Tailored, interactive text messages for enhancing weight loss among African American adults: the TRIMM randomized controlled trial

The Role of Digital Health Technology Interventions in the Prevention of Type 2 Diabetes Mellitus: A Systematic Review

Objectives

Diabetes in the 21st century presents one of the greatest burdens of disease on the global population. Digitally mediated interventions have become imperative in alleviating this disease epidemic. We aimed to systematically review randomized controlled trials (RCTs) on different health technologies for preventing Type 2 diabetes mellitus, and their efficacy in decreasing diabetes risk-related outcomes in at-risk patients in comparison to standard care.

Methods

Five electronic databases were searched between October 2021 and December 2022. Studies including digital health technology interventions used for preventing diabetes development by reducing diabetes risk-related outcomes in at-risk adults (⩾18 years) were identified. Data on glycemic levels, incidence of T2DM, weight, and intervention descriptions were extracted, and the risk of bias (ROB) was assessed.

Results

Nine studies met the inclusion criteria and 5 studies (56%) achieved clinically significant outcomes in at least one of the following: decreased weight (22%), glycemic levels (22%), or incidence of T2DM (11%). Two of the 3 (67%) computer-based interventions effectively reduced the HbA1c levels and mean weight of their study population, and 3 of 6 (50%) mobile based interventions (text messages, mobile app, and telehealth) decreased the incidence of T2DM and HbA1c levels. Four studies each had an overall low ROB and one had a high ROB due to attrition.

Conclusion

Preliminary evidence identified in our review demonstrated that health technologies for diabetes prevention are effective for improving diabetes risk-related outcomes. Future research into digital technology protocol and studies of longer duration and more diverse populations are needed for clinical feasibility.

Effectiveness of holistic mobile health interventions on diet, and physical, and mental health outcomes: a systematic review and meta-analysis

Background

Good physical and mental health are essential for healthy ageing. Holistic mobile health (mHealth) interventions-including at least three components: physical activity, diet, and mental health-could support both physical and mental health and be scaled to the population level. This review aims to describe the characteristics of holistic mHealth interventions and their effects on related behavioural and health outcomes among adults from the general population.

Methods

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, China National Knowledge Infrastructure, and Google Scholar (first 200 records). The initial search covered January 1, 2011, to April 13, 2022, and an updated search extended from April 13, 2022 to August 30, 2023. Randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) were included if they (i) were delivered via mHealth technologies, (ii) included content on physical activity, diet, and mental health, and (iii) targeted adults (≥18 years old) from the general population or those at risk of non-communicable diseases (NCDs) or mental disorders. Studies were excluded if they targeted pregnant women (due to distinct physiological responses), individuals with pre-existing NCDs or mental disorders (to emphasise prevention), or primarily utilised web, email, or structured phone support (to focus on mobile technologies without exclusive human support). Data (summary data from published reports) extraction and risk-of-bias assessment were completed by two reviewers using a standard template and Cochrane risk-of-bias tools, respectively. Narrative syntheses were conducted for all studies, and random-effects models were used in the meta-analyses to estimate the pooled effect of interventions for outcomes with comparable data in the RCTs. The study was registered in PROSPERO, CRD42022315166.

Findings

After screening 5488 identified records, 34 studies (25 RCTs and 9 pre-post NRSIs) reported in 43 articles with 5691 participants (mean age 39 years, SD 12.5) were included. Most (91.2%, n = 31/34) were conducted in high-income countries. The median intervention duration was 3 months, and only 23.5% (n = 8/34) of studies reported follow-up data. Mobile applications, short-message services, and mobile device-compatible websites were the most common mHealth delivery modes; 47.1% (n = 16/34) studies used multiple mHealth delivery modes. Of 15 studies reporting on weight change, 9 showed significant reductions (6 targeted on individuals with overweight or obesity), and in 10 studies reporting perceived stress levels, 4 found significant reductions (all targeted on general adults). In the meta-analysis, holistic mHealth interventions were associated with significant weight loss (9 RCTs; mean difference -1.70 kg, 95% CI -2.45 to -0.95; I2 = 89.00%) and a significant reduction in perceived stress levels (6 RCTs; standardised mean difference [SMD] -0.32; 95% CI -0.52 to -0.12; I2 = 14.52%). There were no significant intervention effects on self-reported moderate-to-vigorous physical activity (5 RCTs; SMD 0.21; 95%CI -0.25 to 0.67; I2 = 74.28%) or diet quality scores (5 RCTs; SMD 0.21; 95%CI -0.47 to 0.65; I2 = 62.27%). All NRSIs were labelled as having a serious risk of bias overall; 56% (n = 14/25) of RCTs were classified as having some concerns, and the others as having a high risk of bias.

Interpretation

Findings from identified studies suggest that holistic mHealth interventions may aid reductions in weight and in perceived stress levels, with small to medium effect sizes. The observed effects on diet quality scores and self-reported moderate-to-vigorous physical activity were less clear and require more research. High-quality RCTs with longer follow-up durations are needed to provide more robust evidence. To promote population health, future research should focus on vulnerable populations and those in middle- and low-income countries. Optimal combinations of delivery modes and components to improve efficacy and sustain long-term effects should also be explored.

Funding

National Research Foundation, Prime Minister's Office, Singapore, under its Campus for Research Excellence and Technological Enterprise (CREATE) Programme and Physical Activity and Nutrition Determinants in Asia (PANDA) Research Programme.

Automated Messaging Delivered Alongside Behavioral Treatment for Weight Loss: Qualitative Study

BACKGROUND

Mobile health interventions for weight loss frequently use automated messaging. However, this intervention modality appears to have limited weight loss efficacy. Furthermore, data on users' subjective experiences while receiving automated messaging-based interventions for weight loss are scarce, especially for more advanced messaging systems providing users with individually tailored, data-informed feedback.

OBJECTIVE

The purpose of this study was to characterize the experiences of individuals with overweight or obesity who received automated messages for 6-12 months as part of a behavioral weight loss trial.

METHODS

Participants (n=40) provided Likert-scale ratings of messaging acceptability and completed a structured qualitative interview (n=39) focused on their experiences with the messaging system and generating suggestions for improvement. Interview data were analyzed using thematic analysis.

RESULTS

Participants found the messages most useful for summarizing goal progress and least useful for suggesting new behavioral strategies. Overall message acceptability was moderate (2.67 out of 5). From the interviews, 2 meta-themes emerged. Participants indicated that although the messages provided useful reminders of intervention goals and skills, they did not adequately capture their lived experiences while losing weight.

CONCLUSIONS

Many participants found the automated messages insufficiently tailored to their personal weight loss experiences. Future studies should explore alternative methods for message tailoring (eg, allowing for a higher degree of participant input and interactivity) that may boost treatment engagement and efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05231824; https://clinicaltrials.gov/study/NCT05231824.

Mobile-phone text messaging to promote ideal cardiovascular health in women

OBJECTIVE

Ideal cardiovascular health (CVH) was developed to promote CVH as a key component of primordial prevention. Mobile short message service (SMS) is useful for improving health behaviours. We aim to test the effectiveness of SMS intervention in women to improve CVH.

METHODS

In a single-blinded, randomised, controlled study, 620 women, aged 35-70 years, without cardiovascular disease, were enrolled in SMS intervention versus no SMS. CVH metrics by self-report, and biochemical laboratory, anthropometric and blood pressure measurements were collected during home visits at baseline and 9 months. Women were categorised as having poor (0-2), intermediate (3-4) or ideal (5-7) CVH according to the number of ideal CVH metrics. Participants were randomised 1:1 to SMS intervention versus control. SMS was sent every 5-6 days for 9 months. The primary outcome was the difference in the proportion of women with ideal CVH between SMS and control groups at 9 months. Rates of intermediate CVH, poor CVH and each of the seven ideal CV health metrics at 9 months were key secondary endpoints.

RESULTS

At 9 months, there was no significant difference between groups for the primary outcome (16.3% at baseline and 13.3% at 9 months, and 10.1% and 11.1%, in SMS and control groups, respectively, adjusted RR 1.0; 95% CI 0.6 to 1.6). Similarly, there were no significant differences between groups for the key secondary endpoints. SMS had an acceptance rate of 94.9%.

CONCLUSIONS

Behavioural SMS intervention did not improve rates of ideal CVH in women, despite being feasible and well received.

TRIAL REGISTRATION NUMBER

6377.

