed to test differences between subgroups. The correlation between SPFL and HPL was computed by Pearson's r. Multivariate linear regression analyses were used to explore 1) the association between SPFL and HPL adjusted for demographic characteristics 2) the associations between SPFL and HPL in BMI.

RESULTS

The majority (63.1%) of all participants (n = 222) scored low on SPFL and 34.5% scored inadequate or problematic on HPL. No significant educational or weight-status differences were found in SPFL or HPL levels. On most levels, women compared to men and older compared to younger employees scored significantly higher. A small positive correlation between the two mean levels was found, r = .25, P < .001 (n = 203). Multivariate linear regression analyses showed a significant association between SPFL and HPL (B = .31, 95% CI = .15-.48). No significant associations between SPFL and HPL in BMI were found.

CONCLUSIONS

This study suggests there is room for improvement in SPFL and HPL among adults with a low and medium level of education. Future research should consider comparing low and middle socioeconomic with high socioeconomic groups when exploring food and health literacy. Regarding health promotion activities for adults with a low and medium level of education, it is recommended to focus on improving both food and health literacy. Furthermore, more research is needed to explore direct proxies of weight-status to better understand the role of food and health literacy in overweight patterns.

Obesity in early onset breast cancer in African American patients

Obesity is a modifiable risk factor in breast cancer patients and is predictive of disease outcomes in early-onset breast cancer survivors. The purpose of this review is to summarize the current evidence in the association between early-onset breast cancer and obesity, specifically in African-American women. Reviewing the molecular mechanisms and social determinants of disease in this population can provide a foundation for future interventions in prevention, detection, and treatment aiming at improving outcomes for young breast cancer patients.

Effectiveness of eHealth Nutritional Interventions for Middle-Aged and Older Adults: Systematic Review and Meta-analysis

BACKGROUND

The risk of development of chronic diseases related to poor nutrition increases with age. In the face of an aging population, it is important for health care sectors to find solutions in delivering health services efficiently and effectively to middle-aged and older adults.

OBJECTIVE

The aim of this systematic review and meta-analysis was to consolidate the literature that reported the effectiveness of eHealth apps in delivering nutritional interventions for middle-aged and older adults.

METHODS

A literature search from five databases (PubMed, CINAHL, Cochrane, Web of Science, and Global Health) from the past 5 years was performed. Studies were selected for inclusion that used eHealth to deliver nutritional interventions to adults aged 40 years and above, and reported health and behavioral outcomes. Two independent reviewers searched for research articles and assessed the eligibility of studies to be included in the review. A third reviewer resolved disagreements on study inclusion. We also assessed the quality of the included studies using the CONSORT 2010 checklist.

RESULTS

A total of 70 studies were included for analysis. The study quality ranged from 44% to 85%. The most commonly used eHealth intervention type was mobile apps (22/70, 31%). The majority of studies (62/70, 89%) provided multicomponent health interventions, which aimed to improve nutrition and other health behaviors (eg, exercise, smoking cessation, medication adherence). Meta-analysis results indicated high and significant heterogeneity; hence, conclusions based on these results should be considered with caution. Nonetheless, the results generally showed that eHealth interventions improved anthropometric and clinical outcomes, but not behavioral outcomes such as fruit and vegetable consumption.

CONCLUSIONS

The use of eHealth apps to deliver health interventions has been increasing in recent years, and these apps have the potential to deliver health services to a larger group of people. Our findings showed that the effectiveness of eHealth apps to deliver health interventions for middle-aged to older adults was supported by the improvement of anthropometric and clinical outcomes. Future work could aim to develop research frameworks in administering eHealth interventions to address heterogeneity in this field of research.

Economic evaluation of a farm-to-Special Supplemental Nutrition Programme for Women, Infants and Children intervention promoting vegetable consumption

OBJECTIVE

To evaluate the cost and cost-effectiveness of a farm-to-Special Supplemental Nutrition Programme for Women, Infants and Children (WIC) intervention to promote vegetable intake and the redemption of WIC vouchers for produce purchases at farmers' markets.

DESIGN

An economic analysis was undertaken using data from a pilot of the intervention. Vegetable intake was assessed with a reflection spectroscopy device (the Veggie Meter® [VM]) and via self-report. Voucher redemption was reported by WIC. Total and per participant intervention costs and cost-effectiveness ratios (expressed as cost per intervention effect) were estimated in 2019 US dollars over a 6-month period from the perspective of the agency implementing the intervention.

SETTING

A large, urban WIC agency.

PARTICIPANTS

Participants were 297 WIC-enrolled adults.

RESULTS

Post-intervention, VM scores, self-reported vegetable intake and voucher redemption were higher in the intervention as compared with the control study group. Over the 6-month period, intervention costs were $31 092 ($194 unit cost per participant). Relative to the control group, the intervention cost $8·10 per increased VM score per participant, $3·85 per increased cup/d of vegetables consumed per participant and $3·29 per increased percentage point in voucher redemption per participant.

CONCLUSIONS

Intervention costs and cost-effectiveness ratios compared favourably with those reported for other interventions targeting vegetable intake in low-income groups, suggesting that the programme may be cost effective in promoting vegetable purchases and consumption. As there is no benchmark against which to compare cost-effectiveness ratios expressed as cost per unit of effectiveness, conclusions regarding whether this is the case must await further research.

Adherence to the 24-hour movement guidelines and adiposity in a cohort of at risk youth: A longitudinal analysis

BACKGROUND

The 24-hour movement guidelines provide recommendations for physical activity, screen time and sleep duration for children.

OBJECTIVES

Describe adherence to the guidelines and their cross-sectional and longitudinal associations with adiposity from childhood to adolescence.

METHODS

Data are from the QUALITY Cohort. Children were followed at 8 to 10 years (childhood; n = 630), 10 to 12 years (early adolescence; n = 564) and 15 to 17 years (adolescence; n = 377). Physical activity, screen time, and sleep duration were measured by accelerometry and questionnaires. Body mass index z-scores (zBMI), waist circumference, waist-to-height ratio and percent body fat were based on clinical measurements. Multiple linear regressions estimated associations.

RESULTS

In childhood, early adolescence and adolescence, 14%, 6%, and 0% of participants met the 24-hour movement guidelines, respectively. Meeting fewer guideline components was cross-sectionally associated with higher adiposity at each visit. Meeting fewer guideline components in childhood was longitudinally associated with higher adiposity at later visits. For example, those meeting none of the guideline components (vs all) in childhood had a 1.66 SD (95% CI: 0.42, 2.89) higher zBMI in early adolescence.

CONCLUSION

Few participants met the guidelines. Not meeting the guidelines in childhood is associated with higher adiposity 2 and 7 years later. Interventions are needed to increase adherence to the 24-hour movement guidelines across childhood and adolescence.

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 systematic review of interventions to increase breakfast consumption: a socio-cognitive perspective

OBJECTIVE

Regular breakfast skipping is related to unhealthy dietary behaviours, such as consuming an overall poorer quality diet and lower rates of physical activity, both of which are linked to a higher BMI. Adolescent breakfast skippers struggle with mental focus, sleep issues and lower grades. Solutions that can be implemented to overcome breakfast skipping are needed.

