Effectiveness and Feasibility of a Self-guided Mobile App Targeting Emotional Well-being in Healthy Adults: 4-Week Randomized Controlled Trial

BACKGROUND

Commercial smartphone apps designed to promote emotional well-being are becoming increasingly popular, but few apps have been empirically validated.

OBJECTIVE

This study examined the feasibility and effectiveness of a self-guided app designed to reduce daily stress via positive messaging and tailored short inspirational talks (ie, peps).

METHODS

A total of 166 participants (n=112, 67.5% female; mean age 38.48, SD 6.73 years) were recruited through social media advertising and randomized into an intervention (Hey Lemonade app plus twice daily mood monitoring using the Multidimensional Mood Questionnaire [MDMQ]) or active control (twice daily mood monitoring [MDMQ]) group. Primary (coping self-efficacy [CSE]; 3 subscales) and secondary outcomes (vitality, satisfaction with life, perceived stress, positive and negative affect, and hassles and uplifts) were measured at the baseline (week 1) and end point (week 4). The app evaluation questions were assessed at week 2. All interactions and measurements were collected on the internet and through the apps.

RESULTS

In total, of 166 participants, 125 (75.3%) completed the trial. There were no differences in dropout rates between the groups (62/81, 76% intervention; 63/85, 74% control). There were significant group-by-time interactions for vitality and hassles but no significant effect for CSE total (P=.05). For the intervention group, the change from baseline to week 4 was significant for vitality (P=.002) and hassles (P=.004), CSE total (P=.008), and CSE Emotional subscale (P=.02). For the control group, any changes over 4 weeks were not significant for any outcome. There was a significant group-by-time interaction for MDMQ calmness (P=.04). By week 4, calmness was significantly higher in the intervention group (P=.046). Of those in the intervention group at week 2 (n=68), 39 (57%) participants recommended the app and 41 (60%) participants wanted to continue using it. Pep talks and customizable voice options were the most popular features.

CONCLUSIONS

Participants who had access to the smartphone app on an as-needed basis over the 4-week trial showed significant improvements in emotional well-being indicators. More broadly, this suggests that simple accessible solutions may generate meaningful well-being outcomes. Whether these changes are sustained and can be generalized to other population groups is yet to be determined.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ANZCTR) 12622001005741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384304&isReview=true.

The invisible burden of managing COVID-19 for Australian women: Cognitive labor and public health information

Providing accurate and timely public health information is an ongoing challenge for public health officials. The COVID-19 pandemic has exacerbated such challenges and presented unique difficulties in providing public health information, through the parallel rise of an "infodemic" of mis/dis-information. Understanding why individuals select, use and change their public health information seeking behaviors around COVID-19, and the relationship of these decisions relative to participant characteristics, is therefore an important step in understanding and responding to infodemics. This study used a qualitative survey (n = 255) and free-text qualitative questions to ask (1) Why participants use an information source, (2) How participants used an information source, and (3) How information seeking behavior has changed since the COVID-19 pandemic. Participants were primarily women, born in Australia, with de-facto/married relationships, without children at home, with university/college qualifications, and employed full-time or unemployed/retired. Most participants identified "easiness" and "immediacy" as reasons why they chose and used information, with sources primarily used for planning, communication, and decision making. A minority of participants changed their information seeking behavior since the COVID-19 pandemic. Those who did change, desired more immediate and accurate information. Emergent themes of care and anxiety were also noted, raising questions around the impact of mental load and cognitive labor in some female populations. Women may be suffering from increased cognitive labor and a gendering of public health information seeking behavior in the context of COVID-19. The impact of these attributes on women requires greater empirical research and consideration amongst front line practitioners and public health professionals.

Madness of the crowd: Understanding mass behaviors through a multidisciplinary lens

Mass or crowd behaviors refer to those that occur at a group level and suggest that crowds behave differently to individuals. Mass behaviors are typically triggered by a significant societal event. The ongoing COVID-19 pandemic has provided many tangible examples of crowd behaviors that have been observed globally, suggesting possible common underlying drivers. It is important to provide a deeper understanding of such behaviors to develop mitigation strategies for future population-level challenges. To gain deeper insight into a variety of crowd behaviors, we perform a conceptual analysis of crowd behaviors using three detailed case studies covering observable behavior (panic buying and health protective actions) and mass beliefs (conspiracy theories) that have resulted or shifted throughout the pandemic. The aim of this review was to explored key triggers, psychological drivers, and possible mitigation strategies through a mixture of theory and published literature. Finally, we create experimental mathematical models to support each case study and to illustrate the effects of manipulating key behavioral factors. Overall, our analyses identified several commonalties across the case studies and revealed the importance of Social Identity Theory and concepts of trust, social connection, and stress.