A systematic review and meta-analysis of weight loss in control group participants of lifestyle randomized trials

Randomized clinical trials (RCTs) of lifestyle modification have reported beneficial effects of interventions, compared to control. Whether participation in the control group has benefits is unknown. To determine whether control group participants experience weight loss during the course of RCTs. After prospective registration (PROSPERO CRD42021233070), we conducted searches in Medline, Scopus, Web of Science, Cochrane library and Clinicaltrials.gov databases from inception to May 2021 without language restriction to capture RCTs on dietary advice or physical activity interventions in adults with overweight, obesity or metabolic syndrome. Data extraction and study quality assessment was performed by two independent reviewers. Weight loss in the control group, i.e., the difference between baseline and post-intervention, was pooled using random effects model generating mean difference and 95% confidence interval (CI). Heterogeneity was assessed using the I² statistical test. Subgroup meta-analysis was performed stratifying by follow-up period, type of control group protocols and high-quality studies. Among the 22 included studies (4032 participants), the risk of bias was low in 9 (40%) studies. Overall, the controls groups experienced weight loss of − 0.41 kg (95% CI − 0.53 to − 0.28; I² = 73.5% p < 0.001). To identify a result that is an outlier, we inspected the forest plot for spread of the point estimates and the confidence intervals. The magnitude of the benefit was related to the duration of follow-up (− 0.51 kg, 95% CI − 0.68, − 0.3, for 1–4 months follow-up; − 0.32 kg, 95% CI − 0.58, − 0.07, 5–12 months; − 0.20 kg, 95% CI − 0.49, 0.10, ≥ 12 months). In high-quality studies we found an overall weight loss mean difference of − 0.16 (95% CI − 0.39, 0.09) with a considerable heterogeneity (I² = 74%; p < 0.000). Among studies including control group in waiting lists and combining standard care, advice and material, no heterogeneity was found (I² = 0%, p = 0.589) and (I² = 0%, p = 0.438); and the mean difference was − 0.84 kg (95% CI − 2.47, 0.80) and − 0.65 kg (95% CI − 1.03, − 0.27) respectively. Participation in control groups of RCTs of lifestyle interventions had a benefit in terms of weight loss in meta-analysis with heterogeneity. These results should be used to interpret the benefits observed with respect to intervention effect in trials. That control groups accrue benefits should be included in patient information sheets to encourage participation in future trials among patients with overweight and obesity.

The Efficacy of Health Information Technology in Supporting Health Equity for Black and Hispanic Patients With Chronic Diseases: Systematic Review

Background

Racial inequity persists for chronic disease outcomes amid the proliferation of health information technology (HIT) designed to support patients in following recommended chronic disease self-management behaviors (ie, medication behavior, physical activity, and dietary behavior and attending follow-up appointments). Numerous interventions that use consumer-oriented HIT to support self-management have been evaluated, and some of the related literature has focused on racial minorities who experience disparate chronic disease outcomes. However, little is known about the efficacy of these interventions.

Objective

This study aims to conduct a systematic review of the literature that describes the efficacy of consumer-oriented HIT interventions designed to support self-management involving African American and Hispanic patients with chronic diseases.

Methods

We followed an a priori protocol using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-Equity 2012 Extension guidelines for systematic reviews that focus on health equity. Themes of interest included the inclusion and exclusion criteria. We identified 7 electronic databases, created search strings, and conducted the searches. We initially screened results based on titles and abstracts and then performed full-text screening. We then resolved conflicts and extracted relevant data from the included articles.

Results

In total, there were 27 included articles. The mean sample size was 640 (SD 209.5), and 52% (14/27) of the articles focused on African American participants, 15% (4/27) of the articles focused on Hispanic participants, and 33% (9/27) included both. Most articles addressed 3 of the 4 self-management behaviors: medication (17/27, 63%), physical activity (17/27, 63%), and diet (16/27, 59%). Only 15% (4/27) of the studies focused on follow-up appointment attendance. All the articles investigated HIT for use at home, whereas 7% (2/27) included use in the hospital.

Conclusions

This study addresses a key gap in research that has not sufficiently examined what technology designs and capabilities may be effective for underserved populations in promoting health behavior in concordance with recommendations.

Effectiveness of Mobile Phone and Web-Based Interventions for Diabetes and Obesity Among African American and Hispanic Adults in the United States: Systematic Review

Background

Mobile health (mHealth) and web-based technological advances allow for new approaches to deliver behavioral interventions for chronic diseases such as obesity and diabetes. African American and Hispanic adults experience a disproportionate burden of major chronic diseases.

Objective

This paper reviews the evidence for mHealth and web-based interventions for diabetes and obesity in African American and Hispanic adults.

Methods

Literature searches of PubMed/Medline, The Cochrane Library, EMBASE, CINAHL Plus, Global Health, Scopus, and Library & Information Science Source were conducted for relevant English-language articles. Articles identified through searches were reviewed by 2 investigators and, if they met the inclusion criteria, were extracted and assessed for risk of bias. Findings were summarized in tabular and narrative format. The overall strength of the evidence was assessed as high, moderate, low, or insufficient on the basis of risk of bias, consistency of findings, directness, precision, and other limitations.

Results

Searches yielded 2358 electronic publications, 196 reports were found to be eligible for inclusion, and 7 studies met the eligibility criteria. All 7 included studies were randomized control trials. Five studies evaluated the effectiveness of an mHealth intervention for weight loss, including one that evaluated the effectiveness for diabetes and two studies focused on diabetes. Of all the studies that focused on weight loss, 3 reported significant differences in weight loss in participants in the intervention group compared with those in the usual care group. Although all studies on diabetes control showed greater improvement in glycemic control for the intervention group compared to that in the control group, only one study showed a significant difference between the 2 groups.

Conclusions

This analysis indicates that there are few published studies that assessed mHealth interventions among minority populations and focused on weight or diabetes. Although the overall strength of evidence was low for diabetes control, it was moderate for weight loss, and our findings suggest that mHealth and web-based interventions may provide a promising approach for interventions among African American and Hispanic adults who have obesity or diabetes.

Monday-focused tailored rapid interactive mobile messaging for weight management 2 (MTRIMM2): results from a randomized controlled trial

BACKGROUND

Text-messaging interventions can reach many individuals across a range of socioeconomic groups, at a low cost. Few randomized controlled trials (RCTs) of text-messaging weight loss interventions have been conducted in United States.

METHODS

From September of 2016 to September of 2018, we conducted a two-parallel group, superiority, RCT of a 16-week text-messaging, weight loss intervention in Baltimore, Maryland, in overweight and obese adults younger than 71, who were able to receive text-messages. Our objective was to assess the effect of receiving the message content only (in printed documents distributed at baseline and week 8), versus receiving messages via short messaging service (SMS) on weight loss (primary outcome), body mass index, perceived exercise benefits and barriers, self-efficacy, and physical activity (PA). The random allocation sequence was equally balanced intervention groups by gender and age groups. Participants were randomized after the baseline assessment. Then, participants and most study staff were unblinded. Follow-up assessments were conducted at 8-, 16-, and 42-week post randomization. We performed intention-to-treat analysis using mixed linear regression models.

RESULTS

Of the 155 adults randomized (printed messages =77, SMS =78), 87.1% were women, 53.5% were African Americans, and 93.5% non-Hispanic. Participants who completed at least one follow-up assessment were included in regression analyses (n=145, printed messages =74, SMS =71). Compared to baseline, at the 42-week assessment, the average percent weight loss was 1.23 for the SMS group (P=0.006) and 0.86 for the printed messages group (P=0.047). Both groups experienced small reductions in weight (printed messages: -0.96 kg, P=0.022; SMS: -1.19 kg, P=0.006), BMI (printed messages: -0.32, P=0.035; SMS: -0.52, P=0.002), and percent energy from fat consumption (printed messages: -1.43, P=0.021; SMS: -2.14, P≤0.001). No statistically significant between groups differences were detected for any of the study outcomes. SMS response rates were not statistically significantly associated with study outcomes. No adverse events were reported.

CONCLUSIONS

A semi-tailored SMS weight loss intervention among overweight and obese adults was not statistically superior in efficacy to paper-based messaging.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04506996.

Optimization of an mHealth lifestyle intervention for families with hereditary cancer syndromes: Study protocol for a multiphase optimization strategy feasibility study

BACKGROUND

Individuals at increased hereditary risk of cancer are an important target for health promotion and cancer prevention interventions. Health-4-Families uses the Multiphase Optimization STrategy (MOST) framework and is designed to pilot digital delivery strategies for a distance-based, 16-week intervention to promote weight management, healthy diet, and increased physical activity among individuals with BRCA1/BRCA2 or DNA mismatch repair (MMR) pathogenic germline variants. This communication describes participant recruitment and the design of the Health-4-Families pilot study.

METHODS

Health-4-Families is a full-factorial (16 condition) randomized pilot study of four lifestyle intervention components: social networking, telephone or email coaching, text messaging, and self-monitoring. The primary outcome was feasibility and satisfaction with these study components. Participants with pathogenic germline variants were identified via clinic surveillance lists and advocacy organizations and were invited to participate with family members. All participants had to report meeting at least one of the following criteria: (1) having a BMI ≥ 25 kg/m², (2) consuming <5 servings of fruit and vegetables per day, or (3) getting <150 min of moderate-to-vigorous intensity activity per week.

RESULTS

The majority of screened potential participants with pathogenic variants (83%) were eligible; 86% of those eligible provided informed consent and 79% (n = 104) completed baseline. A total of 206 family members were nominated by study participants and 49% (n = 102) completed baseline.