DESIGN

A systematic literature review was undertaken to identify programmes that aimed to increase breakfast eating. Following the PRISMA framework, studies were sourced to examine details of behaviour change, evidence of theory use and other important programme learnings and outcomes.

SETTING

Breakfast consumption empirical studies published from 2000 onwards.

PARTICIPANTS

Nineteen empirical studies that aimed to improve breakfast eating behaviour.

RESULTS

Out of the nineteen studies examined, ten studies reported an increase in breakfast consumption frequency for the entire study group or subgroups. Seven studies found no change, one was inconclusive and one observed a decrease in breakfast frequency. Positive changes to the dietary quality of breakfast were observed in five of the studies that did not observe increased frequency of breakfast consumption. Only six studies reported using theory in the intervention.

CONCLUSIONS

This evidence review points needed to extend theory application to establish a reliable evidence base that can be followed by practitioners seeking to increase breakfast eating rates in their target population.

Promoting adherence to physical activity among individuals with cardiovascular disease using behavioral counseling: A theory and research-based primer for health care professionals

Physical activity (PA) promotion remains a cornerstone of primary and secondary prevention efforts to reduce morbidity and mortality from cardiovascular disease (CVD). While frontline health care providers (HCPs; e.g., family physicians, cardiologists, registered nurses, nurse practitioners, etc.) are in an optimal position to administer PA-promoting interventions to their patients, many HCPs may feel ill-equipped to address common obstacles to implementing and maintaining complex health behavior change. Behavioral counseling refers to a collection of theory- and empirically-supported strategies and approaches to health behavior promotion that can be learned and applied by HCPs for CVD prevention and treatment. In this selective review, we discuss prominent theories of health behavior change and the empirical intervention literature regarding PA promotion in community and CVD-samples and provide practical recommendations for integrating effective behavioral counseling strategies to clinical practice for frontline HCPs. We argue that behavioral counseling interventions for PA can be effectively executed within the contextual constraints of health settings through subtle shifts in communication strategies and brief counseling approaches. The administration of behavioral counseling for PA by HCPs has enormous potential to reduce CVD incidence and progression at a population level.

A latent class analysis of dietary behaviours associated with metabolic syndrome: a retrospective observational cross-sectional study

BACKGROUND

Obesity defined solely by the Body Mass Index (BMI) may not reflect the true heterogeneity of the obese population. This study aimed to classify the dietary behaviours of overweight and obese individuals and to explore the relationship between patterns of dietary behaviour and cardiometabolic risk factors.

METHODS

A total of 259 patients who visited an outpatient weight management clinic at a tertiary hospital and underwent a dietary behaviour assessment between January 2014 and February 2019 were enrolled in the study. Dietary behaviours were assessed in three domains with nine categories, including choice of food (frequently eating out and consumption of instant/fast/takeaway food), eating behaviour (irregular meals; frequent snacking, including eating at night; emotional eating; and overeating/binge eating), and nutrient intake (high-fat/high-calorie foods, salty food, and poorly balanced diet). Latent class analysis (LCA) was used to classify the subjects according to these categories. Associations between latent class and metabolic syndrome were assessed by logistic regression.

RESULTS

The subjects were classified into three LCA-driven classes, including a referent class of healthy but unbalanced eaters (n = 118), a class of emotional eaters (n = 53), and a class of irregular unhealthy eaters (n = 88). Compared with the referent class, emotional eaters had a significantly higher BMI (beta = 3.40, P < 0.001) accompanied by metabolic syndrome (odds ratio 2.88, 95% confidence interval 1.16-7.13).

CONCLUSIONS

Our three LCA-driven obesity phenotypes could be useful for assessment and management of obesity and metabolic syndrome. The association between emotional eaters and higher BMI and metabolic syndrome was stronger than that with other eaters. Thus, emotional regulation strategies might have benefit for emotional eater's diet.

What do we know about physical activity interventions in vocational education and training? A systematic review

BACKGROUND

Although the health benefits of physical activity (PA) are well known, young people's level of PA is often insufficient and tends to decline in adolescence. Numerous studies have investigated the effectiveness of PA-promoting interventions among young people, but none have reviewed the effectiveness of PA interventions in the vocational education and training (VET) setting. This systematic review aims to (1) synthesize and review the available literature on PA-promoting interventions in VET and (2) examine the effects of these interventions on PA-related outcomes such as PA level, physical fitness, physiological parameters, or psychological factors.

METHODS

Five electronic databases were searched for studies involving adolescents aged 15 to 20 years that took place in VET settings and evaluated the effects of interventions with a PA component on PA-related outcomes such as PA level, physical fitness, physiological parameters, or psychological factors. The screening process and the quality assessment were conducted by two independent reviewers; data extraction was conducted by one reviewer and verified by another.

RESULTS

The literature search identified 18,959 articles and 11,282 unique records. After the screening process, nine studies, all coming from European or Asian countries, met the pre-defined eligibility criteria and were included in qualitative analyses. All but two studies reported significant improvements for at least one PA-related outcome. The interventions substantially differed in their development approaches (top-down vs. bottom-up approaches), complexity (multi- vs. single-component), and addressed behavior (multi-behavioral vs. single-behavioral). The most conspicuous finding was that bottom-up approaches tend to improve outcomes at the psychological level and top-down approaches at the physical level. Regarding the interventions' complexity and addressed behavior, we did not reveal any conclusive results.

CONCLUSION

This systematic review highlights the varying effects of PA-promoting interventions in VET. Nevertheless, heterogeneous effects, overall weak study quality and availability of studies only from two continents limited our ability to draw clear conclusions about the potentially most effective intervention strategies. Therefore, future research should focus on high-quality studies with long-term follow-ups to make recommendations for practical use.

TRIAL REGISTRATION

PROSPERO CRD42018109845.

An exploration using system dynamics modelling of population-level mindfulness, mindful eating and healthy weight following intervention

BACKGROUND

Mindful eating has been introduced as a strategy to help prevent overweight and obesity.

AIM

The purpose of this research was to develop a simple system dynamics model to investigate the impact of different interventions on population level mindfulness, mindful eating and healthy weight over a 10-year period.

METHODS

A model was constructed and outcomes analysed following the addition of four mindful eating interventions, including decreasing busyness (formal and informal work), promotion of mindful eating (e.g. classes and media), promotion of mindfulness, reduction of external eating cues (decreased portion sizes and variety) or a combination of all interventions.

RESULTS

The model projected that if the current situation was to continue over the next 10-year period, there would be a small decrease of 0.6% in the healthy-weight population despite a 42% increase in people practising mindfulness and 40% increase in people eating mindfully. Of the four interventions introduced, decreasing busyness had the greatest impact on the number of people practising mindfulness, eating mindfully and of a healthy weight. However, when all four interventions were introduced together this resulted in the greatest (19%) increase in the proportion of healthy-weight people.

CONCLUSIONS

The study suggests that mindful eating can be improved through intervention, however, the interventions will not greatly contribute to improving the healthy-weight population unless implemented in combination.