The Psychosocial Impacts of COVID-19 on a Sample of Australian Adults: Cross-sectional Survey and Sentiment Analysis

BACKGROUND

The COVID-19 pandemic has had enormous impacts on people's lives, including disruptions to their normal ways of behaving, working, and interacting with others. Understanding and documenting these experiences is important to inform the ongoing response to COVID-19 and disaster preparedness efforts.

OBJECTIVE

The aim of this study was to examine the psychosocial impacts of COVID-19 on a sample of Australian adults.

METHODS

The data analyzed were derived from a larger cross-sectional survey of Australian adults that was administered during the month of May 2020. Participants (N=3483) were asked in which ways COVID-19 had most greatly impacted them; the responses produced a text data set containing 1 COVID-19 impact story for each participant, totaling 86,642 words. Participants also completed assessments of their sociodemographic characteristics (sex, age, financial stress), level of concern related to COVID-19, personality trait profile, and satisfaction with life. Impact stories were analyzed using sentiment analysis and compared against the Theoretical Domains Framework to determine the most frequently impacted life domains. Finally, a multinomial regression analysis, stratified by participant sex, was conducted to identify the associations of psychological and demographic socializations with sentiment toward COVID-19.

RESULTS

In total, 3483 participants completed the survey, the majority of whom were female (n=2793, 80.2%). Participants' impact stories were most commonly categorized as neutral (1544/3483, 44.3%), followed by negative (1136/3483, 32.6%) and positive (802/3483, 23.1%). The most frequently impacted life domains included behavioral regulation, environmental context and resources, social influences, and emotions, suggesting that the COVID-19 pandemic was impacting these areas of participants' lives the most. Finally, the regression results suggested that for women, lower satisfaction with life and higher financial stress were associated with increased likelihood of negative, rather than positive, sentiment (P<.001); however, the proportion of variance in the sentiment that was explained was very small (<5%).

CONCLUSIONS

Participant sentiment toward COVID-19 varied. High rates of neutral and negative sentiment were identified. Positive sentiment was identified but was not as common. Impacts to different areas of people's lives were identified, with a major emphasis on behavioral regulation and related domains such as social influences, environmental context and resources, and emotions. Findings may inform the development of mental health and social support resources and interventions to help alleviate the psychosocial consequences of disaster response measures.

Weight Loss and Usage of an Online Commercial Weight Loss Program (the CSIRO Total Wellbeing Diet Online) Delivered in an Everyday Context: Five-Year Evaluation in a Community Cohort

BACKGROUND

Obesity is a global public health challenge, and there is a need for more evidence-based self-management programs that support longer-term, sustained weight loss.

OBJECTIVE

This study used data from the Commonwealth Scientific and Industrial Research Organisation (CSIRO) Total Wellbeing Diet Online program to determine the reach and weight loss results over its first 5 years.

METHODS

Participants were adults who joined the commercial weight loss program of their own volition between October 2014 and September 2019 (N=61,164). Information collected included year of birth, sex, height, weight, and usage data (eg, entries into the food diary, views of the menu, and program content). Weight loss and percentage of starting body weight lost were calculated. Members were divided into 2 groups for analysis: "stayers" were members who signed up for at least 12 weeks of the program and recorded a weight entry at baseline and at the end of the program, while "starters" began the program but did not record a weight after 12 weeks. Descriptive statistics and multiple linear regression were used to describe weight loss and determine the member and program characteristics associated with weight loss.

RESULTS

Data were available from 59,686 members for analysis. Members were predominately female (48,979/59,686, 82.06%) with an average age of 50 years (SD 12.6). The average starting weight was 90.2 kg (SD 19.7), and over half of all members (34,195/59,688, 57.29%) were classified as obese. At week 12, 94.56% (56,438/59,686) of the members had a paid program membership, which decreased to 41.48% (24,756/59,686) at 24 weeks. At week 12, 52.03% (29,115/55,958) of the remaining members were actively using the platform, and by week 24, 26.59% (14,880/55,958) were using the platform. The average weight loss for all members was 2.8 kg or 3.1% of their starting body weight. Stayers lost 4.9 kg (5.3% of starting body weight) compared to starters, who lost 1.6 kg (1.7% of starting body weight). Almost half (11,082/22,658, 48.91%) the members who stayed on the program lost 5% or more of their starting body weight, and 15.48% (3507/22,658) achieved a weight loss of 10% or more. Of the members who were classified as class 1 obese when they joined the program, 41.39% (3065/7405) who stayed on the program were no longer classified as obese at the end, and across all categories of obesity, 24% (3180/13,319) were no longer classified as obese at the end of the program. Based on multiple linear regression, platform usage was the strongest predictor of weight loss (β=.263; P<.001), with higher usage associated with greater weight loss.