DISCUSSION

Recruitment data suggest that individuals with pathogenic germline variants, who are at increased risk for hereditary cancers, are motivated to participate in digital lifestyle interventions. This recruitment success highlights the importance of identifying and prioritizing effective and efficient intervention components for hereditary cancer families. We intend to use the outcomes of our pilot study to inform a fully-powered factorial study for this community.

The nudge strategies for weight loss in adults with obesity and overweight: A systematic review and meta-analysis

Obesity and overweight conditions have become major health challenges worldwide. The exploration of effective weight loss strategies is essential. Nudges are currently advancing approaches that represent a new and better method for changing the behaviors of people. However, the effectiveness of nudge interventions on weight loss in overweight people who may be obese has not been synthesized in a systematic manner. In this study, a systematic literature search was performed. Only randomized controlled trials (RCTs) were considered. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated as summary statistics. In total, 25 RCTs involving a population of 5,929 individuals were included. Significant effects of the nudge strategy on weight loss (WMD: -0.96 kg, 95% CI: -1.49 to -0.43), body mass index (WMD: -0.3 kg/m², 95% CI: -0.41 to -0.19) and waist circumference (WMD: -0.75 cm, 95% CI: -1.23 to -0.27) were observed. The subgroup analysis showed that the reduction in body weight associated with nudge interventions was significant in younger and more obese people. Moreover, the effect of nudge intervention on weight loss weakened over time. Overall, the nudge strategy can promote changes in weight loss, body mass index and waist circumference of adults, albeit at a mild magnitude and in particular types of individuals. Nudge strategies can be recommended to clinical practitioners and policy-makers to promote obesity management.

Improvements in Diet and Physical Activity-Related Psychosocial Factors Among African Americans Using a Mobile Health Lifestyle Intervention to Promote Cardiovascular Health: The FAITH! (Fostering African American Improvement in Total Health) App Pilot Study

BACKGROUND

African Americans continue to have suboptimal cardiovascular health (CVH) related to diet and physical activity (PA) behaviors compared with White people. Mobile health (mHealth) interventions are innovative platforms to improve diet and PA and have the potential to mitigate these disparities. However, these are understudied among African Americans.

OBJECTIVE

This study aims to examine whether an mHealth lifestyle intervention is associated with improved diet and PA-related psychosocial factors in African Americans and whether these changes correlate with diet and PA behavioral change.

METHODS

This study is a retrospective analysis evaluating changes in diet and PA-related self-regulation, social support, perceived barriers, and CVH behaviors (daily fruit and vegetable intake and moderate-intensity PA [MPA] per week) in 45 African American adults (mean age 48.7 years, SD 12.9 years; 33/45, 73% women) enrolled in the FAITH! (Fostering African American Improvement in Total Health) app pilot study. The intervention is a 10-week, behavioral theory-informed, community-based mHealth lifestyle intervention delivered through a mobile app platform. Participants engaged with 3 core FAITH! app features: multimedia education modules focused on CVH with self-assessments of CVH knowledge, self-monitoring of daily fruit and vegetable intake and PA, and a sharing board for social networking. Changes in self-reported diet and PA-related self-regulation, social support, perceived barriers, and CVH behaviors were assessed by electronic surveys collected at baseline and 28 weeks postintervention. Changes in diet and PA-related psychosocial factors from pre- to postintervention were assessed using paired 2-tailed t tests. The association of changes in diet and PA-related psychosocial variables with daily fruit and vegetable intake and MPA per week was assessed using Spearman correlation. Associations between baseline and 28-week postintervention changes in diet and PA-related psychosocial measures and CVH behaviors with covariates were assessed by multivariable linear regression.

RESULTS

Participants reported improvements in 2 subscales of diet self-regulation (decrease fat and calorie intake, P=.01 and nutrition tracking, P<.001), one subscale of social support for healthy diet (friend discouragement, P=.001), perceived barriers to healthy diet (P<.001), and daily fruit and vegetable intake (P<.001). Improvements in diet self-regulation (increase fruit, vegetable, and grain intake, and nutrition tracking) and social support for healthy diet (friend encouragement) had moderate positive correlations with daily fruit and vegetable intake (r=0.46, r=0.34, and r=0.43, respectively). A moderate negative correlation was observed between perceived barriers to healthy diet and daily fruit and vegetable intake (r=-0.25). Participants reported increases in PA self-regulation (P<.001). Increase in social support subscales for PA (family and friend participation) had a moderate positive correlation with MPA per week (r=0.51 and r=0.61, respectively).

CONCLUSIONS

Our findings highlight key diet and PA-related psychosocial factors to target in future mHealth lifestyle interventions aimed at promoting CVH in African Americans.

Implementing texting programs in the P.O.W.E.R. (preventing obesity with eating right) medical group visit for weight loss

BACKGROUND

The effect of incorporating mobile technology to support participants' lifestyle change and weight loss in medical group visits has not been well studied in a safety-net setting.

RATIONALE AND DESIGN

Thus, the rationale of the current study was to examine the effect of text messaging in a medical group visit, and test the effect of two texting programs (12 weeks and 20 weeks), compared to those who did not receive text-messaging in the Preventing Obesity With Eating Right (POWER) group visit program. The primary outcome was weight loss.

RESULTS

We found that those enrolled in the 20-week and 12-week texting programs attended more group visit sessions than those enrolled in the POWER group only (p < 0.001). Both POWER and POWER + 20-week texting groups had a significant reduction in weight at their final group visit compared to their baseline (POWER, 114 ± 27 kg vs. 112 ± 26 kg, p < 0.001; POWER + 20-week texting, 111 ± 28 kg vs. 109 ± 28 kg, p < 0.01), but not the 12-week texting group (114 ± 29 kg vs. 113 ± 29 kg, p = 0.22), with no differences between the groups. The number of group visits was correlated with a decrease in weight (rs  = 0.12, p < 0.05).

CONCLUSION

In conclusion, text messaging programs led to more attendance in the medical group visits, but not greater weight loss or reduction in HbA1c than the POWER group obesity program alone. Further studies are needed to maximize the beneficial effects of texting programs in medical group visits in underserved minority populations.

Feasibility and potential efficacy of commercial mHealth/eHealth tools for weight loss in African American breast cancer survivors: pilot randomized controlled trial

Weight management after breast cancer (BC) treatment in African American (AA) women is crucial to reduce comorbid conditions and health disparities. We examined feasibility and potential efficacy of commercial eHealth/mHealth tools for weight management in AA BC survivors in New Jersey. Participants (N = 35) were randomized to an intervention (SparkPeople) plus activity tracker, Fitbit Charge (n = 18), or wait-list active control group (Fitbit only, n = 17). Anthropometric, behavioral, and quality of life (QOL) outcomes were collected at baseline, 3, 6, and 12 months. Differences in outcomes were assessed using intent-to-treat analysis. Retention was 97.1%. Both groups lost weight, with no significant differences between groups. At month 6, mean weight change was: intervention: -1.71 kg (SD 2.33; p = .006), 33.3% lost ≥3% of baseline weight; control: -2.54 kg (SD 4.00, p = .002), 23.5% lost ≥3% weight. Intervention participants achieved significant improvements in waist circumference (-3.56 cm, SD 4.70, p = .005), QOL (p = .030), and use of strategies for healthy eating (p = .025) and decreasing calories (p < .001). Number of days logged food per week was associated with decreases in waist circumference at 6 months (β -0.79, 95% CI, -1.49, -0.09, p = .030) and 12 months (β -2.16, 95% CI, -4.17, -0.15, p = .038). Weight loss was maintained at 12 months. This is the first study to demonstrate potential efficacy of commercial eHealth/mHealth tools for weight loss in AA BC survivors, without additional counseling from the research team. If effective, they may be convenient weight loss tools that can be easily and widely disseminated. Clinical Trials registration: ClinicalTrials.gov NCT02699983.

Harnessing Digital Health Technologies to Remotely Manage Diabetic Foot Syndrome: A Narrative Review

About 422 million people worldwide have diabetes and approximately one-third of them have a major risk factor for diabetic foot ulcers, including poor sensation in their feet from peripheral neuropathy and/or poor perfusion to their feet from peripheral artery disease. The current healthcare ecosystem, which is centered on the treatment of established foot disease, often fails to adequately control key reversible risk factors to prevent diabetic foot ulcers leading to unacceptable high foot disease amputation rate, 40% recurrence of ulcers rate in the first year, and high hospital admissions. Thus, the latest diabetic foot ulcer guidelines emphasize that a paradigm shift in research priority from siloed hospital treatments to innovative integrated community prevention is now critical to address the high diabetic foot ulcer burden. The widespread uptake and acceptance of wearable and digital health technologies provide a means to timely monitor major risk factors associated with diabetic foot ulcer, empower patients in self-care, and effectively deliver the remote monitoring and multi-disciplinary prevention needed for those at-risk people and address the health care access disadvantage that people living in remote areas. This narrative review paper summarizes some of the latest innovations in three specific areas, including technologies supporting triaging high-risk patients, technologies supporting care in place, and technologies empowering self-care. While many of these technologies are still in infancy, we anticipate that in response to the Coronavirus Disease 2019 pandemic and current unmet needs to decentralize care for people with foot disease, we will see a new wave of innovations in the area of digital health, smart wearables, telehealth technologies, and “hospital-at-home” care delivery model. These technologies will be quickly adopted at scale to improve remote management of diabetic foot ulcers, smartly triaging those who need to be seen in outpatient or inpatient clinics, and supporting acute or subacute care at home.