Combined health risks of cigarette smoking and low levels of physical activity: a prospective cohort study in England with 12-year follow-up

OBJECTIVES

To (1) estimate the combined risks of cigarette smoking and physical inactivity for chronic disease, disability and depressive symptoms and (2) determine whether risks associated with these behaviours are additive or synergistic.

DESIGN AND SETTING

Longitudinal observational population study using data from Waves 2 (2004/2005) through 8 (2016/2017) of the English Longitudinal Study of Ageing, a prospective study of community-dwelling older adults in England.

PARTICIPANTS

6425 men and women aged ≥52 years (mean (SD) 65.88 (9.34) years) at baseline.

MAIN OUTCOME MEASURES

Smoking status (never, former, current) and level of physical activity (high, defined as moderate/vigorous physical activity (MVPA) more than once a week; low, defined as MVPA once a week or less) were self-reported at Wave 2 baseline. Self-rated health, limiting long-standing illness, chronic conditions (coronary heart disease (CHD), stroke, cancer, chronic lung disease) and depressive symptoms were reported in each biennial wave.

RESULTS

Both smoking and low levels of physical activity were associated with increased risk of incident health problems over the 12-year follow-up period. Current smokers with low levels of physical activity had especially high risks of developing fair/poor self-rated health, CHD, stroke, cancer and chronic lung disease compared with highly active never smokers (adjusted relative risk range 1.89-14.00). While additive effects were evident, tests of multiplicative interactions revealed no evidence of large synergistic effects of smoking and low physical activity (Bayes factor range 0.04-0.61), although data were insensitive to detect smaller effects.

CONCLUSIONS

Among older adults in England, there was no evidence of large synergistic effects of smoking and low levels of physical activity on risk of developing chronic disease or depressive symptoms over 12 years. However, additive effects of smoking and low levels of physical activity were evident, underscoring the importance of each of these lifestyle risk behaviours for disease onset.

A narrative review of the use of agent-based modeling in health behavior and behavior intervention

Studies of health behaviors and behavior intervention have begun to explore the potential of agent-based modeling (ABM). A review of how ABMs have been used in health behavior, behavior intervention, and corresponding insights is warranted. The goal of this study was to provide a narrative review of the applications of ABMs in health behavior change and intervention. I will focus on two perspectives: (a) the mechanism of behavior and behavior change and (b) ABMs' use for behavior intervention. I identified and reviewed 17 ABMs applied to behaviors including physical activity, diet, alcoholic drinking, smoking, and drug use. Among these ABMs, I grouped their mechanisms of behavior change into four categories and evaluated the advantages and disadvantages of each mechanism. For behavior intervention, I evaluated the use of ABMs on levels of individual, interpersonal, and neighborhood environment. Various behavior change mechanisms and simplifications existed because of our limited knowledge of behaviors at the individual level. Utility maximization was the most frequently used mechanism. ABMs offered insights for behavior intervention including the benefits of upstream interventions and multilevel intervention, as well as balances among various factors, outcomes, and populations. ABMs have been used to model a diversity of behaviors, populations, and interventions. The use of ABMs in health behavior is at an early stage, and a major challenge is our limited knowledge of behaviors at the individual level.

A Comparison of Physical Activity Mobile Apps With and Without Existing Web-Based Social Networking Platforms: Systematic Review

BACKGROUND

Physical activity mobile apps present a unique medium to disseminate scalable interventions to increase levels of physical activity. However, the effectiveness of mobile apps has previously been limited by low levels of engagement. Existing Web-based social networking platforms (eg, Facebook and Twitter) afford high levels of popularity, reach, and sustain engagement and, thus, may present an innovative strategy to enhance the engagement, and ultimately the effectiveness of mobile apps.

OBJECTIVE

This study aimed to comparatively examine the effectiveness of, and engagement with, interventions that incorporate physical activity mobile apps in conjunction with and without existing Web-based social networking platforms (eg, Facebook and Twitter).

METHODS

A systematic review was conducted by following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines. A systematic search of the following databases was conducted: Medline, PsycINFO, Web of Science, Scopus, CINAHL, ProQuest, SPORTDiscus, EMBASE, and Cochrane. According to the comparative objective of this review, 2 independent literature searches were conducted. The first incorporated terms related to apps and physical activity; the second also incorporated terms related to Web-based social networking. The results of the two searches were synthesized and compared narratively.

RESULTS

A total of 15 studies were identified, 10 incorporated a physical activity app alone and 5 incorporated an app in conjunction with an existing Web-based social networking platform. Overall, 10 of the 15 interventions were effective in improving one or more physical activity behaviors. Specifically, improvements in physical activity behaviors were reported in 7 of the 10 interventions incorporating physical activity apps alone and in 3 of the 5 interventions incorporating physical activity apps in conjunction with existing Web-based social networking platforms. Interventions incorporating physical activity apps alone demonstrated a decline in app engagement. In contrast, the physical activity apps in conjunction with existing Web-based social networking platforms showed increased and sustained intervention engagement.

CONCLUSIONS

The interventions incorporating physical activity apps in conjunction with and without existing Web-based social networking platforms demonstrated effectiveness in improving physical activity behaviors. Notably, however, the interventions that incorporated existing Web-based social networking platforms achieved higher levels of engagement than those that did not. This review provides preliminary evidence that existing Web-based social networking platforms may be fundamental to increase engagement with physical activity interventions.

Impact of the HealthMatters Train-the-Trainer Program on the Health and Health Behaviors of Staff Supporting Adults With Intellectual and Developmental Disabilities

The health status and health behaviors among support staff providing daily support for people with intellectual and developmental disabilities (IDD-SS) in community-based organizations (CBOs) have not been systematically studied. This study examined the health impact of IDD-SS workers who participated in a HealthMatters Program: Train-the-Trainer Certified Instructor Workshop followed by implementing a 12-week HealthMatters Program for people with intellectual and developmental disabilities (IDD) that they care for as part of their employment. A total of 48 IDD-SS were enrolled into either an intervention (n = 28) or control group (n = 20). IDD-SS in the intervention group received an 8-hour HealthMatters Program: Train-the-Trainer Workshop immediately prior to teaching a 12-week HealthMatters Program for people with IDD. Assessments were conducted with IDD-SS before and after completing the 12-week HealthMatters Program to evaluate whether IDD-SS experienced any benefit of the training and teaching the program on their own health and health behaviors. Relative to the control group, the IDD-SS in the intervention group showed significant improvements in social/environmental supports for nutrition (F = 4.92, p = .032), exercise outcome expectations (F = 6.58, p = .014), nutrition outcome expectations (F = 8.87, p = .005), fruit and vegetable intake (F = 13.62, p = .001), knowledge of fruit and vegetable intake recommendations (F = 11.25, p = .002), and stages of change for eating fruits and vegetables (F = 6.86, p = .012). Results demonstrated that IDD-SS benefited from the health education programming. Findings support the need to develop programs and organizational policies for health promotion activities for direct care staff.