CONCLUSIONS

This comprehensive evaluation of a commercial, online weight loss program showed that it was effective for weight loss, particularly for members who finished the program and were active in using the platform and tools provided. If the results demonstrated here can be achieved at an even greater scale, the potential social and economic benefits will be extremely significant.

Individual differences and changes in lifestyle behaviours predict decreased subjective well-being during COVID-19 restrictions in an Australian sample

Background

Due to the coronavirus disease 2019 (COVID-19) pandemic, social distancing practices were introduced to curb infection rates in many countries. The purpose of this study was to assess the effects of these restrictions on behaviours and well-being and whether individual differences predict changes in well-being.

Methods

Australian adults participated in a cross-sectional, online survey during May 2020. The survey captured demographic information; health behaviours; personality traits; life satisfaction and COVID-19-related attitudes, financial concerns, perceived risks and impacts.

Results

In total, 3745 (86.8% of 4313) participants completed all items. Participants were mostly female (85.7%) and 56.4 years (standard deviation [SD] = 12.6) on average. Over 95.0% of the sample indicated they had been social distancing or isolating. Health behaviours and well-being had generally worsened, with social connections being the most negatively affected. Life satisfaction was significantly lower since restrictions. For changes in life satisfaction, extroversion was a risk factor and openness to experience was a protective factor.

Conclusions

Overall, well-being was negatively impacted by the COVID-19 pandemic and associated social distancing particularly in this sample containing mainly older women. In future, it will be crucial to understand why and who may be differentially affected, to encourage behaviours that are protective of well-being.

Modified Fasting Compared to True Fasting Improves Blood Glucose Levels and Subjective Experiences of Hunger, Food Cravings and Mental Fatigue, But Not Cognitive Function: Results of an Acute Randomised Cross-Over Trial

Recent dietary trends have prompted growing support for a variety of fasting paradigms involving extreme restriction or nil-caloric intake on fasting days. Some studies indicate that fasting may negatively influence factors including cognitive function through inducing fatigue, which may prove problematic in the context of completing a range of cognitively demanding activities required by daily obligations such as work. This randomised within-subjects cross-over trial explored the effects of true fasting (i.e., nil-caloric intake) versus modified fasting, the latter of which involved two sub-conditions: (1) extended distribution (three small meals distributed across the day; 522 kcal total); and (2) bulking (two meals eaten early in the day; 512 kcal total) over a period of 7.5 h on a single day with a 7-day washout period between conditions. Participants were n = 17 females (Body Mass Index (BMI) Mean (M) = 25.80, Standard Deviation (SD) = 2.30) aged 21-49 years. Outcomes included cognitive function, subjective mental fatigue, satiety, food cravings and blood glucose. Results showed that there were no differences in cognitive test performance between conditions;however, both modified fasting sub-conditions had improved blood glucose levels, cravings, hunger and fullness compared to true fasting. Moreover, subjective mental fatigue was significantly reduced in the modified fasting conditions relative to true fasting. Overall, results indicated that the subjective experience of true fasting and modified fasting is different, but that cognition does not appear to be impaired.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

A Mobile Phone App Designed to Support Weight Loss Maintenance and Well-Being (MotiMate): Randomized Controlled Trial

Background

Few people successfully maintain lost weight over the longer term. Mobile phones have the potential to deliver weight loss management programs that can encourage self-monitoring while also providing some behavioral therapy to assist users in developing personal skills that may be necessary for improved longer term weight loss maintenance.

Objective

The aim of this study was to evaluate a program supporting weight maintenance, which uses a behaviorally based mobile phone app to manage weight, food, exercise, mood, and stress.

Methods

In a randomized controlled trial over 24 weeks, the full version of the app (MotiMate) was compared with a control app (monitoring only; excluding mood and stress) for its effect on weight, diet, and psychological well-being. Both apps had the same visual appearance and were designed to deliver all intervention content without face-to-face contact. The control version included features to track weight, food intake, and exercise with limited feedback and no encouraging/persuasive features. The intervention app included more persuasive and interactive features to help users track their weight, food intake, and physical activity and prompted users to enter data each day through notifications and included a mood and stress workshopping tool. Participants were recruited through advertising and existing databases. Clinic visits occurred at baseline, 4 weeks, 8 weeks, 12 weeks, and 24 weeks. At all visits, the clinical trial manager recorded body weight, and participants then completed a computer-delivered survey, which measured psychological and lifestyle outcomes. Objective app usage data were recorded throughout the trial.