Treatment of Obesity: Beyond the Diet

Obesity affects 2 of 5 Americans, and nearly 1 of 10 is considered severely obese, with the greatest risk of morbidity and mortality. A reduction in body weight of 2% to 5% can lead to improvements in cardiovascular health, with weight loss maintenance associated with the best health outcomes. Lifestyle interventions that focus on changes in diet and physical activity behaviors are best to maintain weight loss. This article provides a review of the treatment of adult obesity with a focus on dietary interventions.

Optimizing an Obesity Treatment Using the Multiphase Optimization Strategy Framework: Protocol for a Randomized Factorial Trial

Background

Effective weight loss interventions exist, yet few can be scaled up for wide dissemination. Further, none has been fully delivered via text message. We used the multiphase optimization strategy (MOST) to develop multicomponent interventions that consist only of active components, those that have been experimentally determined to impact the chosen outcome.

Objective

The goal of this study is to optimize a standalone text messaging obesity intervention, Charge, using the MOST framework to experimentally determine which text messaging components produce a meaningful contribution to weight change at 6 months.

Methods

We designed a 6-month, weight loss texting intervention based on our interactive obesity treatment approach (iOTA). Participants are randomized to one of 32 experimental conditions to test which standalone text messaging intervention components produce a meaningful contribution to weight change at 6 months.

Results

The project was funded in February 2017; enrollment began in January 2018 and data collection was completed in June 2019. Data analysis is in progress and first results are expected to be submitted for publication in 2021.

Conclusions

Full factorial trials are particularly efficient in terms of cost and logistics when leveraged for standalone digital treatments. Accordingly, MOST has the potential to promote the rapid advancement of digital health treatments. Subject to positive findings, the intervention will be low cost, immediately scalable, and ready for dissemination. This will be of great potential use to the millions of Americans with obesity and the providers who treat them.

Trial Registration

ClinicalTrials.gov NCT03254940; https://clinicaltrials.gov/ct2/show/NCT03254940

International Registered Report Identifier (IRRID)

RR1-10.2196/19506

Protocol for a systematic review and meta-analysis of culturally adapted internet- and mobile-based health promotion interventions

INTRODUCTION

High rates of immigration pose challenges for the healthcare systems of many countries to offer high-quality care to diverse populations. Advancing health interventions with incorporating the cultural background of diverse populations can be helpful to overcome this challenge. First studies suggest that culturally diverse populations might benefit from culturally adapted internet-based and mobile-based interventions (IMI) to promote health behaviours. However, the effectiveness of culturally adapted IMIs for health promotion interventions has not been evaluated systematically. Therefore, the aim of this review is to assess the effectiveness of culturally adapted IMIs regarding health promotion. Additionally, the cultural adaptation features of these interventions will be outlined.

METHODS AND ANALYSIS

Randomised controlled trials (RCTs) investigating the effectiveness of culturally adapted IMIs to promote health behaviours in the field of healthy eating, smoking cessation, alcohol consumption, physical activity and sexual health behaviour will be identified via a systematic search of the databases MEDLINE, Embase, PsycINFO, CENTRAL. The preliminary search has been conducted on the 26 August 2019 and will be updated in the process. Data will be pooled meta-analytically in case of at least three included studies reporting on the same outcome. Moreover, a narrative synthesis of the included studies will be conducted. The risk of bias will be assessed using the Cochrane Collaboration's tool for the Quality Assessment of RCTs V. 2.0. Publication bias will be assessed using funnel plots.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. The results of this study will be published in a peer-reviewed international journal.

PROSPERO REGISTRATION NUMBER

PROSPERO; CRD42020152939.

Effectiveness of a self-regulation intervention for weight loss: A randomized controlled trial

OBJECTIVES

To evaluate effectiveness and acceptability of a novel intervention, based on self-regulation theory, for weight loss.

DESIGN

A two-arm parallel group design was employed.

METHODS

Adult participants with a BMI ≥ 30 kg/m² and the aim to lose weight were recruited and randomized to either a control or intervention group. Both groups were asked to weigh themselves daily for eight weeks. The intervention group was encouraged to use a weight tracking app, and complete daily and weekly questionnaires to prompt action planning, reflection, and evaluation of actions. Participants chose daily actions from a menu of 53 behaviours. The primary outcome was weight change after 8 weeks, assessed using linear mixed effects models. At follow-up, 20 intervention group participants were interviewed regarding their experiences in the trial.

RESULTS

100 participants were recruited, and 98% were followed up at 8 weeks. Mean weight loss was -4.18 kg (SD = 3.84) in the intervention compared to -1.01 kg (SD = 2.67) in the control group; the adjusted difference was -3.20 kg (95% CI -4.49, -1.92). Participants rated the intervention's usefulness as 8.25 (SD = 2.04) on a scale from 1 to 10. Adherence was a significant independent predictor of weight loss success (-1.54 kg per one SD, 95% CI -2.16, -0.93), but not a mediator of the intervention effect. Participants reported that the intervention enabled them to experiment with and identify effective weight loss actions.

CONCLUSIONS

Guiding participants through the self-regulation process was feasible, acceptable to participants, and led to significantly greater short-term weight loss than unguided self-weighing.

A systematic review with meta-analyses of text message-delivered behaviour change interventions for weight loss and weight loss maintenance

Short Message Service (SMS)-delivered behaviour change interventions are frequently used to support weight management. This systematic review examines the effectiveness of SMS-delivered behaviour change interventions for weight management. Electronic databases were searched for randomised controlled trials (RCTs) comparing SMS-delivered adult weight management interventions to control groups, published between 1990 and 2018. Weight change was examined using random effects meta-analyses at intervention cessation and postintervention follow-up. Subgroup analyses examined intervention duration, SMS frequency, theory use, SMS interactivity, and SMS tailoring. Fifteen studies met inclusion criteria (2705 participants). For weight loss interventions (n = 12, 1977 participants), the mean difference in weight change was -2.28 kg (95% confidence interval [CI] -3.17 to -1.36 kg). No studies reported postintervention follow-up. For weight loss maintenance interventions (n = 3, 728 participants), the mean difference in weight change was -0.68 kg (95% CI, -1.31 to -0.05 kg), and postintervention follow-up (n = 2, 498 participants) effects were -0.57 kg (95% CI, -1.67 to 0.53 kg). No subgroup differences were found. SMS-delivered behaviour change interventions for weight loss led to significant small to moderate weight loss and weight loss maintenance compared with control groups. Evidence on long-term effects is limited. SMS-delivered behaviour change interventions are a potentially effective and scalable intervention option for obesity treatment.

Safety and feasibility of various fasting-mimicking diets among people with multiple sclerosis

BACKGROUND

Fasting-mimicking diets have shown promise in experimental autoimmune encephalitis and are currently being investigated among people with multiple sclerosis (MS). Ensuring adherence to diet changes is critical to determining the efficacy of such interventions.

OBJECTIVE

Our primary aim was to evaluate the safety and feasibility of several fasting-mimicking diets and investigate whether various levels of clinical support improve diet adherence among people with MS. Secondarily, this study evaluated the impact of fasting-mimicking diets on weight and patient-reported outcomes (PROs).

METHODS

We conducted three pilot studies (two randomized controlled for 6 months; one randomized with transition to single arm) restricting either the amount or timing of calorie intake over 24 or 48 weeks. Interventions included calorie restriction (daily or intermittently) or time-restricted feeding. Adherence measures varied across studies but were collected at study visits along with weight and PRO data.

RESULTS

A total of 90 participants enrolled; 70 completed the studies, with no serious adverse events reported. Overall adherence to the calorie restriction diets was poor. When participants were tasked with maintaining a diet in a pragmatic setting, neither previously completed intense clinical support and education, nor weekly electronic communication throughout the diet period appeared to improve diet adherence. Participants who were able to adhere to a calorie restriction diet predictably lost weight. In contrast to calorie restriction, adherence to a time-restricted feeding (TRF) diet was relatively good. No statistically significant changes in PROs were observed in an intention-to-treat analysis.

CONCLUSION

The role diet may play in clinical outcomes in MS remains unknown, as class I evidence is lacking. Diet adherence remains a primary barrier to the feasible conduct of large, randomized controlled diet trials. Strict adherence to a TRF dietary change may be more feasible than calorie restriction and should be considered in future fasting-mimicking diet trials. ClinicalTrials.gov Registry:A Pilot Study of Intermittent Calorie Restriction in Multiple Sclerosis - NCT02647502. A Pragmatic Trial of Dietary Programs in People with Multiple Sclerosis (MS) - NCT02846558.