Boosting healthy food choices by meal colour variety: results from two experiments and a just-in-time Ecological Momentary Intervention

Background

Dietary guidelines typically specify rather complex goals and indicators for healthy food choices, such as nutrient and energy content patterns. However, translating these complex goals into practice in real life is often a major obstacle for many people. The present studies propose an intervention strategy for boosting healthy food choices by prompting consumers at a meaningful moment with a simple behavioural trigger, that is to eat a colourful lunch. Effectivity and feasibility of this intervention strategy were tested in two laboratory experiments and one real-life, smartphone-based Ecological Momentary Intervention.

Methods

In Studies 1 and 2, 83 / 42 participants self-served four meals (colourful, typical, healthy, and low-calorie) / three meals (colourful, typical, and varied) from a Fake Food Buffet. In Study 3, 80 participants recorded images of 1,210 lunch meals over a period of 3 weeks using mobile visual food recording. In the second week, participants additionally received a daily smartphone prompt to eat a colourful lunch. In all studies, participants were asked to rate the prompts’ feasibility.

Results

Prompting participants to eat a colourful meal increased the proportion of healthy foods consumed compared to typical meals in all three studies. In Studies 1 and 2, colourful meals contained more fruit and vegetables, while in Study 3 the prompt increased vegetable consumption. Furthermore, participants evaluated colourful meals to be the tastiest (Study 1) and most pleasant, and reported that the prompt was easy to follow and act upon.

Conclusions

Results suggest that prompting individuals to eat colourful meals is a promising strategy to facilitate healthy food choices in daily life.

Trial registration

German Clinical Trials Register, DRKS00017552 (Study 3; retrospectively registered on 24^th June 2019).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7306-z) contains supplementary material, which is available to authorized users.

Development of a Complex Intervention to Improve Adherence to Antidiabetic Medication in Older People Using an Anthropomorphic Virtual Assistant Software

Introduction: Improving adherence to antidiabetic medication is crucial, resulting in improved health outcomes, cost reduction, and minimization of waste. A lack of underlying theory in existing interventions may explain the limited success in sustaining behavior change. This paper describes the development of a theory and evidence-based complex intervention to improve adherence to oral antidiabetics in older people via a software prototype with an anthropomorphic virtual assistant.

Methods: The Behavior Change Wheel (BCW) was used to develop a theoretical understanding of the change process, corresponding to the first phase of the Medical Research Council Framework for developing and evaluating complex interventions. At the BCW core is a model of human behavior (COM-B), which posits that human behavior (B) results from the interaction between capabilities (C), opportunities (O), and motivation (M). Literature-derived medication adherence determinants were mapped onto COM-B components. Then, intervention functions (IFs) were selected employing the APEASE criteria. Finally, standardized behavior change techniques (BCTs) were chosen based on their suitability and their effectiveness on medication adherence trials. The prototype was developed for android devices; its core was implemented in Unity3D, using a female 3D virtual assistant, named Vitória.

Results: Two COM-B components were identified as main targets for behavior change—psychological capability and reflective motivation; these were linked with four IFs—education, persuasion, enablement, and environmental restructuring. Eleven BCTs were, in turn, linked with the IFs. An example of a BCT is “problem solving”; it requires users to pinpoint factors influencing non-adherence and subsequently offers strategies to achieve the desired behavior. BCTs were operationalized into the dialogues with Vitória and into supplementary software features. Vitória communicates with users verbally and non-verbally, expressing emotions. Input options consist of buttons or recording values, such as medication taken.

Conclusion: The present approach enabled us to derive the most appropriate BCTs for our intervention. The use of an explicit bundle of BCTs, often overlooked in interventions promoting medication adherence, is expected to maximize effectiveness and facilitates replication. The first prototype is being refined with users and health professionals’ contributions. Future work includes subjecting the prototype to usability tests and a feasibility trial.

What do cost-effective health behaviour-change interventions contain? A comparison of six domains

OBJECTIVES

To help implement behaviour change interventions (BCIs) in practice it is important to be able to characterize their key components. This study compared broad features of cost-effective BCIs that addressed smoking, diet, physical activity, alcohol and sexual health. It also assessed the association of these with the magnitude of the cost-effectiveness estimates.

METHODS

A content analysis of 79 interventions based on 338 intervention descriptions was conducted, using the Behaviour Change Wheel (BCW) to classify intervention content in terms of intervention functions, and the BCT taxonomy to identify and categorise component Behaviour Change Techniques (BCT). Regression analysis identified the association of these with upper (pessimistic) and lower (optimistic) cost-effectiveness estimates.

RESULTS

The most and least common functions and BCT clusters were education (82.3%) and shaping knowledge (79.7%), and coercion (3.8%) and covert learning (2.5%). Smoking interventions contained the largest ([Formula: see text] = 12) number of BCTs and were most cost-effective. Several other factors were associated with worse (coercionfunction βupper = 36551.24; shaping knowledgeBCT βlower = 2427.78; comparison of outcomesBCT βupper = 9067.32; repetition and substitutionBCT βupper = 7172.47) and better (modellingfunction βlower = -2905.3; environmental restructuringfunction βupper = -8646.28; reward and threatBCT βupper = -5577.59) cost-effectiveness (p<0.05).

DISCUSSION

Cost-effective BCIs rely heavily on education with smoking interventions exhibiting the most comprehensive range of BCTs. Providing an example to aspire to, restructuring the environment and rewarding positive behaviour may be associated with greater cost-effectiveness.

Childhood Obesity Prevention in Africa: A Systematic Review of Intervention Effectiveness and Implementation

Childhood obesity is of increasing concern in many parts of Africa. We conducted a systematic search and review of published literature on behavioural childhood obesity prevention interventions. A literature search identified peer-reviewed literature from seven databases, and unindexed African journals, including experimental studies targeting children age 2–18 years in African countries, published in any language since 1990. All experimental designs were eligible; outcomes of interest were both behavioural (physical activity, dietary behaviours) and anthropometric (weight, body mass index, body composition). We also searched for process evaluations or other implementation observations. Methodological quality was assessed; evidence was synthesised narratively as a meta-analysis was not possible. Seventeen articles describing 14 interventions in three countries (South Africa, Tunisia and Uganda) were included. Effect scores indicated no overall effect on dietary behaviours, with some beneficial effects on physical activity and anthropometric outcomes. The quality of evidence was predominantly weak. We identified barriers and facilitators to successful interventions, and these were largely resource-related. Our systematic review highlights research gaps in targeting alternative settings to schools, and younger age groups, and a need for more rigorous designs for evaluating effectiveness. We also recommend process evaluations being used more widely.

Social cognitive theory-based intervention to promote physical activity among prediabetic rural people: a cluster randomized controlled trial

Background

The present randomized controlled trial (RCT) evaluated the effectiveness of a theory-based physical activity (PA) intervention for rural patients with prediabetes. It was hypothesized that a PA intervention program based on the social cognitive theory (SCT) will modify fasting blood sugar (FBS) among rural people with prediabetes, which in turn will result in a decrease in diabetes incidence in the rural area.