Results

A total of 88 adults who had lost and maintained at least 5% of their body weight within the last 2 years were randomized (45 MotiMate and 43 control). Overall, 75% (66/88) were female, and 69% (61/88) completed week 24 with no differences in dropout by condition (χ²_1,87=0.7, P=.49). Mixed models suggested no significant changes in weight or psychological outcomes over 24 weeks regardless of condition. Of 61 completers, 53% (32/61) remained within 2% of their starting weight. Significant increases occurred over 24 weeks for satisfaction with life and weight loss self-efficacy regardless of app condition. Diet and physical activity behaviors did not vary by app or week. Negative binomial models indicated that those receiving the full app remained active users of the app for 46 days longer than controls (P=.02). Users of the full version of the app also reported that they felt more supported than those with the control app (P=.01).

Conclusions

Although some aspects of the intervention app such as usage and user feedback showed promise, there were few observable effects on behavioral and psychological outcomes. Future evaluation of the app should implement alternative research methods or target more specific populations to better understand the utility of the coping interface.

Trial Registration

Australia New Zealand Clinical Trials Registry ACTRN12614000474651; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366120

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

Breaking habits with mindful snacking? An email-based intervention targeting unwanted snacking habits in an Australian sample

OBJECTIVE

To investigate the potential for an email-based, mindful eating exercise to improve unwanted snacking habits.

METHOD

Australian participants (N = 78, 86% female) with unwanted snacking habits engaged in a mindful eating email-based intervention, over a practice period of two weeks. All measures were completed using an online survey. Habit strength was measured using the Self-Report Habit Index (SHRI). Mindful eating was measured using the Mindful Eating Questionnaire (MEQ) and self-compassion was measured using the Self-Compassion Scale (SCS). Participants were emailed a mindful eating exercise and asked to make action plans to practice it. Reminders to perform the task were sent via email after one week. After two weeks, the MEQ, SCS and SHRI were readministered.

RESULTS

Habit strength significantly increased over the two-week period and self-compassion significantly decreased. The amount of practice reported was not associated with these changes, but self-reported effort expended during practice sessions was partially associated.

DISCUSSION

The intervention resulted in increased habit strength; potential mechanisms underlying these changes are discussed. Decreased self-compassion may be linked to both the electronic delivery of the intervention and the nature of the mindful eating task.

Randomized Trial of a High Protein, Partial Meal Replacement Program with or without Alternate Day Fasting: Similar Effects on Weight Loss, Retention Status, Nutritional, Metabolic, and Behavioral Outcomes

Higher-protein diets, meal replacements, and greater early weight loss have separately been associated with greater weight loss. We compared a high-protein, meal replacement program with daily energy restriction (DER) to one which provided greater energy restriction adding alternate day fasting (ADF + DER; alternating days of modified-fasting and DER plus 1 ad libitum day/week) on retention, weight loss, physiological, nutritional, and behavioral markers. Participants were randomized to ADF + DER or DER for 16 weeks (n = 162, age 40 ± 8 years BMI 36 ± 6 kg/m² (Mean ± SD)) plus 8 weeks weight maintenance. At week 16 weight change was -10.7 ± 0.5 kg and -11.2 ± 0.6 kg in ADF + DER and DER groups (treatment NS). Fat mass, visceral adipose tissue, and lean mass (p < 0.05) were similarly reduced between treatments. Weight loss was sustained to 24 weeks (treatment NS). Fasting LDL-cholesterol, triglycerides, insulin, hsCRP, glucose, and blood pressure all improved (p < 0.05; treatment NS). Transferrin saturation, ferritin, serum zinc, folate, and B12 improved (p < 0.05; treatment NS). Plasma thiamine and vitamin D levels decreased, reflecting lower carbohydrate intakes and seasonal changes, respectively. Food cravings, quality of life, and mood improved (treatment NS). Energy, fatigue, and pain improved slightly more in DER (p < 0.05). This study supports the use of higher protein, meal replacement programs with or without ADF in weight management.

Incorporating a Static Versus Supportive Mobile Phone App Into a Partial Meal Replacement Program With Face-to-Face Support: Randomized Controlled Trial

Background

Mobile phone apps may be acceptable to users and could improve retention and adherence over more traditional methods, but there is mixed literature supporting their efficacy. In the weight management space, very little is known about how a mobile phone app integrating features beyond text messaging (short message service) can affect behavior, particularly when combined with face-to-face support.

Objective

The objective of this study was to examine the effectiveness of a mobile phone app when combined with a partial meal replacement program including face-to-face support. This paper compares a static versus supportive app over a 6-month randomized trial for effects on weight loss, weight-related biomarkers, and psychological outcomes.