Testing the effectiveness of a weight loss intervention to enhance self-regulation in adults who are obese: protocol for a randomised controlled trial

INTRODUCTION

Previous trials finding an effect of self-monitoring on weight loss have considered the effect to be mediated by self-regulatory processes. However, a qualitative think-aloud study asking people to record thoughts and feelings during weighing showed that self-regulation occurs only rarely without further instruction. The aim of this trial is to test a novel intervention guiding people through the self-regulatory processes to see whether it facilitates weight loss.

METHODS AND ANALYSES

A parallel group, randomised controlled trial will be conducted to test the concept that a self-regulation intervention for weight loss increases weight loss compared with daily self-weighing without further support. One hundred participants with a body mass index ≥30 kg/m² will be randomised to either the control or intervention group. The control group will be asked to weigh themselves daily for 8 weeks, the intervention group will be encouraged to follow the self-regulation intervention. They will be prompted to weigh daily, track their weight using an app, plan daily actions for weight loss and reflect on their action plans on a weekly basis. This self-regulation cycle will allow them to experiment with different weight loss strategies and identify effective and sustainable actions. Primary and process outcomes will be measured at baseline and 8 weeks' follow-up. Linear regression analysis of the primary outcome, weight change, will assess the early effectiveness of the intervention. The process outcomes liking, perceived effectiveness, as well as usage and barriers with regard to the self-regulation intervention, will be assessed through qualitative analysis of follow-up interviews and quantitative analysis of adherence rates and responses to a final questionnaire.

ETHICS AND DISSEMINATION

This trial was reviewed and approved by the NHS National Research Ethics Committee and the Health Research Authority (reference number: 18/SC/0482). The findings of the trial will be published in peer reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

ISRCTN14148239, prerecruitment.

PROTOCOL VERSION

Version 1.1, 7 December 2018.

Strategies to reduce attrition in weight loss interventions: A systematic review and meta-analysis

The primary objective of the study was to identify the effect of intervention strategies on attrition within a weight loss programme among adults aged 18 to 65 years. The secondary objective of the study was to assess the impact of such intervention strategies among female-only weight loss programmes. The literature search was performed in Ovid (CINAHL Plus, MEDLINE, EMBASE, Cochrane [Cochrane Database of Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register], and PsycINFO). Studies must have identified weight loss as the main aim and compared the primary weight loss programme alone (control) with the primary weight loss programme coupled with an additional intervention strategy (intervention). Papers must have had a mean participant age between 18 and 65 years and available in English. Fifty-seven trials met the inclusion criteria and were included in the meta-analysis. Strategies that successfully reduced attrition included the incorporation of financial incentives (n = 8), a multicomponent approach (n = 13), and use of self-monitoring technology (n = 4). The majority of studies were of low to moderate methodological quality because of insufficient reporting. A limited number of female-only trials were found (n = 13). Implementation of financial incentives, multicomponent interventions, and self-monitoring technology help reduce attrition among adult weight loss programmes. Further studies are required to identify the impact of intervention strategies on attrition in women.

Use of Telehealth to Enhance Care in a Family-Centered Childhood Obesity Intervention

Family-centered childhood obesity interventions have been found to be effective. We describe the use of telehealth for tailored behavior change support in a family-centered randomized trial. Children of 2 to 12 years with body mass index ≥85th percentile were randomized to Enhanced Primary Care (EPC) or Enhanced Primary Care + Coaching (EPC + C). EPC + C received 6 health coach visits (in-person or by video or phone call) over 1 year. Telehealth modalities included interactive text messaging, video calls, and an online community resource map. There were 360 children randomized to the EPC + C arm; 87% of parents completed ≥1 health coaching contacts. Overall, 93% parents were sent text messages of which 99% responded at least once. About 72% parents were very satisfied with the message content and 97% were satisfied with information provided about community health resources. The high level of participant engagement and satisfaction suggests that telehealth is feasible and acceptable in family-centered childhood obesity programs.

Community Engagement in the Development of an mHealth-Enabled Physical Activity and Cardiovascular Health Intervention (Step It Up): Pilot Focus Group Study

BACKGROUND

Community-based participatory research is an effective tool for improving health outcomes in minority communities. Few community-based participatory research studies have evaluated methods of optimizing smartphone apps for health technology-enabled interventions in African Americans.

OBJECTIVE

This study aimed to utilize focus groups (FGs) for gathering qualitative data to inform the development of an app that promotes physical activity (PA) among African American women in Washington, DC.

METHODS

We recruited a convenience sample of African American women (N=16, age range 51-74 years) from regions of Washington, DC metropolitan area with the highest burden of cardiovascular disease. Participants used an app created by the research team, which provided motivational messages through app push notifications and educational content to promote PA. Subsequently, participants engaged in semistructured FG interviews led by moderators who asked open-ended questions about participants' experiences of using the app. FGs were audiorecorded and transcribed verbatim, with subsequent behavioral theory-driven thematic analysis. Key themes based on the Health Belief Model and emerging themes were identified from the transcripts. Three independent reviewers iteratively coded the transcripts until consensus was reached. Then, the final codebook was approved by a qualitative research expert.

RESULTS

In this study, 10 main themes emerged. Participants emphasized the need to improve the app by optimizing automation, increasing relatability (eg, photos that reflect target demographic), increasing educational material (eg, health information), and connecting with community resources (eg, cooking classes and exercise groups).

CONCLUSIONS

Involving target users in the development of a culturally sensitive PA app is an essential step for creating an app that has a higher likelihood of acceptance and use in a technology-enabled intervention. This may decrease health disparities in cardiovascular diseases by more effectively increasing PA in a minority population.

Before and after: craving, mood, and background stress in the hours surrounding drug use and stressful events in patients with opioid-use disorder

RATIONALE

Ecological momentary assessment (EMA) of specific events usually focuses more on antecedents and concomitants than on aftermaths.

OBJECTIVES

To examine mental state both before and after discrete episodes of stress and drug use.

METHODS

For up to 16 weeks, outpatients on opioid-agonist treatment carried smartphones on which they initiated entries for stressful events (SEs) or lapses to drug use (DUs), and thrice daily when randomly prompted (RPs). Participants rated their stress, opioid craving, cocaine craving, and moods. RP entries within 5 h of an event were analyzed and compared to other RPs.

RESULTS

Stress, negative mood, and craving were generally higher before and after DUs and SEs compared to background levels in participants with at least one DU (n = 149) or SE (n = 158). Before DUs, there were increases in negative mood, opioid craving, and cocaine craving, but not background stress. Before SEs, there were increases in background stress, opioid craving, and cocaine craving, but not negative mood. These changes were more variable after events than before. Neither DUs nor SEs were significantly related to positive mood.

CONCLUSIONS

Stress increased before stressful-event entries, but was less evident before drug use. Craving increased in the hours before drug use and stressful events-and remained elevated in the hours after either event. These results suggest a stronger link between drug use and craving than between drug use and stress. Lapses to drug use did not improve mood or reduce stress, at least not at our 1-h-bin time resolution, suggesting that if such benefits exist, they are brief.

Good intentions are not enough: how informatics interventions can worsen inequality

Health informatics interventions are designed to help people avoid, recover from, or cope with disease and disability, or to improve the quality and safety of healthcare. Unfortunately, they pose a risk of producing intervention-generated inequalities (IGI) by disproportionately benefiting more advantaged people. In this perspective paper, we discuss characteristics of health-related interventions known to produce IGI, explain why health informatics interventions are particularly vulnerable to this phenomenon, and describe safeguards that can be implemented to improve health equity. We provide examples in which health informatics interventions produced inequality because they were more accessible to, heavily used by, adhered to, or effective for those from socioeconomically advantaged groups. We provide a brief outline of precautions that intervention developers and implementers can take to guard against creating or worsening inequality through health informatics. We conclude by discussing evaluation approaches that will ensure that IGIs are recognized and studied.

Text messaging approach improves weight loss in patients with nonalcoholic fatty liver disease: A randomized study

BACKGROUND & AIMS

Nonalcoholic fatty liver disease (NAFLD) is emerging as the most common liver disease. The only effective treatment is 7%-10% weight loss. Mobile technology is increasingly used in weight management. This study was performed to evaluate the effects of text messaging intervention on weight loss in patients with NAFLD.

METHODS

Thirty well-defined NAFLD patients (mean age 52 years, 67% females, mean BMI 38) were randomized 1:1 to control group: counselling on healthy diet and exercise, or intervention group: text messages in addition to healthy life style counselling. NAFLD text messaging program sent weekly messages for 22 weeks on healthy life style education. Primary outcome was change in weight. Secondary outcomes were changes in liver enzymes and lipid profile.