Methods

A cluster RCT on prediabetic people was conducted in Ahar, East Azerbaijan Province, Iran. A PA intervention in prediabetes was performed over 16 weeks of follow-ups in 12 villages (six per arm). Residents (n = 272; n = 136 per arm) were invited to participate in the study through rural health care centers during screening for eligibility. Participants in the intervention and control groups were informed of their prediabetic conditions and encouraged to make appropriate changes to their lifestyles to modify their prediabetes. The intervention was an educational program delivered over 16 weeks and involved behavioral change techniques. Through the education program, the intervention group received one session per week lasting about 90 min (a total of 16 sessions). The importance of risk control with PA, the duration of hill climbing, as well as exercise and safety tips were explained in a brochure that was given to the participants. Anthropometric measures, glycemic status, and PA were evaluated at the beginning of the program and after 16 weeks of follow-up.

Results

The PA program showed a reduction in FBS mg/dl at 16 weeks (large-effect-size Cohen’s d = −0.63, p = 0.001) compared to the control condition. PA intervention led to a large effect size on diastolic blood pressure (BP, − 1.01) and a medium effect size for systolic BP (− 0.57), body mass index (BMI, − 0.33), and weight (− 0.35). Based on generalized linear mixed model analysis, significant reductions in FBS (mg/dl), BMI, weight, and diastolic BP were found in the intervention group compared to the control group.

Conclusion

Our results support the effectiveness of an SCT-based PA intervention to reduce the risk of prediabetes developing into diabetes among rural patients with prediabetes. Findings suggest that implementation of SCT-based PA intervention for a rural population at risk of diabetes has potential benefits.

Trial registration

Iranian Registry of Clinical Trials, IRCT201607198132N4. Registered on 1 September 2017. Prospectively registered.

Improving Blood Pressure Among African Americans With Hypertension Using a Mobile Health Approach (the MI-BP App): Protocol for a Randomized Controlled Trial

BACKGROUND

African Americans shoulder significant disparities related to hypertension (HTN), which is a serious public health problem in the city of Detroit, Michigan, where more than 80% of the population is African American. Connectivity through smartphones, use of home blood pressure (BP) monitoring, and newly developed mobile health (mHealth) interventions can facilitate behavioral changes and may improve long-term self-care for chronic conditions, but implementation of a combined approach utilizing these methods has not been tested among African American patients with uncontrolled HTN. Since African Americans are more likely than other racial or ethnic subgroups to utilize the emergency department (ED) for ambulatory care, this presents an opportunity to intervene on a population that is otherwise difficult to reach.

OBJECTIVE

The MI-BP app aims to reduce health disparities related to HTN in the community by employing a user-centered intervention focused on self-BP monitoring, physical activity, reduced sodium intake, and medication adherence. We seek to test the efficacy of MI-BP, an mHealth app for HTN self-management, on BP control (primary aim), physical activity, sodium intake, and medication adherence (secondary aim) in African Americans with HTN. This study also seeks to evaluate the cost-effectiveness of MI-BP when compared with usual care methods.

METHODS

This is a 1-year randomized controlled trial that will recruit individuals who have uncontrolled HTN from 2 EDs in the city of Detroit, with a planned sample size of 396 randomized participants. To be eligible for inclusion, potential participants must be African American, 25 to 70 years old, previously diagnosed with HTN, have a smartphone compatible with MI-BP, and have uncontrolled BP at triage and on repeat measurement at least 1-hour post triage vitals. Once a participant is deemed eligible, all study procedures and subsequent follow-up visits (8 in total) are conducted at the Wayne State University Clinical Research Service Center. We seek to determine the effect of MI-BP on BP for 1 year (using BP control and mean systolic BP as coprimary outcomes and physical activity, sodium intake, and medication adherence as secondary outcomes) compared with usual care controls.

RESULTS

Recruitment for this study began in January 2018. The study will continue through 2021.

CONCLUSIONS

As the first of its kind conducted in an ED setting, MI-BP was designed to document the efficacy and acceptability of a multicomponent mHealth approach to help African Americans with uncontrolled BP modify their lifestyle to better manage their HTN. We expect to lay the foundation to sustainably reduce HTN-related health disparities through better integration of multiple behavior self-monitoring and improve outcomes for those who traditionally rely on the ED for chronic disease care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02360293; http://clinicaltrials.gov/ct2/show/NCT02360293.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/12601.

The effect of the "Follow in my Green Food Steps" programme on cooking behaviours for improved iron intake: a quasi-experimental randomized community study

BACKGROUND

Nutritional iron deficiency is one of the leading factors for disease, disability and death. A quasi-experimental randomized community study in South-West Nigeria explored whether a branded behaviour change programme increased the use of green leafy vegetables (greens) and iron-fortified bouillon cubes in stews for improved iron intake.

METHODS

A coinflip assigned the intervention to Ile-Ife (Intervention town). Osogbo (Control town) received no information. At baseline 602 mother-daughter pairs (daughters aged 12-18) were enrolled (Intervention: 300; Control: 302). A Food Frequency Questionnaire assessed the addition of cubes and greens to stews, the primary outcome. Secondary outcomes were the addition of cubes and greens to soups and changes in behavioural determinants measured using the Theory of Planned Behaviour. Structural Equation Modelling (SEM) evaluated the impact of the intervention on behavioural determinants and behaviour.

RESULTS

The data of 527 pairs was used (Intervention: 240; Control: 287). The increase in greens added to stews was larger in the Intervention town compared to the Control town (M_Intervention = 0.3 [SE = 0.03]; M_Control = 0.0 [SE = 0.04], p < 0.001, r = 0.36). Change in iron-fortified cubes added to stews did not differ between towns (p = 0.07). The increase in cubes added to soups was larger in the Intervention town compared to the Control Town (M_Intervention = 0.9 [SE = 0.2] vs M_Control = 0.4 [SE = 0.1], p < .0001, r = 0.20). Unexpectedly, change in greens added to soups was larger in the Control town compared to the Intervention town (M_Intervention = - 0.1 [SE = 0.1]; M_Control = 0.5 [SE = 0.1], p = 0.003, r = 0.15). The intervention positively influenced awareness of anaemia and the determinants of behaviour in the Intervention town, with hardly any change in the Control town. Baseline SEMs could not be established, so no mediation analyses were done. Post-intervention SEMs highlighted the role of habit in cooking stews.

CONCLUSIONS

The behaviour change programme increased the amount of green leafy vegetables added to stews and iron-fortified cubes added to soups. Future research should assess the long-term impact and the efficacy of the programme as it is scaled up and rolled out.

Cardiovascular Health of Construction Workers in Hong Kong: A Cross-Sectional Study

Background: Given a shortage of construction workers, it is important to develop strategies to avoid early retirement caused by cardiovascular diseases in Hong Kong. Objectives: (1) to describe the cardiovascular health of construction workers in Hong Kong, (2) to examine the demographic differences in cardiovascular health, and (3) to examine the association between health behaviors and cardiovascular health factors. Methods: 626 registered construction workers were included in the analysis. Blood chemistry, blood pressure, weight, and height were measured. Face-to-face questionnaire interviews for health behaviors were conducted. Results: Approximately two-thirds of the construction workers achieved only three out of the seven “ideal” cardiovascular health metrics. The younger, more educated, and female subjects had better cardiovascular health scores than the older, less educated, and male counterparts. Fish and seafood consumption was associated with (1) ideal weight status and (2) ideal cholesterol level, whereas less soft drink consumption was associated with ideal cholesterol level. Conclusions: The findings highlighted the importance of promoting cardiovascular health in the construction industry. This study provided some insights for future interventions, which should include increasing fish and seafood intake, decreasing soft drink consumption, and enhancing the health literacy amongst older, less educated, and male construction workers.