Methods

Overweight and obese adults (71.2% female, 104/146; mean 48.11, SD 11.75 years) were recruited to participate in the weight loss study, and they were randomized on a 1:1 basis using a computer algorithm. The supportive app (n=75) provided information, food intake recording, rewards, prompts for regular interaction through reminders, and the opportunity to review personal compliance with the dietary program. The static app (n=71) included only recipes and weight loss information. Both groups recieved equal amounts of face-to-face support in addition to app.

Results

The overall reduction in app usage over 24 weeks was lower for the supportive app in comparison with the static app; approximately 39.0% (57/146) of the users were still using the app at week 24. Despite the promising results for app usage, there were no differences in weight loss between groups (F1,128.12=0.83, P=.36). However, it should be noted that almost 60% (49/84) of all participants lost 5% or more of body weight during the trial. No weight-related biomarkers were significantly different between groups. Both groups experienced an increase in positive mood, but this was significantly higher for those who received the static app (F1,118.12=4.93, P=.03).

Conclusions

Although the supportive app was well received by users, we found little evidence of the added benefit of this versus the static app in combination with face-to-face support in a community-delivered weight loss program. Future versions of the app may incorporate more unique behavioral techniques beyond those provided by the consultant to improve the potency of the app.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12613000547741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364187 (Archived by WebCite http://www.webcitation.org/6yivwfMI9)

Supporting the Delivery of Total Knee Replacements Care for Both Patients and Their Clinicians With a Mobile App and Web-Based Tool: Randomized Controlled Trial Protocol

Background

Total knee replacement (TKR) surgeries have increased in recent years. Exercise programs and other interventions following surgery can facilitate the recovery process. With limited clinician contact time, patients with TKR have a substantial burden of self-management and limited communication with their care team, thus often fail to implement an effective rehabilitation plan.

Objective

We have developed a digital orthopedic rehabilitation platform that comprises a mobile phone app, wearable activity tracker, and clinical Web portal in order to engage patients with self-management tasks for surgical preparation and recovery, thus addressing the challenges of adherence to and completion of TKR rehabilitation. The study will determine the efficacy of the TKR platform in delivering information and assistance to patients in their preparation and recovery from TKR surgery and a Web portal for clinician care teams (ie, surgeons and physiotherapists) to remotely support and monitor patient progress.

Methods

The study will evaluate the TKR platform through a randomized controlled trial conducted at multiple sites (N=5) in a number of states in Australia with 320 patients undergoing TKR surgery; the trial will run for 13 months for each patient. Participants will be randomized to either a control group or an intervention group, both receiving usual care as provided by their hospital. The intervention group will receive the app and wearable activity tracker. Participants will be assessed at 4 different time points: 4 weeks before surgery, immediately before surgery, 12 weeks after surgery, and 52 weeks after surgery. The primary outcome measure is the Oxford Knee Score. Secondary outcome measures include quality of life (Short-Form Health Survey); depression, anxiety, and stress (Depression, Anxiety, and Stress Scales); self-motivation; self-determination; self-efficacy; and the level of satisfaction with the knee surgery and care delivery. The study will also collect quantitative usage data related to all components (app, activity tracker, and Web portal) of the TKR platform and qualitative data on the perceptions of the platform as a tool for patients, carers, and clinicians. Finally, an economic evaluation of the impact of the platform will be conducted.

Results

Development of the TKR platform has been completed and deployed for trial. The research protocol is approved by 2 human research ethics committees in Australia. A total of 5 hospitals in Australia (2 in New South Wales, 2 in Queensland, and 1 in South Australia) are expected to participate in the trial.

Conclusions

The TKR platform is designed to provide flexibility in care delivery and increased engagement with rehabilitation services. This trial will investigate the clinical and behavioral efficacy of the app and impact of the TKR platform in terms of service satisfaction, acceptance, and economic benefits of the provision of digital services.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12616000504415; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370536 (Archived by WebCite at http://www.webcitation.org/6oKES0Gp1)

The weight balancing act and allostasis: Commentary on the Homeostatic Theory of Obesity

The current article provides commentary on the Homeostatic Theory of Obesity and associated Circle of Discontent. A strength of this theory is that it points to the requirement for multiple avenues of societal change, largely through policy and regulation. The current authors suggest consideration of allostasis, coping style and habituation in addition to the existing model. Incorporation of these into the Homeostatic Theory of Obesity may help to expand its explanatory power and associated avenues of intervention. Whatever else is done, it is likely that to meaningfully address the epidemic of obesity and associated chronic disease will require policy and regulation as well as targeted behavioural strategies aiming to reduce allostatic load.