RESULTS

Intervention group lost an average of 6.9 lbs. (P = .03) compared to gain of 1.8 lbs. in the control group (P = .45). Intervention group also showed a decrease in ALT level (-12.5 IU/L, P = .035) and improvement in serum triglycerides (-28 mg/dL, P = .048). There were no changes in the control group on serum ALT level (-6.1 IU/L, P = .46) and on serum triglycerides (-20.3 mg/dL P = .27). Using one-way analysis of variance, change in outcomes in intervention group compared to control group was significant for weight (P = .02) and BMI (P = .02).

CONCLUSIONS

Text messaging on healthy life style is associated with reduction in weight in NAFLD patients. Larger studies are suggested to examine benefits on liver histology, and assess long-term impact of this approach in patients with NAFLD.

Using text messages to promote health in African-Americans: #HeartHealthyandCancerFree

OBJECTIVES

African-Americans are vulnerable to both cancer and cardiovascular disease (CVD) due to intricately connected risk factors. Use of text messages is an innovative method to provide health information to reduce these risks. The aim of this study was to test the feasibility and acceptability of a text messaging intervention to reduce CVD and cancer risk factors in African-Americans.

DESIGN

We developed an intervention using text messages culturally tailored for African-Americans over age 50 who were at risk (one or more modifiable risk factors) for CVD and/or cancer. Sociodemographic data, biologic measures, cancer screening practices, and general health status were assessed. Group interviews were conducted to assess feasibility and acceptability.

RESULTS

Participants were primarily female (69%), aged 58 ± 5 years, who were married (59%) and worked full time (56%). In terms of feasibility and acceptability, themes of encouragement through text messages received and a desire for a longer study period emerged from group interviews with participants. Participants experienced significant decreases in waist circumference (41 ± 5 vs 40 ± 5, p = .002), systolic blood pressure (147 ± 25 mmHg vs 138 ± 20 mmHg, p = .009), diastolic blood pressure (87 ± 16 mmHg vs 82 ± 10 mmHg, p = .02), total cholesterol (194 ± 35 mg/dL vs 173 ± 32 mg/dL, p < .001), and low-density lipoprotein levels (100 ± 32 mg/dL vs 86 ± 29 mg/dL, p = .015). Five participants had colorectal cancer screening, two had prostate cancer screening, and four had mammograms.

CONCLUSIONS

Use of text messages was widely accepted among participants. Significant CVD risk reductions and increased cancer screenings were noted. Future studies should incorporate innovative strategies such as text messaging in promoting health in vulnerable populations.

Addressing people and place microenvironments in weight loss disparities (APP-Me): Design of a randomized controlled trial testing timely messages for weight loss behavior in low income Black and White Women

BACKGROUND

Behavioral interventions for weight loss have been less effective in lower income and black women. These poorer outcomes may in part be related to these women having more frequent exposures to social and physical situations that are obesogenic, i.e., eating and sedentary cues or situations.

OBJECTIVES

Working with obese, lower income Black and White Women, Addressing People and Place Microenvironments (APP-Me) was designed to create awareness of self-behavior at times and places of frequent eating and sedentary behavior.

DESIGN

APP-Me is being evaluated in a randomized controlled trial with 240 participants recruited from federally qualified health centers located in a single Midwestern city. All participants complete four weeks of ecological momentary assessments (EMA) of situations and behavior. At the end of the four weeks, participants are randomized to enhanced usual care (UC) or UC plus APP-Me.

METHODS

APP-Me is an automated short messaging system (SMS). Messages are text, image, audio, or a combination, and are delivered to participants' mobile devices with the intent of creating awareness at the times and places of frequent eating or sedentary behavior. The EMA data inform the timing of message deliveries.

SUMMARY

This project aims to create and test timely awareness messages in a subpopulation that has not responded well to traditional behavioral interventions for weight loss. Novel aspects of the study include the involvement of a low income population, the use of data on time and place of obesogenic behavior, and message delivery time tailored to an individual's behavioral patterns.

Patient-Selected Strategies for Post Cardiac Rehabilitation Exercise Adherence in Heart Failure

PURPOSE

The aim of this study was to evaluate the use of patient-selected exercise adherence strategies following cardiac rehabilitation (CR).

DESIGN

Twenty patients with heart failure (HF) were recruited and randomly assigned to the intervention or control group at completion of CR.

METHODS

The intervention included the use of six adherence strategies (logs, graphs, pedometers, phone follow-up, education, and a letter from CR staff), which were provided for 6 weeks post CR and during home-based exercise. After 6 weeks, the intervention group selected strategies to continue, and only those were provided for the last 6 weeks. At 12 weeks, patients were retested.

FINDINGS

Patients with HF demonstrated improvement in distance walked and less HF symptoms and adhered to exercise at levels recommended during CR.

CONCLUSION

Inclusion of patient-selected adherence strategies supports continued exercise and helps to sustain physiological improvements.

CLINICAL RELEVANCE

Results from this study have implications for CR programs serving HF patients and provide insight into adherence strategies.

Role of the family doctor in the management of adults with obesity: a scoping review

OBJECTIVES

Obesity management is an important issue for the international primary care community. This scoping review examines the literature describing the role of the family doctor in managing adults with obesity. The methods were prospectively published and followed Joanna Briggs Institute methodology.

SETTING

Primary care. Adult patients.

INCLUDED PAPERS

Peer-reviewed and grey literature with the keywords obesity, primary care and family doctors. All literature published up to September 2015. 3294 non-duplicate papers were identified and 225 articles included after full-text review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were extracted on the family doctors' involvement in different aspects of management, and whether whole person and person-centred care were explicitly mentioned.

RESULTS

110 papers described interventions in primary care and family doctors were always involved in diagnosing obesity and often in recruitment of participants. A clear description of the provider involved in an intervention was often lacking. It was difficult to determine if interventions took account of whole person and person-centredness. Most opinion papers and clinical overviews described an extensive role for the family doctor in management; in contrast, research on current practices depicted obesity as undermanaged by family doctors. International guidelines varied in their description of the role of the family doctor with a more extensive role suggested by guidelines from family medicine organisations.

CONCLUSIONS

There is a disconnect between how family doctors are involved in primary care interventions, the message in clinical overviews and opinion papers, and observed current practice of family doctors. The role of family doctors in international guidelines for obesity may reflect the strength of primary care in the originating health system. Reporting of primary care interventions could be improved by enhanced descriptions of the providers involved and explanation of how the pillars of primary care are used in intervention development.

Are Nomothetic or Ideographic Approaches Superior in Predicting Daily Exercise Behaviors?

OBJECTIVES

The understanding of how stress influences health behavior can provide insights into developing healthy lifestyle interventions. This understanding is traditionally attained through observational studies that examine associations at a population level. This nomothetic approach, however, is fundamentally limited by the fact that the environment- person milieu that constitutes stress exposure and experience can vary substantially between individuals, and the modifiable elements of these exposures and experiences are individual-specific. With recent advances in smartphone and sensing technologies, it is now possible to conduct idiographic assessment in users' own environment, leveraging the full-range observations of actions and experiences that result in differential response to naturally occurring events. The aim of this paper is to explore the hypothesis that an ideographic N-of-1 model can better capture an individual's stress- behavior pathway (or the lack thereof) and provide useful person-specific predictors of exercise behavior.

METHODS

This paper used the data collected in an observational study in 79 participants who were followed for up to a 1-year period, wherein their physical activity was continuously and objectively monitored by actigraphy and their stress experience was recorded via ecological momentary assessment on a mobile app. In addition, our analyses considered exogenous and environmental variables retrieved from public archive such as day in a week, daylight time, temperature and precipitation. Leveraging the multiple data sources, we developed prediction algorithms for exercise behavior using random forest and classification tree techniques using a nomothetic approach and an N-of-1 approach. The two approaches were compared based on classification errors in predicting personalized exercise behavior.

RESULTS

Eight factors were selected by random forest for the nomothetic decision model, which was used to predict whether a participant would exercise on a particular day. The predictors included previous exercise behavior, emotional factors (e.g., midday stress), external factors such as weather (e.g., temperature), and self-determination factors (e.g., expectation of exercise). The nomothetic model yielded an average classification error of 36%. The ideographic N-of-1 models used on average about two predictors for each individual, and had an average classification error of 25%, which represented an improvement of 11 percentage points.

CONCLUSIONS

Compared to the traditional one-size-fits-all, nomothetic model that generalizes population-evidence for individuals, the proposed N-of-1 model can better capture the individual difference in their stressbehavior pathways. In this paper, we demonstrate it is feasible to perform personalized exercise behavior prediction, mainly made possible by mobile health technology and machine learning analytics.

The effectiveness of smoking cessation, physical activity/diet and alcohol reduction interventions delivered by mobile phones for the prevention of non-communicable diseases: A systematic review of randomised controlled trials

BACKGROUND

We conducted a systematic review to assess the effectiveness of smoking cessation, physical activity (PA), diet, and alcohol reduction interventions delivered by mobile technology to prevent non-communicable diseases (NCDs).