Interventions to improve physical activity among socioeconomically disadvantaged groups: an umbrella review

Background

People from socioeconomically disadvantaged population groups are less likely to be physically active and more likely to experience adverse health outcomes than those who are less disadvantaged. In this umbrella review we examined across all age groups, (1) the effectiveness of interventions to improve physical activity among socioeconomically disadvantaged groups, (2) the characteristics of effective interventions, and (3) directions for future research.

Methods

PubMed/MEDLINE and Scopus were searched up to May 2017 to identify systematic reviews reporting physical activity interventions in socioeconomically disadvantaged populations or sub-groups. Two authors independently conducted study screening and selection, data extraction (one author, with data checked by two others) and assessment of methodological quality using the ‘Assessment of Multiple Systematic Reviews’ scale. Results were synthesized narratively.

Results

Seventeen reviews met our inclusion criteria, with only 5 (30%) reviews being assessed as high quality. Seven (41%) reviews focused on obesity prevention and an additional four focused on multiple behavioural outcomes. For pre school children, parent-focused, group-based interventions were effective in improving physical activity. For children, school-based interventions and policies were effective; few studies focused on adolescents and those that did were generally not effective; for adults, there was mixed evidence of effectiveness but characteristics such as group-based interventions and those that focused on physical activity only were associated with effectiveness. Few studies focused on older adults. Across all ages, interventions that were more intensive tended to be more effective. Most studies reported short-term, rather than longer-term, outcomes and common methodological limitations included high probability of selection bias, low response rates, and high attrition.

Conclusions

Interventions can be successful at improving physical activity among children from socioeconomically disadvantaged groups, with evidence for other age groups weak or inconclusive. More high-quality studies in this population group are needed, which adopt strategies to increase recruitment rates and reduce attrition, report longer term outcomes, and provide adequate intervention details, to allow determination of the characteristics of effective interventions. We recommend that the benefits of physical activity be recognised more broadly than obesity prevention in future studies, as this may have implications for the design and appeal of interventions.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0676-2) contains supplementary material, which is available to authorized users.

Promoting Healthy Eating and Physical Activity Behaviors: A Systematic Review of Multiple Health Behavior Change Interventions Among Cancer Survivors

Multiple health behavior change (MHBC) interventions have great potential for enhancing health and well-being following cancer diagnosis and treatment. However, the characteristics and effects of MHBC interventions remain elusive for cancer survivors. The main purpose of this study was to evaluate the effectiveness of MHBC interventions on healthy eating and physical activity behaviors among cancer survivors. A secondary aim was to examine the effect of using a simultaneous and sequential design approach to MHBC (ie, changing both behaviors at the same time or one after the other). Randomized controlled trials reporting the impact of a MHBC intervention on both healthy eating and physical activity behaviors among cancer survivors were retrieved from MEDLINE, Cochrane Library, and PsycINFO. A total of 27 MHBC interventions were identified; most (92.6%) were designed to promote simultaneous change in both behaviors and assessed end-of-treatment effect among breast cancer survivors. MHBC interventions led by nurses or multidisciplinary teams showed the most compelling evidence for small to moderate improvement in both behaviors, with interventions that lasted ≥17 weeks more likely to improve both behaviors. This study identifies research priorities and provides preliminary evidence for clinical decision making and advancements in MHBC intervention design and delivery for clinical oncology.

Effectiveness of User- and Expert-Driven Web-based Hypertension Programs: an RCT

INTRODUCTION

The effectiveness of self-guided Internet-based lifestyle counseling (e-counseling) varies, depending on treatment protocol. Two dominant procedures in e-counseling are expert- and user-driven. The influence of these procedures on hypertension management remains unclear. The objective was to assess whether blood pressure improved with expert-driven or user-driven e-counseling over control intervention in patients with hypertension over a 4-month period.

STUDY DESIGN

This study used a three-parallel group, double-blind randomized controlled design.

SETTING/PARTICIPANTS

In Toronto, Canada, 128 participants (aged 35-74 years) with hypertension were recruited. Participants were recruited using online and poster advertisements. Data collection took place between June 2012 and June 2014. Data were analyzed from October 2014 to December 2016.

INTERVENTION

Controls received a weekly e-mail newsletter regarding hypertension management. The expert-driven group was prescribed a weekly exercise and diet plan (e.g., increase 1,000 steps/day this week). The user-driven group received weekly e-mail, which allowed participants to choose their intervention goals (e.g., [1] feel more confident to change my lifestyle, or [2] self-help tips for exercise or a heart healthy diet).

MAIN OUTCOME MEASURES

Primary outcome was systolic blood pressure measured at baseline and 4-month follow-up. Secondary outcomes included cholesterol, 10-year Framingham cardiovascular risk, daily steps, and dietary habits.

RESULTS

Expert-driven groups showed a greater systolic blood pressure decrease than controls at follow-up (expert-driven versus control: -7.5 mmHg, 95% CI= -12.5, -2.6, p=0.01). Systolic blood pressure reduction did not significantly differ between user- and expert-driven. Expert-driven compared with controls also showed a significant improvement in pulse pressure, cholesterol, and Framingham risk score. The expert-driven intervention was significantly more effective than both user-driven and control groups in increasing daily steps and fruit intake.

CONCLUSIONS

It may be advisable to incorporate an expert-driven e-counseling protocol in order to accommodate participants with greater motivation to change their lifestyle behaviors, but more studies are needed.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03111836.

Using agent-based modeling to study multiple risk factors and multiple health outcomes at multiple levels

Most health studies focus on one health outcome and examine the influence of one or multiple risk factors. However, in reality, various pathways, interactions, and associations exist not only between risk factors and health outcomes but also among the risk factors and among health outcomes. The advance of system science methods, Big Data, and accumulated knowledge allows us to examine how multiple risk factors influence multiple health outcomes at multiple levels (termed a 3M study). Using the study of neighborhood environment and health as an example, I elaborate on the significance of 3M studies. 3M studies may lead to a significantly deeper understanding of the dynamic interactions among risk factors and outcomes and could help us design better interventions that may be of particular relevance for upstream interventions. Agent-based modeling (ABM) is a promising method in the 3M study, although its potentials are far from being fully explored. Future challenges include the gap of epidemiologic knowledge and evidence, lack of empirical data sources, and the technical challenges of ABM.

Frequency of Diet and Physical Activity Goal Attainment and Barriers Encountered Among Adults With Type 2 Diabetes During a Telephone Coaching Intervention

IN BRIEF Participants with type 2 diabetes established personalized dietary and physical activity goals as behavioral strategies to reduce cardiovascular risk during a 16-week telephone coaching intervention. People were most likely to attain dietary goals that involved altering the intake of specific foods rather than certain nutrients and were more successful at physical activity goals to increase activity levels rather than to add new types of activity. Barriers to goal success included time management, physical limitations/illness, and social/cultural activities.