A mixed-methods investigation of psychological factors relevant to weight maintenance

This study investigated perceptions of and engagement with the concepts of planning and problem-solving, within a weight management sample. A total of 53 participants (62% female, 20–74 years old) completed a semi-structured interview and quantitative measures after a 16-week weight maintenance period. Preliminary weight maintainers (who had maintained losses of, at least 10% of their original weight) were compared with heavier-than-baseline participants (who had re-gained more weight than was originally lost). The maintainers exhibited stronger problem-solving skills ( p < .05). The heavier-than-baseline participants tended towards non-rational problem-solving styles. Qualitatively, the maintainers described more planning events and were more accepting of mistakes than the heavier-than-baseline participants. Implications are discussed.

Cohort Analysis of a 24-Week Randomized Controlled Trial to Assess the Efficacy of a Novel, Partial Meal Replacement Program Targeting Weight Loss and Risk Factor Reduction in Overweight/Obese Adults

Our aim was to design and evaluate a weight-loss program, including a partial meal replacement program, point-of-care testing and face-to-face and smartphone app support, appropriate for delivery in a community pharmacy setting. Overweight or obese adults (n = 146, 71.2% female, 48.18 ± 11.75 years old) were recruited to participate in a 24-week weight loss study and randomised to two app conditions. The dietary intervention was consistent regardless of app. Twelve weeks of clinic appointments with a trained consultant were followed by only app support for an additional 12 weeks. By week 24, retention was 57.5%. There were no differences between app conditions. Based on a cohort analysis of the trial, the mean decrease in weight from baseline to week 24 was 6.43 ± 1.06 kg for males (p < 0.001) and 5.66 ± 0.70 kg for females (p < 0.001). Mixed models also revealed decreases for LDL Cholesterol (−0.13 ± 0.08 mmol/L, nonsignificant), triglycerides (−0.08 ± 0.05 mmol/L, nonsignificant) and an increase in HDL cholesterol (+0.08 ± 0.04 mmol/L, ns) were not significant by week 24. Blood glucose (−0.23 ± 0.08 mmol/L, p = 0.040) and blood pressure (Systolic blood pressure −5.77 ± 1.21 Hg/mm, p < 0.001) were significantly lower at week 24 compared to baseline. Weight loss self-efficacy increased and remained significantly higher than baseline at week 24 (16.85 ± 2.93, p < 0.001). Overall, the program supported participants and was successful in achieving significant weight loss and improvements in health outcomes over 24 weeks.

Contextual and environmental influences on reported dietary energy intake at evening eating occasions

OBJECTIVE

This study sought to determine the simultaneous effect of immediate eating environment variables; portion size, plate size, proximity to food, variety of food, side serves of salad/vegetables and presence of distraction on dietary energy intake (EI), of a reported evening meal, in the participants' real world setting.

DESIGN

A retrospective computer assisted telephone interview collected data on ten immediate eating environment variables, covariates and a 24-hour dietary recall of EI at an evening meal. Multiple regression analysis was conducted to determine relationships of these variables with EI. Significant (P<0.05) standardised beta coefficients (β) are reported.

SETTING

Australia wide, participants' homes.

SUBJECTS

Australian adult males and females (n 150) aged 18-65years.

RESULTS

Of the immediate eating environment variables, the absence of salads/vegetables (β=0.237), increased food variety (β=0.208), presence of music (β=0.207), and the consumption of pre-plated (as opposed to self-served) meals (β=0.195) had a positive association with EI, explaining 16.3% of the variance. Of the covariates, being male was the strongest predictor of EI (β=0.242); and hunger score also had a positive relationship with EI (β=0.190), explaining 17.5% of the variance.

CONCLUSION

This study provides evidence that some immediate food environment variables at an evening eating occasion are associated with EI. Findings suggest there are several strategies that people could implement to assist in controlling their EI and help address over consumption.

Combining Persuasive Technology With Behavioral Theory to Support Weight Maintenance Through a Mobile Phone App: Protocol for the MotiMate App

BACKGROUND

The prevalence of health-focused mobile phone apps available for download increases daily, with weight management apps being among the most proliferative. However, most lack theoretic grounding or evidence of efficacy. There is a significant body of literature which provides evidence for behaviors which are associated with successful weight loss maintenance. Behavioral theory also provides further insight regarding successful behavior change and maintenance.

OBJECTIVE

We aimed to apply this knowledge to the development of the functionality of an app targeting weight loss maintenance.

METHODS

We have subsequently undertaken the development of a persuasive and behavior targeting mobile app (MotiMate) to assist in maintenance of weight loss. MotiMate combines persuasive and behavior change theories in a practical targeted tool through its motivational messages, personalized feedback, and intelligent supportive tools to manage weight, food, exercise, mood and stress.

RESULTS

The development and trial of MotiMate received funding support in May 2014. All 88 volunteers started the trial by December 2014 and were in the process of completing their final visits when this paper was submitted (May 2015). Data analysis is currently underway.