METHODS

We searched for randomised controlled trials (RCTs) of mobile-based NCD prevention interventions using MEDLINE, EMBASE, Global Health, CINAHL (Jan 1990-Jan 2016). Two authors extracted data.

FINDINGS

71 trials were included: smoking cessation (n = 18); PA (n = 15), diet (n = 3), PA and diet (n = 25); PA, diet, and smoking cessation (n = 2); and harmful alcohol consumption (n = 8). 4 trials had low risk of bias. The effect of SMS-based smoking cessation support on biochemically verified continuous abstinence was pooled relative risk [RR] 2.19 [95% CI 1.80-2.68], I2 = 0%) and on verified 7 day point prevalence of smoking cessation was pooled RR 1.51 [95% CI 1.06-2.15], I2 = 0%, with no reported adverse events. There was no difference in peak oxygen intake at 3 months in a trial of an SMS-based PA intervention. The effect of SMS-based diet and PA interventions on: incidence of diabetes was pooled RR 0.67 [95% CI 0.49, 0.90], I2 = 0.0%; end-point weight was pooled MD -0.99Kg [95% CI -3.63, 1.64] I2 = 29.4%; % change in weight was pooled MD -3.1 [95%CI -4.86- -1.3] I2 0.3%; and on triglyceride levels was pooled MD -0.19 mmol/L [95% CI -0.29, -0.08], I2 = 0.0%. The results of other pooled analyses of the effect of SMS-based diet and PA interventions were heterogenous (I2 59-90%). The effects of alcohol reduction interventions were inconclusive.

CONCLUSIONS

Smoking cessation support delivered by SMS increases quitting rates. Trials of PA interventions reporting outcomes ≥3 months showed no benefits. There were at best modest benefits of diet and PA interventions. The effects of the most promising SMS-based smoking, diet and PA interventions on morbidity and mortality in high-risk groups should be established in adequately powered RCTs.

An interpretable health behavioral intervention policy for mobile device users

An increasing number of people use mobile devices to monitor their behavior, such as exercise, and record their health status, such as psychological stress. However, these devices rarely provide ongoing support to help users understand how their behavior contributes to changes in their health status. To address this challenge, we aim to develop an interpretable policy for physical activity recommendations that reduce a user's perceived psychological stress, over a given time horizon. We formulate this problem as a sequential decision-making problem and solve it using a new method that we refer to as threshold Q-learning (TQL). The advantage of the TQL method over traditional Q-learning is that it is "doubly robust" and interpretable. This interpretability is achieved by making model assumptions and incorporating threshold selection into the learning process. Our simulation results indicate that the TQL method performs better than the Q-learning method given model misspecification. Our analyses are performed on data collected from 79 healthy adults over a 7 week period, where the data comprise physical activity patterns collected from mobile devices and self-assessed stress levels of the users. This work serves as a first step toward a computational health coaching solution for mobile device users.

Shape-Up and Eat Right Families Pilot Program: Feasibility of a Weight Management Shared Medical Appointment Model in African-Americans With Obesity at an Urban Academic Medical Center

OBJECTIVES

Disparities in obesity care exist among African-American children and adults. We sought to test the feasibility of a pilot program, a 1-year family-based intervention for African-American families with obesity [shape up and eat right (SUPER)], adopting the shared medical appointment model (SMA) at an urban safety net hospital.

OUTCOMES

Primary outcomes: (1) family attendance rate and (2) program satisfaction. Secondary outcomes: change in body mass index (BMI), eating behaviors, and sedentary activity.

METHODS

Adult parents (BMI ≥ 25 kg/m²) ≥18 years and their child(ren) (BMI ≥ 85th percentile) ages 6-12 years from adult or pediatric weight management clinics were recruited. One group visit per month (n = 12) consisting of a nutrition and exercise component was led by a nurse practitioner and registered dietitian. Height and weight were recorded during each visit. Participants were queried on program satisfaction, food logs and exercise journals, Food Stamp Program's Food Behavior, and the Expanded Food and Nutrition Education Program food checklists.

RESULTS

Thirteen participants from lower socioeconomic zip codes consented [n = 5 mothers mean age 33 years, BMI of 47.4 kg/m² (31.4-73.6 kg/m²); n = 8 children; mean age 9 years, BMI of 97.6th percentile (94-99th percentile); 60% enrolled in state Medicaid]. Average individual attendance was 23.4% (14-43%; n = 13); monthly session attendance rates declined from 100 to 40% by program completion; two families completed the program in entirety. Program was rated (n = 5 adults) very satisfactory (40%) and extremely satisfactory (60%). Pre-intervention, families rated their eating habits as fair and reported consuming sugar-sweetened beverages or sports drinks, more so than watching more than 1 h of television (p < 0.002) or video game/computer activity (p < 0.006) and consuming carbonated sodas (p < 0.004). Post-intervention, reducing salt intake was the only statistically significant variable (p < 0.029), while children watched fewer hours of television and spent less time playing video games (from average 2 to 3 h daily; p < 0.03).

CONCLUSION

Attendance was lower than expected though children seemed to decrease screen time and the program was rated satisfactory. Reported socioeconomic barriers precluded families from attending most sessions. Future reiterations of the intervention could be enhanced with community engagement strategies to increase participant retention.

Effectiveness of mobile health (mHealth) interventions for promoting healthy eating in adults: A systematic review

Unhealthy eating is a major risk factor for chronic disease. However, many current strategies to promote healthy eating are not sustainable over the longer-term. More cost-effective wide-reaching initiatives are urgently needed. Mobile health (mHealth) interventions, delivered via mobile devices, could provide a solution. This systematic review summarized the evidence on the effect of mHealth interventions for promoting healthy eating in adults. A comprehensive systematic search of five scientific databases was conducted using methods adapted from the Cochrane Handbook. Eligible studies were randomized controlled trials (RCTs), published up to 1 July 2016, which examined healthy eating interventions delivered via mobile device. Of 879 articles identified, 84 full text articles were potentially eligible and further assessed, and 23 included. Narrative review results indicated small positive effects of mHealth interventions on healthy eating (5/8 trials) and weight loss (5/13 trials). However, the current evidence base is insufficient (studies are of poor quality) to determine conclusive positive effects. More rigorous RCTs with longer-term (>6months) follow-up are warranted to determine if effects are maintained.

A Review of Technology-Assisted Interventions for Diabetes Prevention

PURPOSE OF REVIEW

The high prevalence of prediabetes and success of the diabetes prevention program (DPP) has led to increasing efforts to provide readily accessible, cost-effective DPP interventions to the general public. Technology-assisted DPP interventions are of particular interest since they may be easier to widely distribute and sustain as compared to traditional in-person DPP. The purpose of this article is to provide an overview of currently available technology-assisted DPP interventions.

RECENT FINDINGS

This review focuses on studies that have examined the use of mobile phone text messaging, smartphone/web-based apps, and telehealth programs to help prevent or delay the onset of incident type 2 diabetes. While there is variability in the results of studies focused on technology-assisted DPP and weight loss interventions, there is evidence to suggest that these programs have been associated with clinically meaningful weight loss and can be cost-effective. Patients who are at risk for diabetes can be offered technology-assisted DPP and weight loss interventions to lower their risk of incident diabetes. Further research should determine what specific combination of intervention features would be most successful.

A Systematic Review of Obesity Disparities Research

CONTEXT

A review of interventions addressing obesity disparities could reveal gaps in the literature and provide guidance on future research, particularly for populations with a high prevalence of obesity and obesity-related cardiometabolic risk.

EVIDENCE ACQUISITION

A systematic review of clinical trials in obesity disparities research that were published in 2011-2016 in PubMed/MEDLINE resulted in 328 peer-reviewed articles. Articles were excluded if they had no BMI, weight, or body composition measure as primary outcome or were foreign (n=201); were epidemiologic or secondary data analyses of clinical trials (n=12); design or protocol papers (n=54); systematic reviews (n=3); or retracted or duplicates (n=9). Forty-nine published trials were summarized and supplemented with a review of ongoing obesity disparities grants being funded by the National, Heart, Lung and Blood Institute.

EVIDENCE SYNTHESIS

Of the 49 peer-reviewed trials, 27 targeted adults and 22 children only or parent-child dyads (5 of 22). Interventions were individually focused; mostly in single settings (e.g., school or community); of short duration (mostly ≤12 months); and primarily used behavioral modification (e.g., self-monitoring) strategies. Many of the trials had small sample sizes and moderate to high attrition rates. A meta-analysis of 13 adult trials obtained a pooled intervention effect of BMI -1.31 (95% CI=-2.11, -0.52, p=0.0012). Institutional review identified 140 ongoing obesity-related health disparities grants, but only 19% (n=27) were clinical trials.

CONCLUSIONS

The reviews call for cardiovascular-related obesity disparities research that is long term and includes population research, and multilevel, policy, and environmental, or "whole of community," interventions.