Modeling multiple health behaviors and general health

Multiple Health Behavior Change assumes health behaviors are related to one another, although research evidence is mixed. More research is needed to understand which behaviors are most closely related and how they collectively predict health. Principle component analysis and structural equation modeling were used to establish a model showing relations between health behaviors, including fruit/vegetable consumption, aerobic and strength exercise, alcohol intake, and smoking, and how these behaviors relate to general physical and mental health functioning in a large, national sample. Although health behaviors were found to coalesce into a health-promoting factor of diet, and exercise, a better overall model fit was found when all behaviors were modeled as separate independent variables. Results suggest that health behaviors relate to one another in complex ways, with perceived health status serving as a mediating variable between specific health behaviors and a factor of physical and mental health. Future research should further investigate how other health behaviors relate to perceptions and overall health, especially among subpopulations.

Effectiveness of an intensive intervention to improve lifestyles in people with intermediate cardiovascular risk (DATE study): Study protocol for a randomized controlled trial

AIM

The aim of this study was to evaluate the effectiveness of an intensive intervention led by primary care nurses for lifestyle modification among people with intermediate cardiovascular risk.

BACKGROUND

Cardiovascular diseases may be prevented by adopting healthy lifestyles. Interventions focused on populations at risk are more efficient than those aimed at the general population. More than 50 per cent of cardiovascular events occur in people with intermediate cardiovascular risk, but only a few studies have targeted this population.

DESIGN

A randomized controlled trial approved in January 2017.

METHODS

We will recruit 208 participants aged 35-74 years who have intermediate cardiovascular risk. They will be selected by consecutive sampling and will be randomized into a control group or intervention group. Individual standardized brief counselling on healthy lifestyles will be provided to both groups. Additionally, individuals from the intervention group will receive four weekly group sessions focusing on cardiovascular risk, healthy diet, moderation in alcohol consumption, daily physical activity, stress management and smoking cessation and two motivational follow-up calls. The primary outcome will be the lifestyle modification measured by total steps recorded by a pedometer, total score on the Mediterranean Diet Adherence Screener and percentage of current smokers.

DISCUSSION

This study will allow us to investigate whether an intensive intervention based on a multifactorial group approach is more effective in lifestyle modification than individual standardized brief counseling among adults with intermediate cardiovascular risk. Our results could lead to the establishment of new strategies for cardiovascular risk management.

Disentangling the effects of a multiple behaviour change intervention for diarrhoea control in Zambia: a theory-based process evaluation

BACKGROUND

Diarrhoea is a leading cause of child death in Zambia. As elsewhere, the disease burden could be greatly reduced through caregiver uptake of existing prevention and treatment strategies. We recently reported the results of the Komboni Housewives intervention which tested a novel strategy employing motives including affiliation and disgust to improve caregiver practice of four diarrhoea control behaviours: exclusive breastfeeding; handwashing with soap; and correct preparation and use of oral rehydration salts (ORS) and zinc. The intervention was delivered via community events (women's forums and road shows), at health clinics (group session) and via radio. A cluster randomised trial revealed that the intervention resulted in a small improvement in exclusive breastfeeding practices, but was only associated with small changes in the other behaviours in areas with greater intervention exposure. This paper reports the findings of the process evaluation that was conducted alongside the trial to investigate how factors associated with intervention delivery and receipt influenced caregiver uptake of the target behaviours.

METHODS

Process data were collected from the eight peri-urban and rural intervention areas throughout the six-month implementation period and in all 16 clusters 4-6 weeks afterwards. Intervention implementation (fidelity, reach, dose delivered and recruitment strategies) and receipt (participant engagement and responses, and mediators) were explored through review of intervention activity logs, unannounced observation of intervention events, semi-structured interviews, focus groups with implementers and intervention recipients, and household surveys. Evaluation methods and analyses were guided by the intervention's theory of change and the evaluation framework of Linnan and Steckler.

RESULTS

Intervention reach was lower than intended: 39% of the surveyed population reported attending one or more face-to-face intervention event, of whom only 11% attended two or more intervention events. The intervention was not equally feasible to deliver in all settings: fewer events took place in remote rural areas, and the intervention did not adequately penetrate communities in several peri-urban sites where the population density was high, the population was slightly higher socio-economic status, recruitment was challenging, and numerous alternative sources of entertainment existed. Adaptations made by the implementers affected the fidelity of implementation of messages for all target behaviours. Incorrect messages were consequently recalled by intervention recipients. Participants were most receptive to the novel disgust and skills-based interactive demonstrations targeting exclusive breastfeeding and ORS preparation respectively. However, initial disgust elicitation was not followed by a change in associated psychological mediators, and social norms were not measurably changed.

CONCLUSIONS

The lack of measured behaviour change was likely due to issues with both the intervention's content and its delivery. Achieving high reach and intensity in community interventions delivered in diverse settings is challenging. Achieving high fidelity is also challenging when multiple behaviours are targeted for change. Further work using improved tools is needed to explore the use of subconscious motives in behaviour change interventions. To better uncover how and why interventions achieve their measured effects, process evaluations of complex interventions should develop and employ frameworks for investigation and interpretation that are structured around the intervention's theory of change and the local context.

TRIAL REGISTRATION

The study was registered as part of the larger trial on 5 March 2014 with ClinicalTrials.gov: NCT02081521 .

The impact of an innovative web-based school nutrition intervention to increase fruits and vegetables and milk and alternatives in adolescents: a clustered randomized trial

Background

The increase in overweight and obesity in adolescents and its health-related consequences highlight the need to develop strategies, which could help them adopt healthy eating habits. The objective of this study was to evaluate the impact of an innovative web-based school nutrition intervention (Team Nutriathlon) aimed at promoting the consumption of vegetables and fruit (V/F) and milk and alternatives (M/A) in high school students and to identify facilitators and/or barriers influencing its success.

Methods

Ten classes of first and second year secondary students (grades 7 and 8) from the Québec City region were randomized into two groups (control n = 89 and intervention n = 193). Participants in the intervention (Team Nutriathlon) were to increase their consumption of V/F and M/A using an innovative web-based platform, developed for this study, over 6 weeks. The control group followed the regular school curriculum. The number of servings of V/F and M/A consumed by students per day was compared between the two groups before, during, immediately after and 10 weeks after the intervention using a web-based platform. Main outcome measures included V/F and M/A servings and facilitators and/or barriers of program success. Repeated measures linear fixed effects models were used to assess the impact of Team Nutriathlon on V/F and M/A consumption. A P-value of <0.05 was considered significant.

Results

Students in the intervention reported a significant increase of 3 servings and 1.8 servings per day of V/F and M/A, respectively, compared to the control group (P < 0.05); however, this was only observed in the short-term. Some factors contributing to the success of Team Nutriathlon included the team aspect of the program, use of the technology and recording results outside of classroom hours.

Conclusion

Team Nutriathlon represents an innovative web-based nutrition program which positively impacts V/F and M/A consumption among high school students. Using web-based or technological platforms may help youth adopt healthy eating habits that will have implications later in adulthood; however, further studies are needed to determine their long-term effects.

Trial registration

NCT03117374 (retrospectively registered).