CONCLUSIONS

The paper has presented a scientifically informed mobile phone app to support weight loss maintenance. Further evaluation of its efficacy is in progress.

TRIAL REGISTRATION

ANZCTR 12614000474651; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366120 (Archived by WebCite at http://www.webcitation.org/6eJeQiKxi).

Eating in groups: Do multiple social influences affect intake in a fast-food restaurant?

This study investigated multiple social influences to determine whether they affect amount eaten at a fast-food environment. Using observational methods, data on meal duration, foods eaten and personal characteristics were collected for 157 McDonald’s patrons. Analysis of covariance revealed that female diners ate less kilojoules when eating in mixed- versus same-sex groups (adjusted difference = 967 kJ, p < .05), while male diners eating in mixed-sex company ate more in groups compared to pairs (adjusted difference = 1067 kJ, p = .019). Influences to increase and restrict the amount eaten can operate simultaneously in an eating environment with gender a critical factor for consideration.

How much does what you eat matter? The potential role of meal size, fat content, and gender on ratings of desirability

This study examined how the amount and type of food that a person eats affects perceptions of their personal desirability, femininity/masculinity, and body size while accounting for any assumed similarity biases. Female students (18 to 59 years old) were recruited through the School of Psychology at the University of Adelaide. Participants (n = 191) rated the characteristics of a fictional person based on information in a personal profile. Profiles were identical aside from experimental manipulations of gender (male/female), meal size (small/large) and meal type (regular fat/high fat) with meal manipulations calculated using nutrient recommendations. Ratings of desirability and body size were affected primarily by meal type with targets described as eating a regular fat meal seen as more desirable (M = 5.40, SD = 0.56) and thinner (M = 3.93, SD = 1.05) than those having a high fat meal (M = 5.09, SD = 0.66; M = 4.29, SD = 1.04) (p = .001). Meal size manipulations affected only ratings of body size with larger meals (M = 4.25, SD = 0.88) resulting in higher ratings relative to smaller meals (M = 3.96, SD = 1.20) (p = .036). Despite a suggestion of interactions between target gender and both meal characteristics for ratings of femininity/masculinity in our results, post-hoc analyses largely failed to reveal any pairwise differences. Perceived similarity to the target did relate to levels of desirability (p = .006), and self-esteem positively associated with ratings of target body size (p = .010). Even though men's perceptions of eating behaviours were not reported in this paper, these findings have implications for a better understanding of social pressures faced not only by women, but also for men, as potentially both genders may be affected by eating norms regarding the healthiness of a meal.

Design and pilot results of a mobile phone weight-loss application for women starting a meal replacement programme

We developed and tested a mobile phone application (app) to support individuals embarking on a partial meal replacement programme (MRP). Overweight or obese women were randomly allocated to one of two study groups. The intervention group received an MRP Support app. The control group received a static app based on the information available with the MRP. A total of 58 adult women (Support n = 28; Control n = 30) participated in the 8-week trial. Their BMI was 26-43 kg/m² Usage data suggested that the intervention group were more engaged with using the app throughout the study period. Mixed modelling revealed that the difference in weight loss between the intervention and control groups (estimated mean, EM = 3.2% and 2.2% respectively) was not significant (P = 0.08). Objective data suggested that users of the Support app were more engaged than those using the control app. A total of 1098 prompts (54%) asking people in the intervention group to enter their meals were completed prior to the evening prompt. Women in the intervention group reported a greater increase in positive affect (i.e. mood) than those in the control group (EM = 0.48 and -0.01, respectively) (P = 0.012). At Week 8, those in the control group reported a greater decrease in the effort they were willing to put into staying on the diet than those who received the Support app (EM = -2.8 and -1.4, respectively) (P = 0.024). The Support app could be a useful adjunct to existing MRPs for psychological outcomes.

Features predicting weight loss in overweight or obese participants in a web-based intervention: randomized trial

Background

Obesity remains a serious issue in many countries. Web-based programs offer good potential for delivery of weight loss programs. Yet, many Internet-delivered weight loss studies include support from medical or nutritional experts, and relatively little is known about purely web-based weight loss programs.

Objective

To determine whether supportive features and personalization in a 12-week web-based lifestyle intervention with no in-person professional contact affect retention and weight loss.

Methods

We assessed the effect of different features of a web-based weight loss intervention using a 12-week repeated-measures randomized parallel design. We developed 7 sites representing 3 functional groups. A national mass media promotion was used to attract overweight/obese Australian adults (based on body mass index [BMI] calculated from self-reported heights and weights). Eligible respondents (n = 8112) were randomly allocated to one of 3 functional groups: information-based (n = 183), supportive (n = 3994), or personalized-supportive (n = 3935). Both supportive sites included tools, such as a weight tracker, meal planner, and social networking platform. The personalized-supportive site included a meal planner that offered recommendations that were personalized using an algorithm based on a user’s preferences for certain foods. Dietary and activity information were constant across sites, based on an existing and tested 12-week weight loss program (the Total Wellbeing Diet). Before and/or after the intervention, participants completed demographic (including self-reported weight), behavioral, and evaluation questionnaires online. Usage of the website and features was objectively recorded. All screening and data collection procedures were performed online with no face-to-face contact.