Reach Out Churches: A Community-Based Participatory Research Pilot Trial to Assess the Feasibility of a Mobile Health Technology Intervention to Reduce Blood Pressure Among African Americans

Innovative strategies are needed to reduce the hypertension epidemic among African Americans. Reach Out was a faith-collaborative, mobile health, randomized, pilot intervention trial of four mobile health components to reduce high blood pressure (BP) compared to usual care. It was designed and tested within a community-based participatory research framework among African Americans recruited and randomized from churches in Flint, Michigan. The purpose of this pilot study was to assess the feasibility of the Reach Out processes. Feasibility was assessed by willingness to consent (acceptance of randomization), proportion of weeks participants texted their BP readings (intervention use), number lost to follow-up (retention), and responses to postintervention surveys and focus groups (acceptance of intervention). Of the 425 church members who underwent BP screening, 94 enrolled in the study and 73 (78%) completed the 6-month outcome assessment. Median age was 58 years, and 79% were women. Participants responded with their BPs on an average of 13.7 (SD = 10.7) weeks out of 26 weeks that the BP prompts were sent. All participants reported satisfaction with the intervention. Reach Out, a faith-collaborative, mobile health intervention was feasible. Further study of the efficacy of the intervention and additional mobile health strategies should be considered.

Peer Group and Text Message-Based Weight-Loss and Management Intervention for African American Women

About 80% of African American (AA) women are overweight or obese. Accessible and effective weight management programs targeting weight loss, weight maintenance and the prevention of weight regain are needed to improve health of AA women. A feasibility study was conducted to examine the feasibility, acceptability, and potential efficacy of a 16-week intervention protocol for weight loss and management that combined daily text messages and biweekly peer group sessions. Modest but statistically significant reductions were detected in weight and body mass index from baseline to 16 weeks. At baseline, 36% of participants were in action and maintenance stages in measures of the stages of change for weight loss and management; this percent increased to 82% at 16 weeks. Findings of this feasibility study provide preliminary evidence of an educational intervention that could motivate women and lead to successful behavior change, and successful weight loss and management for AA women.

Framed, Interactive Theory-Driven Texting: Effects of Message Framing on Health Behavior Change for Weight Loss

More approaches to support weight control are needed, especially among racial minorities who shoulder a disproportionate obesity burden. Using an approach influenced by regulatory fit theory, we conducted a 28-day, 4-arm experimental trial with 89 obese adults recruited from urban, predominantly African American churches to ascertain the efficacy of framed text messages to motivate behaviors conducive to weight loss. Participants were assigned to receive message framing that was matched versus mismatched to their motivational orientation. Results were mixed overall; however, matched texts elicited greater motivation to change eating and exercise behavior, suggesting promise in using motivational approaches to tailor messages.

Technology-Based Interventions for Asthma-Can They Help Decrease Health Disparities?

Asthma is a condition that has consistently demonstrated significant health outcome inequalities for minority populations. One approach used for care of patients with asthma is the incorporation of technology for behavioral modification, symptom monitoring, education, and/or treatment decision making. Whether such technological interventions can improve the care of black and inner-city patients is unknown. We reviewed all randomized controlled trial technological interventions from 2000 to 2015 performed in minority populations. A total of 16 articles met inclusion and exclusion criteria; all but 1 was performed in a childhood or adolescent age group. The interventions used MPEG audio layer-3 players, text messaging, computer/Web-based systems, video games, and interactive voice response. Many used tailored content and/or a specific behavior theory. Although the interventions were based on technology, most required additional special staffing. Subject user satisfaction was positive, and improvements were noted in asthma knowledge, medication adherence, asthma symptoms, and quality of life. Unfortunately, health care utilization (emergency department visits and/or hospitalizations) was typically not improved by the interventions. Although no single intervention modality was vastly superior, the computer-based interventions appeared to have the most positive results. In summary, technology-based interventions have a high level of user satisfaction among minority and urban/low-income individuals with asthma, and can improve asthma outcomes. Further large-scale studies are needed to assess whether such interventions can decrease health disparities in asthma.

Hospitalists' utilization of weight loss resources with discharge texts and primary care contact: a feasibility study

OBJECTIVES

Obesity affects a large proportion of the U.S. population, and hospitalizations may serve as an opportunity to promote weight loss. We sought to determine if multidisciplinary patient-centered inpatient weight loss intervention that included counseling, consults, post-discharge telephone text messages, and primary care follow up was feasible.

METHODS

We conducted a feasibility study focusing on 25 obese hospitalized patients to understand the issues related to rolling out an intensive intervention. Actual weight loss was a secondary outcome and we compared these 25 patients to 28 control patients who were exposed to usual care; weight change was assessed at 1 and 6 months.

RESULTS

Ninety-six percent (24/25) of nutritional consults and 92% (23/25) of physical therapy consults were submitted by hospital providers. All of these doctors were also reminded to counsel their patients about the detrimental health consequences. Fifty-two percent (13/25) and 40% (10/25) were actually seen and counseled by nutrition and physical therapy services respectively, before being discharged. Sixty-eight percent (17/25) received a motivational interviewing counseling session from the principal investigator. All patients were sent text messages and followed with their primary care provider after discharge who received the personalized weight loss discharge instructions that had been given to the patient. The feasibility group lost a mean of 3.0 kg at 6 months and the control group gained an average of 0.20 kg at 6 months post discharge (p = 0.03).

CONCLUSION

Executing a multifaceted weight loss intervention for hospitalized obese patients is feasible, and there may be associated persistent improvements in weight status over time.

Effectiveness of an mHealth intervention to improve the cardiometabolic profile of people with prehypertension in low-resource urban settings in Latin America: a randomised controlled trial

BACKGROUND

Poor diet and physical inactivity strongly affect the growing epidemic of cardiovascular disease worldwide. Mobile phone-based health interventions (mHealth) have been shown to help promote weight loss and increase physical activity and are an attractive approach for health-care systems with limited resources. We aimed to assess whether mHealth with advice for lifestyle improvements would reduce blood pressure, promote weight loss, and improve diet quality and physical activity in individuals with prehypertension living in low-resource urban settings in Latin America.

METHODS

In this parallel-group, randomised controlled trial, we recruited individuals (aged 30-60 years) with systolic blood pressure between 120 and 139 mm Hg, diastolic blood pressure between 80 and 89 mm Hg, or both from health-care centres, workplaces, and community centres in low-resource urban settings in Argentina, Guatemala, and Peru. Participants were randomly assigned to receive either monthly motivational counselling calls and weekly personalised text messages to their mobile phones about diet quality and physical activity for 12 months, or usual care. Randomisation was stratified by country, and we applied minimisation by sex and age groups. Study personnel collecting and analysing data were masked to group assignment. The primary outcomes were mean between-group differences in the changes in systolic and diastolic blood pressure from baseline to 12 months in an intention-to-treat analysis of all participants who completed assessments at 12 months. Secondary outcome measures were changes in bodyweight, waist circumference, and self-reported target behaviours from baseline to 12 months. The trial is registered with ClinicalTrials.gov, number NCT01295216.

FINDINGS

Between March 1, 2012, and Nov 30, 2012, we randomly assigned 637 participants to receive intervention (n=316) or usual care (n=321). 266 (84%) participants in the intervention group and 287 (89%) in the control group were assessed at 12 months. The intervention did not affect change in systolic blood pressure (mean net change -0·37 mm Hg [95% CI -2·15 to 1·40]; p=0·43) or diastolic blood pressure (0·01 mm Hg [-1·29 to 1·32]; p=0·99) compared with usual care. However, we noted a significant net reduction in bodyweight (-0·66 kg [-1·24 to -0·07]; p=0·04) and intake of high-fat and high-sugar foods (-0·75 [-1·30 to -0·20]; p=0·008) in the intervention group compared with the control group. In a prespecified subanalysis, we found that participants in the intervention group who received more than 75% of the calls (nine or more, from a maximum of 12) had a greater reduction of bodyweight (-4·85 [-8·21 to -1·48]) and waist circumference (-3·31 [-5·95 to -0·67]) than participants in the control group. Additionally, participants in the intervention group had an increase in the intake of fruits and vegetables and a decrease in diets high in sodium, fat, and simple sugars relative to participants in the control group. However, we found no changes in systolic blood pressure, diasatolic blood pressure, or physical activity in the group of participants who received more than 75% of the calls compared with the group who received less than 50% of the calls.

INTERPRETATION

Our mHealth-based intervention did not result in a change in blood pressure that differed from usual care, but was associated with a small reduction in bodyweight and an improvement in some dietary habits. We noted a dose-response effect, which signals potential opportunities for larger effects from similar interventions in low-resource settings. More research is needed on mHealth, particularly among people who are poor and disproportionally affected by the cardiovascular disease epidemic and who need effective and affordable interventions to help bridge the equity gap in the management of cardiometabolic risk factors.

FUNDING

National Heart, Lung, and Blood Institute (US National Institutes of Health) and the Medtronic Foundation.