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.

Dietary variables associated with substantial postpartum weight retention at 1-year among women with GDM pregnancy

BACKGROUND

An understanding of the dietary behaviors linked to substantial postpartum weight retention, particularly in women diagnosed with gestational diabetes (GDM), is warranted to focus intervention efforts to prevent future type 2 diabetes. This study evaluates the relationship between dietary food intake at 6-9 weeks postpartum (baseline) and odds of substantial postpartum weight retention (≥ 5 kg) at 1-year in women with GDM.

METHODS

The Study of Women, Infant Feeding and Type 2 Diabetes after GDM pregnancy (SWIFT) is a prospective multi-ethnic cohort (75% minority) of 1035 women (aged 20-45 years) with recent GDM who delivered a singleton, live birth (≥35 weeks gestation) and underwent 2-h 75 g OGTTs, anthropometric measurements and other assessments at 6-9 weeks postpartum (baseline) and annually thereafter. Eight hundred and eighty-eight women without diabetes at baseline completed the 18-item PrimeScreen to assess dietary intake and the 13-item Caffeine Survey to assess beverage intake, and completed 1-year follow-up. Average postpartum weight retention was calculated (1-year postpartum weight minus pre-pregnancy weight). Multivariable logistic regression models that estimated baseline dietary intake and odds of substantial postpartum weight retention (SPPWR ≥5 kg above pre-pregnancy weight) versus not SPPWR adjusted for numerous clinical, sociodemographic and behavioral covariates.

RESULTS

Compared to eating no fried foods, women who reported eating fried foods ≥5 servings/wk. (n = 32) and 2-4 serv/wk. (n = 208), respectively, had a three-fold and two-fold higher odds of SPPWR (OR = 3.38, 95% CI:1.36-8.38, P = 0.009; OR = 1.99, 95% CI:1.30-3.03, P = 0.02), after adjustment for covariates and other foods and soda intake. Soda intake ≥2 serv/wk. versus none was associated with higher odds of SPPWR (OR = 1.95, 95% CI:1.22-3.11, P = 0.005) adjusted for fried foods and covariates, but was attenuated (OR = 1.61,95% CI:0.98-2.66, p = 0.06) after addition of whole eggs and processed meats.

CONCLUSIONS

These findings indicate that interventions should focus on reducing fried foods and soda intake during early postpartum periods to reduce substantial postpartum weight retention in high-risk women with GDM.

TRIAL REGISTRATION

NCT01967030; October 2013, Eunice Kennedy Shriver National Institute of Health and Human Development (NICHD).

Impact of a goal setting and decision support telephone coaching intervention on diet, psychosocial, and decision outcomes among people with type 2 diabetes

OBJECTIVE

Evaluate a 16-week decision support and goal-setting intervention to compare diet quality, decision, and diabetes-related outcomes to a control group.

METHODS

Adults with type 2 diabetes (n=54) were randomly assigned to an intervention or control group. Intervention group participants completed one in-person motivational interviewing and decision support session followed by seven biweekly telephone coaching calls. Participants reported previous goal attempts and set diet- and/or physical activity-related goals during coaching calls. Control group participants received information about local health care resources on the same contact schedule.

RESULTS

There was a significant difference between groups for diabetes empowerment (p=0.045). A significant increase in diet quality, diabetes self-efficacy, and diabetes empowerment, and a significant decrease in diabetes distress and depressive symptoms (all p≤0.05) occurred in the intervention group. Decision confidence to achieve diet-related goals significantly improved from baseline to week 8 but then declined at study end (both p≤0.05).

CONCLUSIONS

Setting specific diet-related goals may promote dietary change, and telephone coaching can improve psychosocial outcomes related to diabetes self-management.

PRACTICE IMPLICATIONS

Informed shared decision making can facilitate progressively challenging yet attainable goals tailored to individuals' lifestyle. Decision coaching may empower patients to improve self-management practices and reduce distress.

Ready, set, go: a cross-sectional survey to understand priorities and preferences for multiple health behaviour change in a highly disadvantaged group

Background

Socially disadvantaged groups, such as Aboriginal Australians, tend to have a high prevalence of multiple lifestyle risk factors, increasing the risk of disease and underscoring the need for services to address multiple health behaviours. The aims of this study were to explore, among a socially disadvantaged group of people attending an Aboriginal Community Controlled Health Service (ACCHS): a) readiness to change health behaviours; b) acceptability of addressing multiple risk factors sequentially or simultaneously; and c) preferred types of support services.

Methods

People attending an ACCHS in regional New South Wales (NSW) completed a touchscreen survey while waiting for their appointment. The survey assessed participant health risk status, which health risks they would like to change, whether they preferred multiple health changes to be made together or separately, and the types of support they would use.

Results

Of the 211 participants who completed the survey, 94 % reported multiple (two or more) health risks. There was a high willingness to change, with 69 % of current smokers wanting to cut down or quit, 51 % of overweight or obese participants wanting to lose weight and 44 % of those using drugs in the last 12 months wanting to stop or cut down. Of participants who wanted to make more than one health change, over half would be willing to make simultaneous or over-lapping health changes. The most popular types of support were help from a doctor or Health Worker and seeing a specialist, with less than a quarter of participants preferring telephone or electronic (internet or smart phone) forms of assistance. The importance of involving family members was also identified.

Conclusions

Strategies addressing multiple health behaviour changes are likely to be acceptable for people attending an ACCHS, but may need to allow flexibility in the choice of initial target behaviour, timing of changes, and the format of support provided.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1701-2) contains supplementary material, which is available to authorized users.

Comparative efficacy of simultaneous versus sequential multiple health behavior change interventions among adults: A systematic review of randomised trials

BACKGROUND

Growing evidence points to the benefits of addressing multiple health behaviors rather than single behaviors.

PURPOSE

This review evaluates the relative effectiveness of simultaneous and sequentially delivered multiple health behavior change (MHBC) interventions. Secondary aims were to identify: a) the most effective spacing of sequentially delivered components; b) differences in efficacy of MHBC interventions for adoption/cessation behaviors and lifestyle/addictive behaviors, and; c) differences in trial retention between simultaneously and sequentially delivered interventions.

METHODS

MHBC intervention trials published up to October 2015 were identified through a systematic search. Eligible trials were randomised controlled trials that directly compared simultaneous and sequential delivery of a MHBC intervention. A narrative synthesis was undertaken.

RESULTS

Six trials met the inclusion criteria and across these trials the behaviors targeted were smoking, diet, physical activity, and alcohol consumption. Three trials reported a difference in intervention effect between a sequential and simultaneous approach in at least one behavioral outcome. Of these, two trials favoured a sequential approach on smoking. One trial favoured a simultaneous approach on fat intake. There was no difference in retention between sequential and simultaneous approaches.

CONCLUSIONS

There is limited evidence regarding the relative effectiveness of sequential and simultaneous approaches. Given only three of the six trials observed a difference in intervention effectiveness for one health behavior outcome, and the relatively consistent finding that the sequential and simultaneous approaches were more effective than a usual/minimal care control condition, it appears that both approaches should be considered equally efficacious. PROSPERO registration number: CRD42015027876.