Results

Across all 3 groups, attrition was high at around 40% in the first week and 20% of the remaining participants each week. Retention was higher for the supportive sites compared to the information-based site only at week 12 (P = .01). The average number of days that each site was used varied significantly (P = .02) and was higher for the supportive site at 5.96 (SD 11.36) and personalized-supportive site at 5.50 (SD 10.35), relative to the information-based site at 3.43 (SD 4.28). In total, 435 participants provided a valid final weight at the 12-week follow-up. Intention-to-treat analyses (using multiple imputations) revealed that there were no statistically significant differences in weight loss between sites (P = .42). On average, participants lost 2.76% (SE 0.32%) of their initial body weight, with 23.7% (SE 3.7%) losing 5% or more of their initial weight. Within supportive conditions, the level of use of the online weight tracker was predictive of weight loss (model estimate = 0.34, P < .001). Age (model estimate = 0.04, P < .001) and initial BMI (model estimate = -0.03, P < .002) were associated with frequency of use of the weight tracker.

Conclusions

Relative to a static control, inclusion of social networking features and personalized meal planning recommendations in a web-based weight loss program did not demonstrate additive effects for user weight loss or retention. These features did, however, increase the average number of days that a user engaged with the system. For users of the supportive websites, greater use of the weight tracker tool was associated with greater weight loss.

When food is neither good nor bad: children's evaluations of transformed and combined food products

This study examined children's subjective perceptions of 'good' and 'bad' foods. Four interactive focus groups were conducted with 27 children aged 5-9 in South Australia. Each focus group was engaged in a food picture sorting activity. Whilst most children were able to discriminate good and bad whole foods or ingredients, they were less able to agree at a group level on the categorization of combined and transformed food products with which they are most likely to be presented in their 'everyday' lives. We discuss this confusion using Mary Douglas's (1966) theory of 'matter out of place'. Accordingly, health promotion messages should cultivate the skills required to reconcile the co-presence of 'good' and 'bad' ingredients in one product or meal.

Combined home and school obesity prevention interventions for children: what behavior change strategies and intervention characteristics are associated with effectiveness?

This review identifies studies describing interventions delivered across both the home and school/community setting, which target obesity and weight-related nutrition and physical activity behaviors in children. Fifteen studies, published between 1998 and 2010, were included and evaluated for effectiveness, study quality, nutrition/activity content, behavior change techniques, and theoretical basis, using validated assessment tools/taxonomies. Seven studies were rated as effective. Behavior change techniques used to engage families, and techniques associated with intervention effectiveness were coded. Effective studies used about 10 behavior change techniques, compared with 6.5 in ineffective studies. Effective interventions used techniques including providing general information on behavior-health links, prompting practice of behavior, and planning for social support/social changes. Different behavior change techniques were applied in the home and school setting. The findings of this review provide novel insights into the techniques associated with intervention effectiveness that can inform the development of public health obesity prevention strategies.

Personal and lifestyle characteristics predictive of the consumption of fast foods in Australia

Objective

To identify key predictors of fast-food consumption from a range of demographic, attitudinal, personality and lifestyle variables.

Methods

We analysed data from a nationwide survey (n= 20 527) conducted in Australia by Nielsen Media Research. Items assessing frequency of fast-food consumption at (1) eat in and (2) take away were regressed onto 12 demographic, seven media consumption, and 23 psychological and lifestyle variables, the latter derived from factor analysis of responses to 107 attitudinal and behavioural items.

Results

Stepwise multiple regression analyses explained 29.6% of the variance for frequency of take-away and 9.6% of the variance for frequency of eat-in consumption of fast foods. Predictors of more frequent consumption of fast food at take away (and, to a lesser extent, eat in) included lower age – especially under 45 years, relative indifference to health consequences of behaviour, greater household income, more exposure to advertising, greater receptiveness to advertising, lesser allocation of time for eating, and greater allocation of time to home entertainment. There were no effects for occupational status or education level.

Conclusions

The effects for age suggest that fast-food take-away consumption is associated with a general cultural shift in eating practices; individual differences in attitudinal and lifestyle characteristics constitute additional, cumulative, predictive factors. The role of advertising and the reasons for the lesser explanatory value of the eat-in models are important targets for further research.